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Issues: Overdose prevention centres (OPC) are non‐residential spaces where people can use illicit drugs (that they have obtained elsewhere) in the presence of staff who can intervene to prevent and manage any overdoses that occur. Many reviews of OPCs exist but they do not explain how OPCs work. Approach: We carried out a realist review, using the RAMESES reporting standards. We systematically searched for and then thematically analysed 391 documents that provide information on the contexts, mechanisms and outcomes of OPCs. Key Findings: Our retroductive analysis identified a causal pathway that highlights the feeling of safety – and the immediate outcome of not dying – as conditions of possibility for the people who use OPCs to build trust and experience social inclusion. The combination of safety, trust and social inclusion that is triggered by OPCs can – depending on the contexts in which they operate – generate other positive outcomes, which may include less risky drug use practices, reductions in blood borne viruses and injection‐related infections and wounds, and access to housing. These outcomes are contingent on relevant contexts, including political and legal environments, which differ for women and people from racialised minorities. Conclusions: OPCs can enable people who live with structural violence and vulnerability to develop feelings of safety and trust that help them stay alive and to build longer term trajectories of social inclusion, with potential to improve other aspects of their health and living conditions. [ABSTRACT FROM AUTHOR]

Approximately 20% of acquired brain injury (ABI) survivors experience reduced psychological wellbeing (PWB). Neuropsychological rehabilitation (NPR) is one approach supporting people with ABI to participate meaningfully in activities despite challenges. Although literature supports NPR effectiveness, little is known about change mechanisms. This systematic realist review identifies what NPR programmes have been designed, delivered, and evaluated for people with ABI to improve PWB and/or quality of life (QOL), as well as providing a context-relevant understanding of what NPR includes and how NPR might lead to positive outcomes. A rapid realist review was conducted in three phases: (1) structured retrieval and evidence extraction; (2) stakeholder consultation; (3) analysis and synthesis. Searches were completed, and findings from 35 publications and one stakeholder consultation were synthesized into a refined logic model. Six context-mechanism-outcome chains (CMOCs) were identified. Participants' relationships to internal experiences, and feelings of self-worth, mastery, and connection appeared to be mechanisms that led to improved PWB and QOL. Adaptation and individualized programmes were also key mechanisms to explain successful NPR. Embedding CMOCs into NPR could improve PWB and/or QOL for people with ABI. The logic model will inform ongoing development of a new online, group-based, NPR programme. [ABSTRACT FROM AUTHOR]

Post-diagnostic support is a significant factor in facilitating personal recovery following a diagnosis of dementia, but access is often inconsistent and insufficient. Recovery Colleges offer peer-led, co-produced courses that can support people to have meaningful lives and have been adapted for use in the context of dementia. A realist review was conducted to understand the application and sustainability of Recovery College dementia courses. An iterative, five-step process combined literature published to 2023 with knowledge from stakeholders with lived and professional experience of dementia involved with Recovery College dementia courses (PROSPERO registration CRD42021293687). Thirty-five documents and discussions with 19 stakeholders were used to build the initial programme theory comprising of 24 context-mechanism-outcome configurations. Reoccurring factors included: attending to aspects of co-production and course delivery to ensure they promoted inclusion and were not compromised by organisational pressures; how stigma impacted access to course opportunities; and embedding personal recovery principles throughout course development to be relevant for people living with dementia and those who support them. People struggling to reconcile their future alongside dementia need practical and emotional support to access and benefit from Recovery College dementia courses, ways to achieve this will be explored through a realist evaluation. [ABSTRACT FROM AUTHOR]

Background: Delirium is a neuropathological syndrome that is characterised by fluctuating impairments in attention, cognitive performance, and consciousness. Since delirium represents a medical emergency, it can be associated with adverse clinical and economic outcomes. Although nursing home residents face a high risk of developing delirium, health care professionals in this field appear to have limited knowledge of delirium despite the critical role they play in the prevention, diagnosis, and treatment of delirium in nursing homes. Objective: The purpose of this realist review is to develop an initial programme theory with the goal of understanding how, why, and under what circumstances educational interventions can improve the delirium-specific knowledge of health care professionals in nursing homes. Methods: This realist review was conducted in accordance with the RAMESES (Realist And Meta-narrative Evidence Synthesis: and Evolving Standards) guidelines and includes the following steps: (1) search strategy and literature review; (2) study selection and assessment; (3) data extraction; (4) data synthesis; and (5) development of an initial programme theory. It also included stakeholder discussions with health care professionals recruited from nursing home care, which focused on their experiences with delirium. Results: From a set of 1703 initially identified publications, ten publications were included in this realist review. Based on these publications, context-mechanism-outcome configurations were developed; these configurations pertained to (1) management support, (2) cognitive impairments among residents, (3) familiarity with residents, (4) participatory intervention development, (5) practical application, (6) case scenarios, (7) support from experts and (8) relevance of communication. Conclusions: Educational interventions aimed at improving the delirium-specific knowledge of health care professionals should feature methodological diversity if they are to enhance health care professionals' interest in delirium and highlight the fundamental contributions they make to the prevention, diagnosis, and treatment of delirium. Educational interventions should also take into account the multidimensional contextual factors that can have massive impacts on the relevant mode of action as well as the responses of health care professionals in nursing homes. The identification of delirium in residents is a fundamental responsibility for nursing home staff. Trial registration: This review has been registered at Open Science Framework https://doi.org/10.17605/OSF.IO/6ZKM3 [ABSTRACT FROM AUTHOR]

Purpose: Given the complex nature of integrated care systems (ICSs), the geographical spread and the large number of organisations involved in partnership delivery, the importance of leadership cannot be overstated. This paper aims to present novel findings from a rapid realist review of ICS leadership in England. The overall review question was: how does leadership in ICSs work, for whom and in what circumstances? Design/methodology/approach: Development of initial programme theories and associated context–mechanism–outcome configurations (CMOCs) were supported by the theory-gleaning activities of a review of ICS strategies and guidance documents, a scoping review of the literature and interviews with key informants. A refined programme theory was then developed by testing these CMOCs against empirical data published in academic literature. Following screening and testing, six CMOCs were extracted from 18 documents. The study design, conduct and reporting were informed by the Realist And Metanarrative Evidence Syntheses: Evolving Standards (RAMESES) training materials (Wong et al., 2013). Findings: The review informed four programme theories explaining that leadership in ICSs works when ICS leaders hold themselves and others to account for improving population health, a sense of purpose is fostered through a clear vision, partners across the system are engaged in problem ownership and relationships are built at all levels of the system. Research limitations/implications: Despite being a rigorous and comprehensive investigation, stakeholder input was limited to one ICS, potentially restricting insights from varied geographical contexts. In addition, the recent establishment of ICSs meant limited literature availability, with few empirical studies conducted. Although this emphasises the importance and originality of the research, this scarcity posed challenges in extracting and applying certain programme theory elements, particularly context. Originality/value: This review will be of relevance to academics and health-care leaders within ICSs in England, offering critical insights into ICS leadership, integrating diverse evidence to develop new evidence-based recommendations, filling a gap in the current literature and informing leadership practice and health-care systems. [ABSTRACT FROM AUTHOR]

Abstract Background Delirium is a neuropathological syndrome that is characterised by fluctuating impairments in attention, cognitive performance, and consciousness. Since delirium represents a medical emergency, it can be associated with adverse clinical and economic outcomes. Although nursing home residents face a high risk of developing delirium, health care professionals in this field appear to have limited knowledge of delirium despite the critical role they play in the prevention, diagnosis, and treatment of delirium in nursing homes. Objective The purpose of this realist review is to develop an initial programme theory with the goal of understanding how, why, and under what circumstances educational interventions can improve the delirium-specific knowledge of health care professionals in nursing homes. Methods This realist review was conducted in accordance with the RAMESES (Realist And Meta-narrative Evidence Synthesis: and Evolving Standards) guidelines and includes the following steps: (1) search strategy and literature review; (2) study selection and assessment; (3) data extraction; (4) data synthesis; and (5) development of an initial programme theory. It also included stakeholder discussions with health care professionals recruited from nursing home care, which focused on their experiences with delirium. Results From a set of 1703 initially identified publications, ten publications were included in this realist review. Based on these publications, context-mechanism-outcome configurations were developed; these configurations pertained to (1) management support, (2) cognitive impairments among residents, (3) familiarity with residents, (4) participatory intervention development, (5) practical application, (6) case scenarios, (7) support from experts and (8) relevance of communication. Conclusions Educational interventions aimed at improving the delirium-specific knowledge of health care professionals should feature methodological diversity if they are to enhance health care professionals’ interest in delirium and highlight the fundamental contributions they make to the prevention, diagnosis, and treatment of delirium. Educational interventions should also take into account the multidimensional contextual factors that can have massive impacts on the relevant mode of action as well as the responses of health care professionals in nursing homes. The identification of delirium in residents is a fundamental responsibility for nursing home staff. Trial registration This review has been registered at Open Science Framework https://doi.org/10.17605/OSF.IO/6ZKM3

The evaluation of the effects of architecture and design in psychiatric hospitals primarily focuses on final outcomes, such as disease progression, and is made from the perspective of evidence-based medicine. Meanwhile, the evidence-informed, realist approach addresses how the intervention works. Understanding the underlying action mechanisms of the intervention is needed to facilitate its scaling-up and adaptation in new environments. This umbrella review reports in which ways architecture and design have an effect on patients' and staff experience in inpatient psychiatric hospital. The search was constructed around three key concepts (psychiatric hospital, design, and staff and patient outcomes) and was conducted across three reference databases (Embase, Medline, and PsychINFO). Academic and gray literature was analyzed. Information on design and architectural features in psychiatric hospitals, their effects on patients and staff experience, and the acting mechanisms enabling these effects were extracted. From 951 original references, 14 full texts were included in the analysis. Design and architectural features (e.g., aesthetic appeal of places, home-like environment) in psychiatric hospitals address patients' stress, boost social interaction, foster patients' autonomy and feelings of control, ensure respect for patient's privacy and dignity, and prevent under-and overstimulation. Using theory-driven evaluation may facilitate future hospital renovation and the evaluation of its effect. [ABSTRACT FROM AUTHOR]

Abstract Background Health is increasingly affected by multiple types of crises. Community engagement is recognised as being a critical element in successful crisis response, and a number of conceptual frameworks and global guideline documents have been produced. However, little is known about the usefulness of such documents and whether they contain sufficient information to guide effective community engagement in crisis response. We undertake a scoping review to examine the usefulness of conceptual literature and official guidelines on community engagement in crisis response using a realist-informed analysis [exploring contexts, mechanisms, and outcomes(CMOs)]. Specifically, we assess the extent to which sufficient detail is provided on specific health crisis contexts, the range of mechanisms (actions) that are developed and employed to engage communities in crisis response and the outcomes achieved. We also consider the extent of analysis of interactions between the mechanisms and contexts which can explain whether successful outcomes are achieved or not. Scope and findings We retained 30 documents from a total of 10,780 initially identified. Our analysis found that available evidence on context, mechanism and outcomes on community engagement in crisis response, or some of their elements, was promising, but few documents provided details on all three and even fewer were able to show evidence of the interactions between these categories, thus leaving gaps in understanding how to successfully engage communities in crisis response to secure impactful outcomes. There is evidence that involving community members in all the steps of response increases community resilience and helps to build trust. Consistent communication with the communities in time of crisis is the key for effective responses and helps to improve health indicators by avoiding preventable deaths. Conclusions Our analysis confirms the complexity of successful community engagement and the need for strategies that help to deal with this complexity to achieve good health outcomes. Further primary research is needed to answer questions of how and why specific mechanisms, in particular contexts, can lead to positive outcomes, including what works and what does not work and how to measure these processes.

Background : Health research capacity strengthening (HRCS) has been deemed as a complex, multifaceted, and dynamic activity. Despite this, most studies that assess the effectiveness of health research capacity strengthening programmes have not employed complexity-aware approaches and therefore, evidence on how and why such programmes work across different contexts is underdeveloped. This realist study seeks to elicit the initial programme theories (IPTs) that describe how and why the 'Developing Excellence in Leadership, Training and Science Africa' (DELTAS Africa) programme – one of the flagship research capacity strengthening programmes in Africa – works to generate research capacity outcomes specifically in the participating African universities. Methods and Analysis : A realist review of the DELTAS Africa programme documents, and relevant published papers that report on similar research capacity interventions will be carried out. This will help to both identify the outcome pathways and underlying assumptions of the DELTAS Africa programme, as well as tacit theories as postulated by other researchers. The review evidence will inform the drafting of the initial programme theories (IPTs). Interviews with the DELTAS Africa programme designing team will be conducted using a realist interviewing technique to unearth ontologically deeper insights on context, mechanism, and outcomes. Using the realist context-mechanism-outcome configurational maps, we will identify how contexts (i.e., within the African universities) shape mechanisms (the processes, reasoning, or behaviours triggered by the HRCS activities) through which the programme brings about an outcome at institutional level. Conclusion: The initial programme theories will describe how and why health research capacity strengthening works, for whom and under what circumstances across the participating African universities. The programme theories will provide policy-relevant insights on the generative causal mechanisms of HRCS; evidence that is critically needed to inform the design, implementation, and evaluation of HRCS initiatives. [ABSTRACT FROM AUTHOR]

Background: Health is increasingly affected by multiple types of crises. Community engagement is recognised as being a critical element in successful crisis response, and a number of conceptual frameworks and global guideline documents have been produced. However, little is known about the usefulness of such documents and whether they contain sufficient information to guide effective community engagement in crisis response. We undertake a scoping review to examine the usefulness of conceptual literature and official guidelines on community engagement in crisis response using a realist-informed analysis [exploring contexts, mechanisms, and outcomes(CMOs)]. Specifically, we assess the extent to which sufficient detail is provided on specific health crisis contexts, the range of mechanisms (actions) that are developed and employed to engage communities in crisis response and the outcomes achieved. We also consider the extent of analysis of interactions between the mechanisms and contexts which can explain whether successful outcomes are achieved or not. Scope and findings: We retained 30 documents from a total of 10,780 initially identified. Our analysis found that available evidence on context, mechanism and outcomes on community engagement in crisis response, or some of their elements, was promising, but few documents provided details on all three and even fewer were able to show evidence of the interactions between these categories, thus leaving gaps in understanding how to successfully engage communities in crisis response to secure impactful outcomes. There is evidence that involving community members in all the steps of response increases community resilience and helps to build trust. Consistent communication with the communities in time of crisis is the key for effective responses and helps to improve health indicators by avoiding preventable deaths. Conclusions: Our analysis confirms the complexity of successful community engagement and the need for strategies that help to deal with this complexity to achieve good health outcomes. Further primary research is needed to answer questions of how and why specific mechanisms, in particular contexts, can lead to positive outcomes, including what works and what does not work and how to measure these processes. [ABSTRACT FROM AUTHOR]

Aims To understand for whom, under what conditions, and how an integrated approach to atrial fibrillation (AF) service delivery works (or does not work). Methods and results A realist review of integrated approaches to AF service delivery for adult populations aged ≥18 years. An expert panel developed an initial programme theory, searched and screened literature from four databases until October 2022, extracted and synthesized data using realist techniques to create context–mechanism–outcome configurations for integrated approaches to AF service, and developed an integrated approach refined programme theory. A total of 5433 documents were screened and 39 included. The refined programme theory included five context–mechanism–outcome configurations for how clinical and system-wide outcomes are affected by the way integrated approaches to AF service delivery are designed and delivered. This review identifies core mechanisms underpinning the already known fundamental components of integrated care. This includes having a central coordinator responsible for service organization to provide continuity of care across primary and secondary care ensuring services are patient centred. Additionally, a fifth pillar, lifestyle and risk factor reduction, should be recognized within an AF care pathway. Conclusion It is evident from our provisional theory that numerous factors need to interlink and interact over time to generate a successfully integrated model of care in AF. Stakeholders should embrace this complexity and acknowledge that the learnings from this review are integral to shaping future service delivery in the face of an aging population and increased prevalence of AF. [ABSTRACT FROM AUTHOR]

We provide a realist review of product launches for Large Language Models (LLMs) in the healthcare industry. Through a systematic search in the Factiva database and the application of a Context, Intervention, Mechanism, Outcome (CIMO) framework, we identified and assessed 23 significant records, representing 17 unique product launches between January 2023 and February 2024. This manuscript contributes to the emerging literature on health LLMs and Generative AI by focusing on actual product launches of healthcare LLM products-a less explored aspect than theoretical potential. Our use of the CIMO framework to dissect the application of LLMs in healthcare adds a fresh perspective to the discourse, helping to understand the outcomes and the mechanisms driving these outcomes. Among the LLM application themes that emerged from our review, we focused on four primary themes: Clinical Care and Health Services, Healthcare Documentation and Data Management, Insurance and Healthcare Financial Services, and Nutrition, Wellness, and Chronic Disease Management. Our findings demonstrate LLMs' potential to transform patient care through personalization and efficiency, highlighting their role in enhancing healthcare delivery systems, reducing administrative burdens, and supporting decision-making processes. Specific implementations by health start-ups and large tech firms discussed in this paper underscore the immediate impact of these technologies on patient care and healthcare management. This realist model offers a new perspective on LLMs within healthcare, providing an empirical basis for future technological integration and policy development in digital health. Our study contributes to understanding how LLMs operate within the healthcare sector, emphasizing the importance of context in their successful deployment and serving as a strategic guide for future AI integration in sensitive healthcare services. [ABSTRACT FROM AUTHOR]

Aim: To identify strategies that develop clinical nursing leadership competencies among staff nurses, and to explain the contextual elements and mechanisms that underpin the development of clinical nursing leadership competencies. Design: Realist review according to the Realist and Meta-narrative Evidence Syntheses—Evolving Standards (RAMESES). Data Sources: PubMed, Embase, CINAHL, Web of Science, Wiley Online Library, PsycInfo and ProQuest were searched from January 2000 until October 2022. Review Methods: Three iterative phases: (1) development of initial programme theory, (2) structured searches for relevant published and grey literature and (3) data synthesis and interpretation by researchers and theory triangulation, and discussions within the research group. Results: Multiple context–mechanism–outcome configurations were extracted from 10 reports that explain how, under what circumstances and why strategies can facilitate (or discourage) staff nurses to act as clinical leaders. Reports were both quantitative and qualitative in design, originating from English-speaking countries only. Conclusions: A logic model was developed and suggests four contexts and five mechanisms underlying the development of clinical nursing leadership. Growth in clinical nursing leadership was mainly experienced through experiential learning, which was enhanced by a supportive relationship with a coach or mentor, the use of reflective practices and modelling from other leaders. Furthermore, a supportive work environment triggers ownership, confidence and motivation, and thereby growth in clinical nursing leadership competencies. Impact: Fostering competencies for clinical leadership among staff nurses requires multifaceted strategies. Strategies are successful if, and only if, they combine learning by doing, by knowing and by observing, and establish a responsive work environment. Hospital policy should ensure that staff nurses have access to reciprocal relationships with role models or a coach. In order to grow as clinical nurse leader, ownership and self-reflection on own leadership behaviour need to be facilitated. [ABSTRACT FROM AUTHOR]

Background This protocol describes a realist review exploring the problem of “missingness” in healthcare, defined as the repeated tendency not to take up offers of care that has a negative impact on the person and their life chances. More specifically, the review looks at the phenomenon of patients missing multiple appointments in primary care in the UK – at the causal factors that influence how patients come to be “missing” in this way, and what interventions might support uptake and “presence” in healthcare. Background research informing this project suggests that a high rate of missed appointments predicted high premature death rates, and patients were more likely to have multiple long-term health conditions and experience significant socioeconomic disadvantage. Most research in this field focuses on population- or service-level characteristics of patients who miss appointments, often making no distinction between causes of single missed appointments and of multiple missed appointments. There have therefore been no interventions for ‘missingness’, accounting for the complex life circumstances or common mechanisms that cause people to repeatedly miss appointments. Methods We use a realist review approach to explore what causes missingness - and what might prevent or address it - for whom, and in what circumstances. The review uses an iterative approach of database searching, citation-tracking and sourcing grey literature, with selected articles providing insight into the causal dynamics underpinning missed appointments and the interventions designed to address them. Discussion The findings of this review will be combined with the findings of a qualitative empirical study and the contributions of a Stakeholder Advisory Group (STAG) to inform the development of a programme theory that seeks to explain how missingness occurs, whom it affects and under what circumstances. This will be used to develop a complex intervention to address multiple missed appointments in primary care. PROSPERO registration CRD42022346006

Background Unprofessional behaviour in healthcare systems can negatively impact staff well-being, patient safety and organisational costs. Unprofessional behaviour encompasses a range of behaviours, including incivility, microaggressions, harassment and bullying. Despite efforts to combat unprofessional behaviour in healthcare settings, it remains prevalent. Interventions to reduce unprofessional behaviour in health care have been conducted – but how and why they may work is unclear. Given the complexity of the issue, a realist review methodology is an ideal approach to examining unprofessional behaviour in healthcare systems. Aim To improve context-specific understanding of how, why and in what circumstances unprofessional behaviours between staff in acute healthcare settings occur and evidence of strategies implemented to mitigate, manage and prevent them. Methods Realist synthesis methodology consistent with realist and meta-narrative evidence syntheses: evolving standards reporting guidelines. Data sources Literature sources for building initial theories were identified from the original proposal and from informal searches of various websites. For theory refinement, we conducted systematic and purposive searches for peer-reviewed literature on databases such as EMBASE, Cumulative Index to Nursing and Allied Health Literature and MEDLINE databases as well as for grey literature. Searches were conducted iteratively from November 2021 to December 2022. Results Initial theory-building drew on 38 sources. Searches resulted in 2878 titles and abstracts. In total, 148 sources were included in the review. Terminology and definitions used for unprofessional behaviours were inconsistent. This may present issues for policy and practice when trying to identify and address unprofessional behaviour. Contributors of unprofessional behaviour can be categorised into four areas: (1) workplace disempowerment, (2) organisational uncertainty, confusion and stress, (3) (lack of) social cohesion and (4) enablement of harmful cultures that tolerate unprofessional behaviours. Those at most risk of experiencing unprofessional behaviour are staff from a minoritised background. We identified 42 interventions in the literature to address unprofessional behaviour. These spanned five types: (1) single session (i.e. one-off), (2) multiple sessions, (3) single or multiple sessions combined with other actions (e.g. training session plus a code of conduct), (4) professional accountability and reporting interventions and (5) structured culture-change interventions. We identified 42 reports of interventions, with none conducted in the United Kingdom. Of these, 29 interventions were evaluated, with the majority (n = 23) reporting some measure of effectiveness. Interventions drew on 13 types of behaviour-change strategy designed to, for example: change social norms, improve awareness of unprofessional behaviour, or redesign the workplace. Interventions were impacted by 12 key dynamics, including focusing on individuals, lack of trust in management and non-existent logic models. Conclusions Workplace disempowerment and organisational barriers are primary contributors to unprofessional behaviour. However, interventions predominantly focus on individual education or training without addressing systemic, organisational issues. Effectiveness of interventions to improve staff well-being or patient safety is uncertain. We provide 12 key dynamics and 15 implementation principles to guide organisations. Future work Interventions need to: (1) be tested in a United Kingdom context, (2) draw on behavioural science principles and (3) target systemic, organisational issues. Limitations This review focuses on interpersonal staff-to-staff unprofessional behaviour, in acute healthcare settings only and does not include non-intervention literature outside the United Kingdom or outside of health care. Study registration This study was prospectively registered on PROSPERO CRD42021255490. The record is available from: www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR131606) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 25. See the NIHR Funding and Awards website for further award information. Plain language summary For this study, we asked: how, why and in what situations can unprofessional behaviour between healthcare staff working in acute care (usually hospitals) be reduced, managed and prevented? We wanted to research how people understand unprofessional behaviour, explore the circumstances leading to unprofessional behaviour and understand how existing approaches to addressing unprofessional behaviour worked (or did not work) across staff groups and acute healthcare organisations. We used a literature review method called a ‘realist review’, which differs from other review methods. A realist review focuses on understanding not only if interventions work but how and why they work, and for whom. This allowed us to analyse a wider range of relevant international literature – not only academic papers. We found 148 sources, which were relevant either because they described unprofessional behaviour or because they provided information on how to address unprofessional behaviour. Definitions of unprofessional behaviour varied, making it difficult to settle on one description. For example, unprofessional behaviour may involve incivility, bullying, harassment and/or microaggressions. We examined what might contribute to unprofessional behaviour and identified factors including uncertainty in the working environment. We found no United Kingdom-based interventions and only one from the United States of America that sought to reduce unprofessional behaviour towards minority groups. Strategies often tried to encourage staff to speak up, provide ways to report unprofessional behaviour or set social standards of behaviour. We also identified factors that may make it challenging for organisations to successfully select, implement and evaluate an intervention to address unprofessional behaviour. We recommend a system-wide approach to addressing unprofessional behaviour, including assessing the context and then implementing multiple approaches over a long time (rather than just once), because they are likely to have greater impact on changing culture. We are producing an implementation guide to support this process. Interventions need to enhance staff ability to feel safe at work, work effectively and support those more likely to experience unprofessional behaviour. Scientific summary Background Unprofessional behaviour (UB) in healthcare systems can have significant negative impact on staff well-being, patient safety and organisational costs. UB encompasses a range of behaviours – such as incivility, microaggressions, harassment and bullying – that remain prevalent in healthcare systems around the world. In 2022, Workforce Race Equality Standard data indicated that the percentage of staff experiencing UB from colleagues in the National Health Service (NHS) was 22.5% for white respondents and 27.6% for ethnic minority respondents. Unprofessional behaviour can impact negatively on the psychological well-being of both targets and witnesses. This may result in higher rates of staff sick leave and turnover. Conservative estimates suggest that damages from bullying alone cost the NHS approximately £2.28 billion per annum. The negative impacts of UB also extend to patient safety, which can be compromised if staff members who are victims of UB are unable to speak up – leading to medical errors and poor patient outcomes. Managing, mitigating and preventing UB can assist in addressing the increasing workforce crisis in health care and declining rates of patient satisfaction, as well as improve patient outcomes. Extant literature has focused predominantly on bullying. Literature exploring the implementation and effectiveness of interventions designed to reduce UB is often underpinned by the belief that the more people know about UB – including how to recognise and challenge it – the more likely it is to be reduced. However, this is very challenging to do and places the responsibility on individuals. Interventions to reduce UB in health care may need to be tailored to specific contexts and may need to go beyond increasing awareness and assertiveness to address deeper systemic issues. This is a complex, widespread and urgent issue that is heavily reliant on context and has negative impact on staff well-being, patient safety and organisational costs. A realist review methodology may be an ideal method for examining the interacting components of UB between staff in acute healthcare settings. Objectives This review aimed to: Conceptualise and refine terminology, by mapping behaviours defined as unprofessional to understand differences and similarities between terms referring to UB (e.g. incivility, bullying, microaggressions) and how these terms are used by different professional groups in acute healthcare settings. Develop and refine context, mechanism and outcome configurations (CMOCs), to understand the causes and contexts of UB, the mechanisms that trigger different behaviours, and the outcomes on staff, patients and the wider system of health care. Identify strategies designed to mitigate, manage and prevent UB and explore how, why and in what circumstances these work and whom they benefit. Produce recommendations and comprehensive resources that support the tailoring, UB and their impacts. Methods Realist reviews seek to understand why an intervention may work in one context but not another. This involves building an understanding of how various contextual factors affect the activation of mechanisms (i.e. changes in participant reasoning) to produce various outcomes. Often these relationships are not well articulated in the literature, so realist research draws on retroductive reasoning to unpack this information, drawing on ‘hunches’ as well as inductive and deductive reasoning to ask, ‘why do things appear as they do?’. The aim of this is to build CMOCs that underpin programme theories and to build an understanding of how contributors drive UB and how different strategies may be used in different contexts to address UB. Realist reviews also enable grey literature to be drawn upon. Our review had six main stages: Formulating initial programme theories drawing on informal literature searches of NHS England, The King’s Fund, British Medical Association, Health and Care Professions Council and NHS Employers websites, as well as literature already known to the study team and in the study protocol. This comprised 38 studies after screening for relevancy and rigour. Performing systematic and purposive searches for peer-reviewed literature on EMBASE, Cumulative Index to Nursing and Allied Health Literature and MEDLINE databases as well as grey literature on Health Management Information Consortium, National Institute for Health and Care Excellence Evidence Search, Patient Safety Network, Google and Google Scholar databases, and NHS Employers and NHS Health Education England websites. Searches were conducted in November 2021, then expanded to include United States of America (USA) literature in August 2022 and updated in December 2022. Selecting appropriate documents while considering rigour and relevance. The above searches identified 5967 total titles and abstracts across all databases after deduplication. We applied strict conceptual-richness criteria to include the most relevant and useful literature. Searching and screening in November 2022 resulted in 64 included sources. Additional searching in August 2022 resulted in the addition of 36 sources; the December 2022 search added a further 10 sources. This meant that 110 sources were used for theory refinement (step 2 onwards) while 38 were used in step 1 for initial theory generation, with 148 sources included in total. Extracting data using NVivo 12 software (QSR International, Warrington, UK) using a mix of inductive and deductive code creation. Key excerpts were also extracted separately into a Word document so that patterns across literature could be collated and investigated. Characteristics of included sources were extracted into an Excel spreadsheet. Synthesising data with the aid of the data categorised within NVivo, where data were coded according to UB definitions, contributors, interventions, and strategies. This enabled us to compare and contrast, reconcile, adjudicate and consolidate different sources of evidence to build an understanding of which contexts affect how interventions work, and why and how various UB contributors may work. Refining and testing initial programme theories against additional identified literature. At this stage, CMOCs and programme theories were either confirmed, refuted or added to our step 2 analysis. Stakeholder feedback was also incorporated at five points in the project through the following process: (1) record theory presentation to stakeholders for refinement, (2) record suggested alterations, (3) perform purposive searching to sense-check non-aligned suggestions, (4) discuss discrepancies within the team to determine consensus and action taken and (5) represent changes made to stakeholders/group for further sense-checking. Results Terminology We explored the use of UB-related terminology in the literature and found that forms of UB can be placed on a spectrum according to how specific they were, whether they were visible to the organisation or their targets, and whether they required a hierarchical structure to occur. We also found that there is little agreement within the literature about how to define dimensions of UB. This may cause confusion and make it challenging to synthesise the literature on this topic. In practice, the lack of a shared definition or understanding of UB could lead to difficulties in understanding its prevalence, reduce the likelihood of individuals reporting UB and hinder the effectiveness of interventions to address UB. Contributors to unprofessional behaviour We explored how UBs are developed and experienced by staff in acute healthcare settings. We were able to create a comprehensive programme theory that categorised contributors into four aspects: Workplace disempowerment: factors such as hierarchy can lead to people becoming an easier target for instigators, foster a sense of unfairness and cause a reduction in psychological safety, which can all facilitate propagation of UB. Organisational uncertainty, confusion and stress: factors such as organisational change or a lack of resources contribute to increased instances and experiences of UB. When staff are more likely to experience a lack of control in their day-to-day work, this can exacerbate pre-existing stress, create challenges in building relationships and worsen UB. Social cohesion: a lack of social cohesion among colleagues – including reduced ability to communicate effectively (e.g. due to stress and pressure as outlined above) – can lead to the undermining of social relationships between staff that would otherwise enable a greater ability to cope with and collectively address UB. Enablement of harmful cultures that tolerate UB: leadership and organisational culture can enable, model or tacitly permit UB. This can create an environment in which UB becomes part of an organisation’s fabric and the social norm. Our programme theory depicts how these contributors interact and, in so doing, identifies the many overlapping mechanisms across each area and type of UB. Outcomes of unprofessional behaviour on staff, patients and organisations Our review identified that UB is experienced more frequently by people from a minoritised background. More broadly, we also highlighted impacts on staff psychological well-being as a result of UB. Intra-professional forms of UB were found to be more harmful to well-being than interprofessional UB, perhaps due to the differing strengths of social ties within and between groups. We identified that the economic impact of UB to organisations is significant. We were able to create a programme theory regarding how the presence of UB can impact staff and thereby patient safety through various mechanisms, such as inability to communicate and loss of learning. Interventions and strategies to reduce or mitigate unprofessional behaviour We identified 42 interventions that sought to reduce UB between acute healthcare staff. The majority were developed and implemented in the USA (n = 30), with none reported from the United Kingdom (UK). The interventions included single-session or multiple-session designs, combined with other actions such as codes of conduct, professional accountability and reporting interventions and structured culture-change interventions. However, most interventions did not draw on theoretical frameworks to inform their design, report theoretical underpinnings, provide an understanding of why and how the intervention is expected to work or report any comprehensive long-term evaluation. Only one intervention targeted UB impacting minoritised groups (racism). Of the 29 studies that assessed intervention effectiveness, the majority (n = 23) reported positive results – but this depended on the outcome measures these studies chose. Interventions drawing on single-session designs were reported as less effective compared to multiple-session interventions. There was a trend towards more complex interventions reporting greater effectiveness. Interventions can have degrees of flexibility, allowing for variation as to which components or strategies participants are exposed to. However, this makes them more resource-intensive to implement and harder to evaluate. We also found (via information from our stakeholder group) that there are interventions taking place in practice that are not adequately reported in the literature, making it difficult to assess their effectiveness. Finally, we did not include interventions to improve civility or professionalism alone, which may also address some contributors to UB. The review identified 13 categories of strategies to reduce UB. These strategies included direct or indirect approaches to instigators (such as informal or disciplinary actions), improving awareness and knowledge of UB for all staff, improving teamwork, setting social norms through leadership role-modelling and code of conduct, and reporting and escalation systems. Improving leadership competence and empathy, workplace redesign and changing recruitment and dismissal processes were also identified, as were external pressures on organisations and strategies to aid implementation. Overall, the strategies highlighted the importance of addressing UB from multiple angles and levels (individual, team, organisational and societal), involving all staff and management levels, and creating a culture of respect and accountability. When do unprofessional behaviour interventions and strategies work? The study identified 12 key dynamics that can be summarised into four broad categories helping to optimise the effectiveness of interventions aimed at reducing UB in healthcare settings. Firstly, if interventions can focus on systemic issues such as organisational uncertainty, this is likely to be more effective than addressing problematic individuals. Secondly, seeking ways to build trust with management and other senior staff members is crucial. This relies on interventions being seen as authentic and leaders being role models. Thirdly, interventions need to be focused on an identified target audience and ensure they are both inclusive and fair. Lastly, there are trade-offs in intervention design that must be considered – that is, whether to build interventions in a theory-based or practice-first manner or to focus on effectiveness or ability to evaluate. For example, interventions encouraging bystanders to intervene are important for culture change but may lead to moral injury if individuals do not feel capable of intervening. Findings also emphasised the importance of maintaining a focus on why reducing UB is important (to improve patient safety and staff psychological well-being), encouraging triage of messages in systems that enable anonymous reporting and comprehensive evaluation of interventions to better understand what works, where and why. We identified a further 15 key implementation principles that may help the effectiveness, sustainability and perception of UB interventions in healthcare organisations. Examples include: covering a broad section of the organisation, co-creation with staff, dedicated staff to lead the work, skilled facilitation, multiple strategies, ongoing evaluation, maximising visibility, assessing the organisational landscape before implementation, early intervention, maximising existing opportunities such as onboarding processes to establish social norms during induction, manager engagement, cultivating perceptions of justice, avoiding mixing of hierarchies in session-based interventions, and avoiding simply moving the target or instigator of UB. Conclusions Unprofessional behaviour is a pervasive issue currently poorly addressed by existing interventions. We identified many contributors to UB, most of which relate to worker disempowerment and organisational barriers. However, most existing interventions do not address these systemic, organisational contributors to UB, instead relying on education or training workshops to boost individual knowledge or awareness, identify problematic individuals or improve UB targets’ ability to speak up. Such approaches may reduce UB prevalence; however, it is unclear whether this has lasting positive impact or improves staff psychological well-being and patient safety. Future interventions would benefit from being designed and tested in UK settings, drawing on contemporary behavioural science principles to help inform their design, and focusing on systemic issues within organisations. We provide 12 key dynamics and 15 implementation principles to guide organisations. Study registration This study was prospectively registered on PROSPERO CRD42021255490. The record is available from: www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR131606) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 25. See the NIHR Funding and Awards website for further award information.

Background Signposting typically refers to an informal process that involves giving information to patients to enable them to access external services and support. It is perceived to reduce demand on primary care and other urgent care services. Methods This focused realist review was conducted rapidly within time constraints. Searches to identify theory were undertaken on MEDLINE, Cumulative Index to Nursing and Allied Health Literature and Social Sciences Citation Index in June 2022 for research published in English from 2016. We selected 22 publications and extracted programme theories from these to develop three priority questions: Question 1: What do people with health and social care needs require from a signposting service to believe it is valuable? Question 2: What resources do providers require to confidently deliver an effective signposting service? Question 3: Under what circumstances should commissioners commission generic or specialist signposting services? Purposive searching was conducted to find a rich sample of studies. UK studies were prioritised to optimise the applicability of synthesis findings. Results The review included 27 items, 4 reviews and 23 studies, a mix of qualitative, evaluations and case studies. Service users value a joined-up response that helps them to navigate the available resources. Key features include an understanding of their needs, suggestion of different options and a summary of recommended actions. Only a small number of service user needs are met by signposting services alone; people with complex health and social care needs often require extended input and time. Front-line providers of signposting services require appropriate training, ongoing support and supervision, good knowledge of relevant and available activities and an ability to match service users to appropriate resources. Front-line providers need to offer a flexible response targeted at user needs. Commissioned signposting services in England (no studies from Scotland, Wales and Northern Ireland) are highly diverse in terms of client groups, staff delivering the service, referral routes and role descriptions. A lack of service evaluation poses a potential barrier to effective commissioning. A shortage of available services in the voluntary and community sector may limit the effectiveness of signposting services. Commissioners should ensure that referrals target intensive support at patients most likely to benefit in the longer term. Conclusions Signposting services need greater clarity of roles and service expectations to facilitate evaluation. Users with complex health and social care needs require intensive, repeat support from specialist services equipped with specific knowledge and situational understanding. A tension persists between efficient (transactional) service provision with brief referral and effective (relational) service provision, underpinned by competing narratives. Do signposting services represent ‘diversion of unwanted demand from primary care/urgent care services’ or ‘improved quality of care through a joined-up response by health, social care and community/voluntary services’? Limitations This realist review was conducted within a tight time frame with a potential impact on methodology; for example, the use of purposive searching may have resulted in omission of relevant evidence. Future work Signposting services require service evaluation and consideration of the issue of diversity. Study registration This study is registered as PROSPERO CRD42022348200. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130588) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 26. See the NIHR Funding and Awards website for further award information. Plain language summary Signposting points people to information, help or advice that they should find useful. Signposting can be delivered face to face, by phone, or virtually, by technology. This review of research brings together what is already known. We have not collected any data ourselves. The review uses realist synthesis. This method tries to understand the whys and ways (the mechanisms and theories) of how things work (or do not work!). It goes beyond whether something works (is effective). It tries to explain why something might work for some people but not others. For example, why an approach may not be helpful for people with disabilities, why it might work in some places but not others and exactly what leads to what effects (what are the ‘key ingredients’). The report answers the following three questions: What do people with health and social care needs require from a signposting service to enable them to believe it is a valuable and useful service? What resources do people providing signposting services require to ensure that they can confidently provide effective signposting services? How can commissioners/funders specify, monitor and evaluate signposting services (generic or specific) to optimise value for money and outcomes for service users? Specifically, do any factors favour funding general over specialist services and vice versa? The diversity of signposting services within health or across social and community services, including voluntary services, makes them difficult to evaluate and compare. Within each service, different people undertake signposting roles: from general practitioners, practice nurses or receptionist to a standalone signposting role, each for a different purpose and intensity. Only a small number of service users potentially benefit from signposting-only services. Many service users have complex health and social care needs and, therefore, need different support extended over a longer time. Scientific summary Introduction Signposting is an informal process that involves giving information to patients to enable them to access external, usually non-clinical, services and support (Harris E, Barker C, Burton K, Lucock M, Astin F. Self-management support activities in primary care: a qualitative study to compare provision across common health problems. Patient Educ Couns 2020;103:2532–9. https://doi.org/10.1016/j.pec.2020.07.003). Signposting also includes self-referral, which often requires patients to contact health and support services by telephone or the internet. Signposting may also take place within clinical interactions or within more extensive social prescribing. Methods A protocol was developed that received input from commissioning and patient and public involvement representatives. This study used realist synthesis to answer three key questions. Information about each is provided below. Initial searches to identify theory were conducted on MEDLINE, Cumulative Index to Nursing and Allied Health Literature and the Social Sciences Citation Index for research published in English from 2016 to current in June 2022. The broad search retrieved 716 unique references and the focused search retrieved 31 references. One reviewer (AB) reviewed the results of the focused and then the broader search and selected 22 studies to use for theory identification. The three reviewers divided these studies between them and extracted initial programme theories in the form of context–mechanism–outcome (CMO) configurations: IF (context) – THEN (mechanism) – LEADING TO (outcome) statements. Extracted data related to IF (WHO? DO WHAT? FOR WHOM?) THEN (THE RESPONSE IS) LEADING TO (WHAT OUTCOMES? FOR WHOM?) followed by the reference source. The team prioritised complete (i.e. three-element) CMO configurations, whenever possible. A limited number of two-element CMO configurations were included when they provided unique insights, for completeness. The signposting programme theories identified are provided in the report. All CMO configurations were checked by a single reviewer experienced in realist synthesis to ensure that they were complete, in a common format, and that the agency (i.e. who was the agent for action) could be identified. The review team then met to discuss the initial programme theories and identified a need to address three complementary perspectives: those of the service user, service provider and commissioner. Identification of programme theory led to the development of a priority question constructed to match each perspective. Question 1 (value and usefulness of signposting) considers the service user perspective: What do people with health and social care needs require from a signposting service to believe it is a valuable and useful service? Question 2 (required resources) considers the perspective of the front-line provider of the signposting service: What resources (training, directories/databases, credible and high-quality services for referral) do providers of front-line signposting services require to confidently deliver effective signposting services? Question 3 (specification, monitoring and evaluation) considers the viewpoint of the commissioner/funder: Under what circumstances should commissioners commission generic or specialist signposting services? Purposive searching was undertaken for each question to find a sample of rich relevant studies. The searching included forward and backward citation searching of relevant studies from the theories searches, focused searches and searching for UK initiatives. Where possible, we predominantly included UK studies to optimise the usefulness of the synthesis findings with a UK context and included studies based on richness, rigour and relevance. All documents with signposting in the title were included along with any qualitative studies of social prescribing and care navigation with multiple occurrences of ‘signposting’ in the full text. Studies from other comparable countries were included where relevant. Several studies supplied data to address more than one question and were therefore included in multiple sections. Formal quality appraisal was not undertaken. An online meeting of the Health Service and Delivery Research Sheffield Evidence Synthesis Centre Public Advisory Group met to provide input into the review. The group were asked about their understanding of the term signposting and their experiences of accessing signposting services. Question 1: What do people with health and social care needs require from a signposting service to believe it is a valuable and useful service? (Service user perspective) Findings for Question 1 are organised under the four identified subquestions. A total of 19 items of evidence were reviewed including 4 reviews and 15 individual items reporting UK studies or service evaluations. The nature of the question meant that studies were mainly qualitative or mixed-methods studies with one quantitative study in the included evidence. Summary of findings for Question 1 (value and usefulness: service user perspective) Service users value a ‘linking’ or ‘joined-up’ response that helps them to navigate resources offered by different organisations and/or by different sectors and helps them to reach an appropriate destination. Key features from a service user viewpoint are an understanding of their needs, presentation of options (together with alternatives if required) and a summary of the recommended action to be taken. This needs to be supported by appropriate matching of opportunities to their needs and resourced provision and capacity so that they can pursue these opportunities. Above all, a signposting service must reduce the ‘patient burden’ encountered in contacts with formal health services when trying to pursue options and alternatives. A key consideration is whether signposting services are conceived to operate in isolation or whether they form the front end of an integrated pathway of care with multiple routes and outcomes. The needs of only a small proportion of those targeted by signposting services are met by signposting services alone. Where people with complex needs interact with signposting services, interaction may require extended time or multiple episodes. Alternatively, they may perceive that their needs were imperfectly or incompletely met by a brief intervention. Effective use of signposting, which requires a clear, and often detailed, understanding of service user needs, may operate against a programme theory that conceives them as an efficient brief intervention to divert service users away from formal health services towards wider resources in the community. Question 2: What resources (training, directories/databases, credible and high-quality services for referral) do providers of front-line signposting services require to confidently deliver effective signposting services? (Service provider perspective) For Question 2, a total of 14 items of evidence were reviewed including 1 review and 13 individual items reporting UK, USA or Canadian studies or service evaluations. The findings from the included studies are discussed within themes. Summary of findings for Question 2 (required resources: service provider perspective) Front-line providers of signposting services require appropriate training, ongoing support and supervision. Front-line providers of signposting services require good knowledge of relevant health, social care, community, voluntary or other agency activities and opportunities to which they feel empowered to refer. Front-line providers of signposting services need be able to match appropriate services or resources to the needs of a service user – this may take time, extensive interaction and the creation of trust over time. Front-line providers of signposting services need to provide a flexible response in order to meet very diverse levels and types of individual needs. Requirements may also differ according to differing levels of availability of complementary services (e.g. where separate health and social care signposting services coexist or not). For a signposting service to be considered useful, those providing signposting services must be confident that, even in times of resource constraint, sufficient appropriate, high-quality resources exist to which they can refer. Question 3: How can commissioners/funders specify, monitor and evaluate signposting services (generic or specific) to optimise value for money and outcomes for service users? Specifically, are there factors that favour funding of generic versus specialist services or vice versa? (Service commissioner/funder perspective) For Question 3, a total of four items of evidence were reviewed; data were extracted from a survey of Clinical Commissioning Groups in England; evaluations of a social prescribing service and a primary care diabetes care navigation service; and a qualitative study of a new care model in Child and Adolescent Mental Health Services. Commissioned signposting services in England (no studies from Wales and Northern Ireland) are highly diverse in terms of client groups, staff delivering the service, referral routes and how the role is described. Evaluation of services is uncommon and is a potential barrier to effective commissioning. Lack of availability of services in the voluntary and community sector may limit the effectiveness of signposting/care navigation in both primary and secondary care and their potential to reduce urgent care use and improve well-being in service users. Brief signposting interventions are sufficient for some service users. Others require intensive support to overcome barriers to engagement with either the care signposting/care navigation process or, subsequently, services to which they are referred. From the commissioner perspective, it is important that referral processes provide intensive support to those most likely to benefit in the longer term. Summary of integrated findings across the three perspectives (service user, service provider and service commissioner/funder) Clarity of roles and expectations is required within signposting services. Signposting services may operate within health or across social and community services including voluntary service provision. Those signposting may include this role within wider clinical [general practitioner (GP) or practice nurse] or administrative roles (receptionists), as one of many functions within tailored social prescribing or care navigation roles, or as a standalone signposting role. This makes evaluation and comparison challenging. Only a small number of service users potentially benefit from signposting-only services. Many users have complex health and social care needs that require intensive and repeated support. Specialist services demand greater empathy, knowledge and situational understanding and so are likely to extend beyond signposting. Service users and service providers need to develop a shared confidence in the signposting role. This requires good communication skills and training, backed up with resources, to firstly identify activities and opportunities and then for adequate levels of resource provision to enable them to be accessed and used. The tension between (1) efficient (transactional) service provision with brief referral and (2) effective (relational) service provision, requiring detailed understanding of individual service user needs, remains unreconciled. This tension is underpinned by competing narratives of ‘diversion of unwanted demand from primary care and other urgent care services’ and of ‘improved quality of care through a joined-up response that encompasses health, social care and community/voluntary services’. Conclusion Signposting services need to achieve greater clarity around roles and the expectations of the service to enable thorough evaluation. Evaluation and comparisons are challenging; signposting services which operate within health or across social and community services, including voluntary service provision, are diverse. The diversity of signposting roles and services makes evaluation and comparisons challenging. Within each service, roles may vary in function and intensity from a recognisable signposting function within a wider clinical (GP or practice nurse) or administrative role (receptionists) through one of many components within tailored social prescribing or care navigation roles to a standalone signposting role. Commissioners of services need to recognise that the complex health and social care needs of many service users require intensive and repeated support. Specialist services demand greater empathy, knowledge and situational understanding, and thus contact is likely to extend in time and scope beyond straightforward signposting. Service users and service providers need to develop a shared confidence in the signposting role. This requires good communication skills and training together with resources; first, to identify relevant activities and opportunities and then to enable service users to access them. The tension between efficient (transactional) service provision with brief referral and effective (relational) service provision, which requires a detailed understanding of individual service user needs, remains unreconciled. This tension is underpinned by competing narratives of whether signposting represents ‘diversion of unwanted demand from primary care and other urgent care services’ or ‘improved quality of care through a joined-up response that encompasses health, social care and community/voluntary services’. Research gaps and priorities The review identified the following research gaps and priorities: There is a need to evaluate different levels of intensity of service provision and their differential benefits and value for money. Productive comparison and evaluation (through benchmarking and audit) of similar services is required (i.e. signposting services to be compared with similar brief services and services providing more intensive and sustained to be compared with similar). Further comparison and evaluation of signposting services could explore levels of service provided by different staff roles. Specialist services may particularly benefit from evaluation tailored to the needs and objectives of each specific service. Issues of cultural diversity are absent from the literature particularly, as they relate to setting up a service; thus, we have identified a need for research around setting up and providing services for diverse populations. Research examining the impact of economic constraints on informal social provision would be potentially informative. Further consideration of the extent to which each service developed should prioritise and manage brief interactions with large numbers of generic users or sustained, and even prolonged, support to a targeted user group with complex health and social needs. Study registration This study is registered as PROSPERO CRD42022348200. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130588) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 26. See the NIHR Funding and Awards website for further award information.

Background A robust Health Technology Assessment (HTA) framework is crucial to address the rising burden of healthcare costs and to inform decision-making to promote high-quality health systems. This research aims to describe the HTA methods and mechanisms for the successful implementation of HTA in the WHO South-East Asia region, and contextualize the synthesized evidence relevant to Indian settings. Methods Realist review involves developing a program theory by conducting a systematic search strategy, screening, study selection, data extraction, and data synthesis. A systematic search for literature will be conducted on PubMed (NCBI), EMBASE (Elsevier), Scopus (Elsevier), Web of Science (Clarivate), and ProQuest Central for identifying the methods used for HTA of health technology interventions. Stakeholder consultations will be conducted to develop a program theory following the Context-Mechanism-Outcome configurations (CMOcs) framework. Searches for primary evidence will be conducted iteratively. Data will be extracted and tested against the programme theory. The proposed realist review will be reported as per the Realist and MEta-narrative Evidence Syntheses: Evolving Standards [RAMESES II] guidelines. Conclusions To our knowledge, there has been no comprehensive review conducted to understand the mechanisms of HTA methods in the WHO South-East Asia region. The findings from the realist review will help us understand the mechanisms through which the HTA could work in WHO South-East Asian countries. We will then contextualize the findings obtained from evidence to Indian settings, based on program theory development through stakeholder consultation. A framework will be developed that can be used by policymakers/HTA experts in India for effective implementation of the same.

Background: As a vulnerable group in HIV control programs, immigrants face various obstacles to HIV testing. Despite the effectiveness of peer interventions on health promotion in HIV testing, relatively little is known about how these interventions work. This realist review aims to understand why, how, and under what conditions peer interventions can improve immigrants’ HIV testing uptake. Methods: We followed the steps suggested by Pawson and colleagues for conducting the realist review. To test a initial program theory, we first systematically searched databases of PubMed, Web of Science, Scopus, Embase, and Cochrane, as well as the websites of UNAIDS, World Bank, Global Fund, WHO, and IOM. After data extraction and quality appraisal, data synthesis was conducted to explain the intervention pathways corresponding to context-mechanism-outcome configurations. Results: Seventeen studies were included in the review. Peer interventions for improving immigrants’ HIV testing uptake worked through four pathways: Following the improvement of communications (as a proximal mechanism): 1) increasing awareness, 2) reduced stigma, 3) improved support, and 4) increased access to services could lead to improved HIV testing uptake among immigrants. The identified mechanisms were influenced by three groups of individual/ interpersonal, service delivery, and structural factors. Conclusion: Peer interventions with multiple strategies to be designed and implemented considering the barriers to HIV testing and also moving beyond one-size-fits-all approaches can successfully improve the immigrants’ HIV testing uptake. The refined program theory in this study can help the healthcare providers and policy-makers promote the immigrants’ HIV testing uptake and reduce the risk of disease transmission.

Abstract Background Adolescent multiple risk behaviour (MRB) is a global health issue. Most interventions have focused on the proximal causes of adolescent MRB such as peer or family influence, with systematic reviews reporting mixed evidence of effectiveness. There is increasing recognition that community mobilisation approaches could be beneficial for adolescent health. There are gaps in the current literature, theory and implementation that would benefit from a realist approach. We use a theory-driven evidence synthesis to assess how and why community mobilisation interventions work/do not work to prevent adolescent MRB and in what contexts. Methods This realist review used a six-stage iterative process, guided by the RAMESES framework. We systematically searched PubMed, MEDLINE, PsycINFO, Web of Science, CINAHL and Sociological Abstracts, from their inception to 2021. Studies were screened for relevance to the programme theory, assessed for rigour and included based on a priori criteria. Two independent reviewers selected, screened and extracted data from included studies. A realist logic of analysis was used to develop context-mechanism-outcome configurations that contributed to our programme theory. Findings We reviewed 35 documents describing 22 separate community mobilisation intervention studies. Most studies (n = 17) had a quality assessment score of three or four (out of four). We analysed the studies in relation to three middle range theories. To uphold our theory that these interventions work by creating a social environment where adolescents are less likely to engage in MRB, interventions should: (1) embed a framework of guiding principles throughout the community, (2) establish community readiness with population data and (3) ensure a diverse coalition with the support of intervention champions. Mechanisms such as empowerment through coalition ownership over the delivery of the intervention, cohesion across the community and motivation to work collaboratively to improve adolescent health are triggered to achieve social environment shifts. However, certain contexts (e.g. limited funding) restrict intervention success as these mechanisms are not fired. Conclusions For community mobilisation interventions to reduce adolescent MRB, the coalitions within them must seek to alter the social environment in which these behaviours occur. Mechanisms including empowerment, cohesion and motivation lead to this shift, but only under certain contexts. Systematic review registration PROSPERO CRD42020205342

Abstract Background Despite evidence supporting the effectiveness of prehabilitation as a new preoperative care pathway to optimise perioperative outcomes, its implementation into routine health care is widely pending. Frail patients might particularly benefit from prehabilitation interventions, but facilitating and hindering factors need to be considered in the implementation process. Thus, our aim was to derive a programme theory on what prehabilitation programmes work for frail patients in what circumstances and why. Methods Following Pawson’s realist review approach, preliminary programme theories on facilitators and barriers were established. General and topic-specific databases were searched systematically for facilitators and barriers to the implementation of prehabilitation for frail patients. Articles were included if they dealt with multimodal prehabilitation programmes prior to surgery in a frail population and if they contained information on facilitators and barriers during the implementation process in the full text. Based on these articles, refined programme theories were generated. Results From 2,609 unique titles, 34 were retained for the realist synthesis. Facilitating factors included the individualisation of prehabilitation programmes to meet the patients’ needs and abilities, multimodality, adaption to the local setting and health care system, endorsement by an ambassador and sharing of responsibilities among a multidisciplinary team. Central barriers for frail patients were transportation, lack of social support, and inadequate, overwhelming information provision. Conclusions Implementing prehabilitation as a new care pathway for frail patients requires organisational readiness and adaptability to the local setting. On an individual level, a clear understanding of responsibilities and of the intervention’s goal among patients and providers are necessary. Added attention must be paid to the individualisation to fit the needs and restrictions of frail patients. This makes prehabilitation a resource-intense, but promising intervention for frail surgery patients. Trial registration PROSPERO (CRD42022335282).

ABSTRACTIn order to tackle biodiversity decline, various Agri-Environmental Programmes (AEPs) have been established in intensive farming countries. Farmers play a crucial role in restoring biodiversity. Therefore, understanding farmers’ participation in AEPs is of vital importance. Yet, a theory-driven understanding of what AEP strategies need to be implemented in which context to motivate farmers to work on AEPs is lacking. We aimed to close this gap by identifying Programme Theories (PTs) for the design and implementation of successful AEPs. We performed a realist review to identify causal relationships between agri-environmental strategies (S), their outcomes (O), and the contextual factors (C) and motivational mechanisms (M) that explain how, when and why AEP outcomes were achieved. The identified strategy-context-mechanism-outcome (SCMO) configurations and underlying theories were clustered on the C–M relationship to develop PTs. 47 studies were included. Based on the available evidence on more than 60 AEPs in 17 intensive farming countries, 10 interrelated PTs were identified. These 10 PTs form a theory-driven framework that summarizes the insights into how, when and why farmers work on successful AEPs. Each PT provides practical insights into the agri-environmental strategies and necessary contextual factors and mechanisms to guide farmers’ behavioural change toward biodiversity conservation.

Effective, accountable and transparent institutions, that engage in inclusive and participatory governance, are crucial for the sustainability of global development investments. However, there is a debate about whether effective approaches to improving governance processes operate from the bottom up (e.g. by enabling citizens to hold service providers accountable) or the top down (by enabling service providers to be held accountable by the State). This paper systematically reviews participation and accountability mechanisms in a range of sectors, drawing on principles of realist evaluation to develop and test middle-range theory using framework synthesis and statistical meta-analysis. We show that interventions promoting citizen engagement through participatory priority setting or accountability mechanisms are often effective in stimulating active citizen engagement in service delivery and realising improvements in access to services, where they facilitate direct engagement between service users and front-line service providers, such as in health care. However, citizen engagement interventions alone are not effective where services are accessed independently of service provider staff, for example road infrastructure. Interventions promoting participation by increasing citizens' pressures on politicians to hold providers to account are also not usually able to influence service delivery. [ABSTRACT FROM AUTHOR]

Background: Adolescent multiple risk behaviour (MRB) is a global health issue. Most interventions have focused on the proximal causes of adolescent MRB such as peer or family influence, with systematic reviews reporting mixed evidence of effectiveness. There is increasing recognition that community mobilisation approaches could be beneficial for adolescent health. There are gaps in the current literature, theory and implementation that would benefit from a realist approach. We use a theory-driven evidence synthesis to assess how and why community mobilisation interventions work/do not work to prevent adolescent MRB and in what contexts. Methods: This realist review used a six-stage iterative process, guided by the RAMESES framework. We systematically searched PubMed, MEDLINE, PsycINFO, Web of Science, CINAHL and Sociological Abstracts, from their inception to 2021. Studies were screened for relevance to the programme theory, assessed for rigour and included based on a priori criteria. Two independent reviewers selected, screened and extracted data from included studies. A realist logic of analysis was used to develop context-mechanism-outcome configurations that contributed to our programme theory. Findings: We reviewed 35 documents describing 22 separate community mobilisation intervention studies. Most studies (n = 17) had a quality assessment score of three or four (out of four). We analysed the studies in relation to three middle range theories. To uphold our theory that these interventions work by creating a social environment where adolescents are less likely to engage in MRB, interventions should: (1) embed a framework of guiding principles throughout the community, (2) establish community readiness with population data and (3) ensure a diverse coalition with the support of intervention champions. Mechanisms such as empowerment through coalition ownership over the delivery of the intervention, cohesion across the community and motivation to work collaboratively to improve adolescent health are triggered to achieve social environment shifts. However, certain contexts (e.g. limited funding) restrict intervention success as these mechanisms are not fired. Conclusions: For community mobilisation interventions to reduce adolescent MRB, the coalitions within them must seek to alter the social environment in which these behaviours occur. Mechanisms including empowerment, cohesion and motivation lead to this shift, but only under certain contexts. Systematic review registration: PROSPERO CRD42020205342 [ABSTRACT FROM AUTHOR]

Background: Despite evidence supporting the effectiveness of prehabilitation as a new preoperative care pathway to optimise perioperative outcomes, its implementation into routine health care is widely pending. Frail patients might particularly benefit from prehabilitation interventions, but facilitating and hindering factors need to be considered in the implementation process. Thus, our aim was to derive a programme theory on what prehabilitation programmes work for frail patients in what circumstances and why. Methods: Following Pawson's realist review approach, preliminary programme theories on facilitators and barriers were established. General and topic-specific databases were searched systematically for facilitators and barriers to the implementation of prehabilitation for frail patients. Articles were included if they dealt with multimodal prehabilitation programmes prior to surgery in a frail population and if they contained information on facilitators and barriers during the implementation process in the full text. Based on these articles, refined programme theories were generated. Results: From 2,609 unique titles, 34 were retained for the realist synthesis. Facilitating factors included the individualisation of prehabilitation programmes to meet the patients' needs and abilities, multimodality, adaption to the local setting and health care system, endorsement by an ambassador and sharing of responsibilities among a multidisciplinary team. Central barriers for frail patients were transportation, lack of social support, and inadequate, overwhelming information provision. Conclusions: Implementing prehabilitation as a new care pathway for frail patients requires organisational readiness and adaptability to the local setting. On an individual level, a clear understanding of responsibilities and of the intervention's goal among patients and providers are necessary. Added attention must be paid to the individualisation to fit the needs and restrictions of frail patients. This makes prehabilitation a resource-intense, but promising intervention for frail surgery patients. Trial registration: PROSPERO (CRD42022335282). [ABSTRACT FROM AUTHOR]

Aim: To create a programme theory of family engagement in paediatric acute care to explicate the relationships between contexts and mechanisms of family engagement that align with family, direct care providers and healthcare organization outcomes. Design: Realist review and synthesis. Data Sources: PubMed, CINAHL, PsycINFO and Web of Science searches for the 2.5‐year period (July 2019–December 2021) following our 2021 scoping review. Review Methods: Following methods described by Pawson and Rycroft‐Malone, we defined the scope of the review, searched for and appraised the evidence, extracted and synthesized study findings and developed a supporting narrative of our results. Results: Of 316 initial citations, 101 were included in our synthesis of the final programme theory. Contexts included family and direct care provider individualism, and the organizational care philosophy and environment. Mechanisms were family presence, family enactment of a role in the child's care, direct care providers facilitating a family role in the child's care, unit/organizational promotion of a family role, relationship building and mutually beneficial partnerships. Outcomes were largely family‐focussed, with a paucity of organizational outcomes studied. We identified four context–mechanism–outcome configurations. Conclusion: This realist review uncovered underlying contexts and mechanisms between patients, direct care providers and organizations in the family engagement process and key components of a mutually beneficial partnership. Given that successful family engagement requires direct care provider and organizational support, future research should expand beyond family outcomes to include direct care providers, particularly nurses and healthcare organization outcomes. Impact: The final programme theory of family engagement in paediatric acute care provides a roadmap for clinicians to develop complex interventions to engage families and evaluate their impact. The components of our final programme theory reflect family engagement concepts that have been evolving for decades. Patient or Public Contribution: The team conducting this review included members from the practice setting (JT & KG). In the future, as we and others use this model in practice, we will seek input for refinement from clinicians, patients and caregivers. [ABSTRACT FROM AUTHOR]

Background: Mindfulness as a modality involves training the innate human capacity for present-moment awareness with a view to cultivating a more harmonious and integrated life experience, especially in the face of hardship. Over the past four decades, the field of mindfulness has grown rapidly. Despite a substantial body of literature outlining the many benefits of mindfulness practice within a range of contexts and populations, the authors noticed that studies addressing the adaptation, application and value of mindfulness-based interventions (MBIs) for adults within socio-economically challenged setting were scant. To address this gap, we conducted a realist review of studies pertaining to MBIs within low socio-economic settings, to determine the extend and nature of research in this sector and culminating in a program theory which may be useful for the design of interventions going forward. Methods: We selected realist review as the methodology as it is well suited to investigating the complex nature of social interventions. The value of realist review is that the exploration of the causal relationships between the mechanisms (M) within a specific context (C) towards particular outcomes (O) offers a deeper understanding of the intervention which may assist in more effective delivery going forward. The review follows the guidelines presented by the Realist and Meta-narrative Evidence Synthesis – Evolving Standards project. Results: Of the 112 documents identified, 12 articles met the inclusion criteria. Of these 12 studies, 10 were conducted in the United States, with little representation across the rest of the globe. The interventions described in these articles were varied. We identified mechanisms that offered beneficial outcomes for participants across a range of contexts, with indications of how interventions might be adapted towards greater accessibility, acceptability, and feasibility within communities. Conclusion: By reviewing the various programs in their respective contexts, we developed a program theory for implementing socio-culturally adapted MBIs in low socio-economic settings. In the future, this program theory could be tested as a means to create a sense of wellbeing for people living in low socio-economic settings. Highlights: • Minimal research found in the field of MBIs within low socio-economic settings • Available studies were analysed and assessed against the "gold standard" of MBSR • A program theory was developed for adapting MBIs for low socio-economic settings [ABSTRACT FROM AUTHOR]

Background: As a vulnerable group in HIV control programs, immigrants face various obstacles to HIV testing. Despite the effectiveness of peer interventions on health promotion in HIV testing, relatively little is known about how these interventions work. This realist review aims to understand why, how, and under what conditions peer interventions can improve immigrants' HIV testing uptake. Methods: We followed the steps suggested by Pawson and colleagues for conducting the realist review. To test a initial program theory, we first systematically searched databases of PubMed, Web of Science, Scopus, Embase, and Cochrane, as well as the websites of UNAIDS, World Bank, Global Fund, WHO, and IOM. After data extraction and quality appraisal, data synthesis was conducted to explain the intervention pathways corresponding to context-mechanism-outcome configurations. Results: Seventeen studies were included in the review. Peer interventions for improving immigrants' HIV testing uptake worked through four pathways: Following the improvement of communications (as a proximal mechanism): 1) increasing awareness, 2) reduced stigma, 3) improved support, and 4) increased access to services could lead to improved HIV testing uptake among immigrants. The identified mechanisms were influenced by three groups of individual/ interpersonal, service delivery, and structural factors. Conclusion: Peer interventions with multiple strategies to be designed and implemented considering the barriers to HIV testing and also moving beyond one-size-fits-all approaches can successfully improve the immigrants' HIV testing uptake. The refined program theory in this study can help the healthcare providers and policy-makers promote the immigrants' HIV testing uptake and reduce the risk of disease transmission. [ABSTRACT FROM AUTHOR]

Identity has been empirically established as a recovery process from serious mental illness (SMI) yet is often overlooked within intervention evaluations. Community arts presents one such intervention with emerging evidence illustrating the potential for recovery to occur within this context. However, research indicates numerous mechanisms may be involved in the identity recovery process, making it difficult to determine what works, for whom and in what context. The current review aimed to generate new theories to explain how, why and in what context community arts enable the identity change recovery process for individuals with SMI. A realist review was conducted between January and September 2021, with 22 articles and reports reviewed and synthesised to develop a theory. A safe and empowering intervention context was found to be vital to activate three key mechanism pathways: (a) feeling in control of SMI through coping; (b) achieving acceptance through connectedness and (c) overcoming personal challenges. The outcome was the development of positive self‐awareness, which enables individuals to redefine identity beyond SMI through both social and personal identities. Novel insights are presented through theory development, utilising the Social Identity Approach to Health and Transformative Learning Theory to conceptualise the findings through a multi‐theoretical lens. Please refer to the Supplementary Material section to find this article's Community and Social Impact Statement. [ABSTRACT FROM AUTHOR]

Background: Migrants and refugees are high-risk populations with often limited health literacy (HL). It is crucial to improve their HL early after arrival. One promising approach is to combine language and HL learning in secondlanguage courses. Objectives: This study reviewed empirical evidence on the promotion of migrants' HL in secondlanguage courses and developed a theory of change to inform innovative projects. Methodology: We conducted a systematic realist review of HL in second language courses in seven scientific databases and a grey literature search. After screening titles, abstracts, and full texts, we identified 21 eligible publications from 13 programs. We systematically analyzed program context and characteristics, evaluation design, and outcomes and developed a theory of change based on the findings. Results: Programs promoting HL in second language courses are diverse in terms of contextual factors, formats, study designs, measures of HL, language improvements, effectiveness, relevant outcomes, and enabling factors. All studies reported improved HL after the program, but to varying degrees. The findings regarding second language improvement are mixed. Seven core components of HL as a social practice emerged. Numerous factors influencing course implementation, outcomes, and sustainability were described in detail. We conceptualized a theory of change for the HL promotion in second language courses. Conclusion: This realist review presents ample empirical evidence that second language courses can promote HL in various ways. However, these courses are complex, heterogeneous, and dependent on multiple factors. Despite these limitations, second language courses show promise as innovative and effective approaches that reach many migrants. Therefore, health promoters, medical professionals, adult educators, and policymakers should collaborate nationally and internationally to leverage this unique opportunity. The theory of change can serve as a blueprint for discussing existing programs thoroughly and developing promising, effective, and sustainable programs. [ABSTRACT FROM AUTHOR]

Participatory workplace interventions to improve workforce musculoskeletal health are infrequently analysed regarding why they work, for whom or under what circumstances. This review sought to identify intervention strategies which achieved genuine worker participation. In total, 3388 articles on participatory ergonomic (PE) interventions were screened; 23 were suitable to analyse within a realist framework identifying contexts, mechanisms of change, and outcomes. The interventions which succeeded in achieving worker participation were characterised by one or more of these contexts: workers' needs as a core starting point; a positive implementation climate; clear distribution of roles and responsibilities; allocation of sufficient resources; and managerial commitment to and involvement in occupational safety and health. Interventions that were organised and delivered in this way generated relevance, meaning, confidence, ownership and trust for the workers in an interrelated and multi-directional manner. With such information, PE interventions may be carried out more effectively and sustainably in the future. Practitioner summary: This review focuses on the question: which mechanisms support genuine worker participation, in what context and with which necessary resources, to reduce musculoskeletal disorders. Results emphasise the importance of starting with workers' needs, making the implementation climate egalitarian, clarifying the roles and responsibilities of all involved, and providing sufficient resources. Abbreviations: PE: participatory ergonomic(s); WMSD: Work-related musculoskeletal disorders; EU: European Union; MSD: Muskuloskeletal disorders; OSH: Occupational health and safety; C: context; M: mechanism; O: outcome; CMOCs: CMO configurations; NPT: Normalization process theory; OECD: The Organisation for Economic Co-operation and Development: EU-OSHA: European Occupational Safety and Health Agency [ABSTRACT FROM AUTHOR]

Abstract Background Maternal smoking in pregnancy is associated with several adverse maternal and infant health outcomes including increased risk of miscarriage, stillbirth, low birth weight, preterm birth, and asthma. Progress to reduce rates of smoking at time of delivery in England have been slow and over the last decade, less than half of pregnant women who accessed services went onto report having quit. This realist review was undertaken to improve the understanding of how smoking cessation services in pregnancy work and to understand the heterogeneity of outcomes observed. Methods The initial programme theory was developed using the National Centre for Smoking Cession and Training Standard Treatment Programme for Pregnant Women and the National Institute for Health and Care Excellence guidance on treating tobacco dependency. A search strategy and inclusion criteria were developed. Four databases were searched to identify published papers and four websites were hand searched to identify any unpublished literature that could contribute to theory building. Realist logic was applied to the analysis of papers to identify the contexts in which the intended behaviour change mechanism(s) were triggered, or not, and towards what outcomes to develop context mechanism outcome configurations. Results The review included 33 papers. The analysis produced 19 context mechanism outcome configurations structured under five closely interconnected domains (i) articulating harm, (ii) promoting support, (iii) managing cravings, (iv) maintaining commitment and (v) building self-efficacy. This review identifies two key processes involved in how services achieve their effects: how material resources are implemented and relationships. Of the two key processes identified, more existing literature was available evidencing how material resources are implemented. However, the review provides some evidence that non-judgemental and supportive relationships with healthcare workers where regular contact is provided can play an important role in interrupting the social cues and social practice of smoking, even where those around women continue to smoke. Conclusions This review clarifies the range of interconnected and bi-directional relationships between services and the personal and social factors in women’s lives. It underscores the importance of aligning efforts across the models five domains to strengthen services’ ability to achieve smoking cessation.

Abstract Background Peer support has been proposed as a promising policy intervention for addressing adverse maternal and child healthcare (MCH) outcomes in sub-Saharan Africa (SSA). Existing reviews on peer support largely draw on evidence from high-income countries or focus on single services like breastfeeding, nutrition or postnatal care. In contrast, this review aims to provide a comprehensive overview of the empirical literature on peer support interventions across various MCH services in sub-Saharan Africa. Specifically, we aim to understand how, why, for whom, and in what circumstances different forms of MCH peer support interventions contribute to improving healthcare outcomes in sub-Saharan Africa. Methods This review follows five iterative steps for undertaking realist reviews (1) defining the review scope; (2) developing initial programme theories; (3) searching for evidence; (4) selecting and appraising evidence; and (5) extracting, analysing and synthesising evidence. Four databases–Cochrane Library, PubMed, CINAHL, and EMBASE–were repeatedly searched between March and June 2021. From a large volume of records retrieved from the database and citation search, 61 papers have been selected for review. We will conduct a second search of the same database covering June 2021 to the present before the final extraction and synthesis. The final list of selected papers will be imported into NVivo 12 software and organised, extracted, analysed and synthesised iteratively to examine and illustrate the causal links between contexts, mechanisms and outcomes of MCH peer support interventions in SSA. We have drawn on the existing literature on peer support in healthcare generally to develop initial programme theories. We will then use the empirical literature on MCH peer support interventions in SSA, inputs from a stakeholders’ workshop in Ghana and a conference presentation to refine the initial programme theory. Discussion The review will develop an explicit theory of peer support intervention in healthcare delivery and provide insights for developing evidence-informed policy on the intervention. Drawing lessons from the different national contexts and diverse areas of MCH in SSA, the review will provide an analytically generalizable programme theory that can guide intervention design and implementation. While focusing on MCH peer support interventions in SSA, the review contributes to evolving conversations on the use of theory for health policy planning and complex intervention design and implementation globally. Trial registration PROSPERO registration ID: CRD42023427751 .

Background: Maternal smoking in pregnancy is associated with several adverse maternal and infant health outcomes including increased risk of miscarriage, stillbirth, low birth weight, preterm birth, and asthma. Progress to reduce rates of smoking at time of delivery in England have been slow and over the last decade, less than half of pregnant women who accessed services went onto report having quit. This realist review was undertaken to improve the understanding of how smoking cessation services in pregnancy work and to understand the heterogeneity of outcomes observed. Methods: The initial programme theory was developed using the National Centre for Smoking Cession and Training Standard Treatment Programme for Pregnant Women and the National Institute for Health and Care Excellence guidance on treating tobacco dependency. A search strategy and inclusion criteria were developed. Four databases were searched to identify published papers and four websites were hand searched to identify any unpublished literature that could contribute to theory building. Realist logic was applied to the analysis of papers to identify the contexts in which the intended behaviour change mechanism(s) were triggered, or not, and towards what outcomes to develop context mechanism outcome configurations. Results: The review included 33 papers. The analysis produced 19 context mechanism outcome configurations structured under five closely interconnected domains (i) articulating harm, (ii) promoting support, (iii) managing cravings, (iv) maintaining commitment and (v) building self-efficacy. This review identifies two key processes involved in how services achieve their effects: how material resources are implemented and relationships. Of the two key processes identified, more existing literature was available evidencing how material resources are implemented. However, the review provides some evidence that non-judgemental and supportive relationships with healthcare workers where regular contact is provided can play an important role in interrupting the social cues and social practice of smoking, even where those around women continue to smoke. Conclusions: This review clarifies the range of interconnected and bi-directional relationships between services and the personal and social factors in women's lives. It underscores the importance of aligning efforts across the models five domains to strengthen services' ability to achieve smoking cessation. [ABSTRACT FROM AUTHOR]

Problem-based learning (PBL) can take many different shapes but has as a common denominator that it builds on the principles of collaborative, constructive, contextual, and self-directed learning. Systematic review approaches that aim to provide insight in what features make PBL work generally fall short, as they tend to disregard the influential role of implementation contexts. The realisvt review approach seems to be promising in this respect, as this type of review aims to address the comprehensive question: What works for whom, in what circumstances, in what respects, and how? This article elaborates on the theoretical foundation of the realist review approach, provides examples and a step-by-step description of how to conduct a realist review, and sketches a promising perspective on the way in which realist reviews can contribute to furthering insight in PBL and its future development. [ABSTRACT FROM AUTHOR]

Background: Peer support has been proposed as a promising policy intervention for addressing adverse maternal and child healthcare (MCH) outcomes in sub-Saharan Africa (SSA). Existing reviews on peer support largely draw on evidence from high-income countries or focus on single services like breastfeeding, nutrition or postnatal care. In contrast, this review aims to provide a comprehensive overview of the empirical literature on peer support interventions across various MCH services in sub-Saharan Africa. Specifically, we aim to understand how, why, for whom, and in what circumstances different forms of MCH peer support interventions contribute to improving healthcare outcomes in sub-Saharan Africa. Methods: This review follows five iterative steps for undertaking realist reviews (1) defining the review scope; (2) developing initial programme theories; (3) searching for evidence; (4) selecting and appraising evidence; and (5) extracting, analysing and synthesising evidence. Four databases–Cochrane Library, PubMed, CINAHL, and EMBASE–were repeatedly searched between March and June 2021. From a large volume of records retrieved from the database and citation search, 61 papers have been selected for review. We will conduct a second search of the same database covering June 2021 to the present before the final extraction and synthesis. The final list of selected papers will be imported into NVivo 12 software and organised, extracted, analysed and synthesised iteratively to examine and illustrate the causal links between contexts, mechanisms and outcomes of MCH peer support interventions in SSA. We have drawn on the existing literature on peer support in healthcare generally to develop initial programme theories. We will then use the empirical literature on MCH peer support interventions in SSA, inputs from a stakeholders' workshop in Ghana and a conference presentation to refine the initial programme theory. Discussion: The review will develop an explicit theory of peer support intervention in healthcare delivery and provide insights for developing evidence-informed policy on the intervention. Drawing lessons from the different national contexts and diverse areas of MCH in SSA, the review will provide an analytically generalizable programme theory that can guide intervention design and implementation. While focusing on MCH peer support interventions in SSA, the review contributes to evolving conversations on the use of theory for health policy planning and complex intervention design and implementation globally. Trial registration: PROSPERO registration ID: CRD42023427751. [ABSTRACT FROM AUTHOR]

Aims and Objectives: To explore evidence on how local nurse leaders can positively influence nurse retention. Background: Nurse turnover and retention is a wicked problem with multiple interrelated factors and no one solution. Local nurse leadership has the potential to positively influence nurse intent to stay directly or via various factors. Design: A realist review. Methods: Having designed a search strategy based on a tentive programme theory, 1386 initial hits in three databases were screened and reduced to 48 research articles published between 2010–2021. The articles' content were coded for findings that supported, refined or contradicted four ContextMechanismOutcome configurations. Results: Sufficient evidence was found to support four guiding lights encouraging local nurse leaders to: (1) foster relational connectedness; (2) enable professional practice autonomy; (3) cultivate healthful workplace cultures; (4) support professional growth and development. Mutuality and reciprocity is also key if leaders themselves are to experience wellbeing and growth. Conclusions: Person‐centred, transformational and resonant local nurse leaders can positively influence nurse intent to stay within the workplace or organisation. Reporting Method: Conform JCN guideline 'What to cover in the main tekst by article type' for reviews. Patient or Public Contribution: No Patient or Public Contribution. [ABSTRACT FROM AUTHOR]

Background: Sexual and reproductive healthcare services (SRHS) are an environment where medical care relevant to sexual violence and abuse (SV) is available. However, barriers to disclosure need to be overcome to allow timely access to this care. There is limited research identifying and explaining how interventions remove barriers and create a safe and supportive environment for disclosure. The purpose of this review was to develop and refine theories that explain how, for whom and in what context SRHS facilitate disclosure. Methods: Following published realist standards we undertook a realist review. After focussing the review question and identifying key contextual barriers, articles pertaining to these were identified using a traditional systematic database search. This strategy was supplemented with iterative searches. Results: Searches yielded 3172 citations, and 28 articles with sufficient information were included to develop the emerging theories. Four evidence-informed theories were developed proposing ways in which a safe and supportive environment for the disclosure of SV is enabled in SRHS. The theories consider how interventions may overcome barriers surrounding SV disclosure at individual, service-delivery and societal levels. Conclusions: Benefits of SRHS engagement with health promotion and health activism activities to address societal level barriers like lack of service awareness and stereotypic views on SV are presented. Although trauma informed practice and person-centred care were central in creating a safe and supportive environment for disclosure the review found them to be poorly defined in this setting. [ABSTRACT FROM AUTHOR]

Background: Existing efforts to understand school-based child sexual abuse (CSA) prevention programs mainly focus on the effectiveness of these programs in increasing participants' CSA knowledge and self-protective skills. There are currently no reviews addressing the underpinning pathways leading to these outcomes. In order to increase our understanding about the underpinning causal and contextual factors and inform the further development of school-based CSA prevention programs, a realist review was conducted to synthesize existing evidence from a broad range of data. Methods: An iterative search of electronic databases and grey literature was conducted, supplemented with citation tracking to locate relevant literature. For quantitative evidence, we considered evaluation studies that focused on students aged 5–18 years, who were enrolled in primary or secondary schools; for other types/formats of studies/documents, no population restrictions were applied. We included school-based CSA prevention programs that focused on improving knowledge of CSA or self-protective skills. Outcomes of interest included knowledge of CSA or self-protective skills. We did not apply methodological filters in terms of the types of studies to be included. Thematic content analysis was conducted to synthesize data. Results: Sixty-two studies were included. Five themes and five overarching Context-Strategy-Mechanism-Outcome configurations (CSMOs) that contributed to the success of school-based CSA interventions were identified, including tailoring programs to participants' cognitive developmental levels, repeated exposure of key concepts and skills, utilization of interactive delivery methods and positive feedback, delivery of positive information and application of the 'train-the-trainer' model. Implications: Findings from this realist review provide insights into the underlying program theory of school-based CSA prevention programs, which can aid in the development and implementation of these programs in the future. [ABSTRACT FROM AUTHOR]

Background Socio-economic inequalities in health have been in the public agenda for decades. General practice has an influential role to play in mitigating the impact of inequalities especially regarding chronic conditions. At the moment, general practice is dealing with serious challenges in relation to workforce shortages, increasing workload and the impact of the COVID-19 pandemic. It is important to identify effective ways so that general practice can play its role in reducing health inequalities. Objectives We explored what types of interventions and aspects of routine care in general practice decrease or increase inequalities in health and care-related outcomes. We focused on cardiovascular disease, cancer, diabetes and/or chronic obstructive pulmonary disease. We explored for whom these interventions and aspects of care work best, why, and in what circumstances. Our main objective was to synthesise this evidence into specific guidance for healthcare professionals and decision-makers about how best to achieve equitable general practice. Design Realist review. Main outcome measures Clinical or care-related outcomes by socio-economic group, or other PROGRESS-Plus criteria. Review methods Realist review based on Pawson’s five steps: (1) locating existing theories, (2) searching for evidence, (3) selecting articles, (4) extracting and organising data and (5) synthesising the evidence. Results Three hundred and twenty-five studies met the inclusion criteria and 159 of them were selected for the evidence synthesis. Evidence about the impact of general practice interventions on health inequalities is limited. To reduce health inequalities, general practice needs to be: connected so that interventions are linked and coordinated across the sector; intersectional to account for the fact that people’s experience is affected by many of their characteristics; flexible to meet patients’ different needs and preferences; inclusive so that it does not exclude people because of who they are; community-centred so that people who receive care engage with its design and delivery. These qualities should inform action across four domains: structures like funding and workforce distribution, organisational culture, everyday regulated procedures involved in care delivery, interpersonal and community relationships. Limitations The reviewed evidence offers limited detail about the ways and the extent to which specific interventions increase or decrease inequalities in general practice. Therefore, we focused on the underpinning principles that were common across interventions to produce higher-level, transferrable conclusions about ways to achieve equitable care. Conclusions Inequalities in general practice result from complex processes across four different domains that include structures, ideas, regulated everyday procedures, and relationships among individuals and communities. To achieve equity, general practice needs to be connected, intersectional, flexible, inclusive and community-centred. Future work Future work should focus on how these five essential qualities can be better used to shape the organisational development of future general practice. Study registration This trial is registered as PROSPERO CRD42020217871. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130694) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 7. See the NIHR Funding and Awards website for further award information. Plain language summary Health inequalities are unfair differences in health across different groups of the population. In the United Kingdom, the health inequality gap in life expectancy between the richest and poorest is increasing and is caused mostly by differences in long-term conditions like cancer and cardiovascular disease and respiratory conditions, such as chronic obstructive pulmonary disease. Partly National Health Service inequalities arise in delays in seeing a doctor and care provided through doctors’ surgery, such as delays in getting tests. This study explored how general practice services can increase or decrease inequalities in cancer, cardiovascular disease, diabetes and chronic obstructive pulmonary disease, under what circumstances and for whom. It also produced guidance for general practice, both local general practices and the wider general practice system, to reduce inequalities. We reviewed existing studies using a realist methodology. This methodology helps us understand the different contexts in which interventions work or not. We found that inequalities in general practice result from complex processes across different areas. These include funding and workforce, perceptions about health and disease among patients and healthcare staff, everyday procedures involved in care delivery, and relationships among individuals and communities. To reduce inequalities in general practice, action should be taken in all these areas and services need to be connected (i.e. linked and coordinated across the sector), intersectional (i.e. accounting for the fact that people’s experience is affected by many of their characteristics like their gender and socio-economic position), flexible (i.e. meeting patients’ different needs and preferences), inclusive (i.e. not excluding people because of who they are) and community-centred (i.e. working with the people who will receive care when designing and providing it). There is no one single intervention that will make general practice more equitable, rather it requires long-term organisational change based on these principles. Scientific summary Background Socio-economic inequalities in health have been in the public health discourse and policy agenda for decades. There is ample evidence showing that inequalities in premature mortality are mainly driven by inequalities in chronic diseases and especially cancer, cardiovascular and respiratory disease. In the most deprived areas of the country, patients with cardiovascular disease (CVD) deal with a four times higher possibility of premature death than patients in the least deprived areas. In this context, general practice as the front door to the healthcare system has an important role to play in reducing inequalities especially when it comes to chronic conditions. The COVID-19 pandemic has highlighted both the range of health inequalities and the importance of general practice in addressing and tackling the problem. However, it has also revealed chronic deficiencies of the sector which combined with the pressure during the pandemic have resulted in a physically and emotionally exhausted workforce and greater scarcity of resources. In this climate, there is an urgent need for action to secure general practice’s future as more equitable and effective for its patients, their families and carers, but also for its workforce. Objectives Our study explored what types of interventions and aspects of routine care in general practice decrease or increase inequalities in healthcare and outcomes among people with or at risk of CVD, cancer, diabetes and/or chronic obstructive pulmonary disease, and for whom these interventions and aspects of care work best, why, and in what circumstances. Our main objective was to synthesise this evidence to produce specific guidance for healthcare professionals and decision-makers about how best to tackle health inequalities in general practice. Methods We conducted a realist review following Pawson’s five iterative steps: (1) locating existing theories, (2) searching for evidence, (3) selecting articles, (4) extracting and organising data and (5) synthesising the evidence. We started with an exploratory literature search and discussions with experts in the field, to identify existing theories that explain how, for whom, why and in what circumstances interventions or care delivered in general practice may increase or decrease health inequalities. Next, we conducted a literature review in two steps. First, we conducted an initial search of systematic reviews of interventions delivered in general practice and focused on CVD, cancer, diabetes and/or chronic obstructive pulmonary disease (COPD) across the Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, Cumulative Index to Nursing and Allied Health Literature, Psychological Information Database, the Web of Science and the Cochrane Library. Second, we extracted all the primary studies included in the systematic reviews which met our inclusion criteria, and we screened them searching for interventions which reported on clinical outcomes or care-related outcomes by socio-economic group, or other PROGRESS-Plus criteria. To be able to review the included studies within the study timeline, we combined steps 3 and 4, so the selection of articles took place at the same time with the data extraction. The data synthesis followed a realist logic which suggests that outcomes are the results of specific causal mechanisms which are triggered only within specific contexts. Accordingly, we combined the evidence into statements of causal relationships (what in realist terms are called context–mechanism–outcome configurations) which connect a context with an outcome through an underlying mechanism. Results We identified 7998 review studies, of which 251 met the inclusion criteria. From the included reviews, we retrieved 6555 primary studies and proceeded with a second round of screening. In total, 325 studies met the inclusion criteria for primary studies and were grouped into three categories: those focusing primarily on inequalities (n = 56), those focusing on an intervention, or an aspect of care targeted at specific disadvantaged groups (n = 137) and those assessing the impact of an intervention without focusing on inequalities but accounting for one or more PROGRESS-Plus criteria (n = 132). The studies involved a wide range of designs, with almost half of them being randomised controlled trials or other experimental design (n = 157). Our review revealed that there is limited research on interventions that aim to decrease inequalities in general practice or evidence about the effect of general practice interventions by PROGRESS-Plus criteria. Given the diversity of the included articles and the lack of in-depth information, instead of specific characteristics of interventions we focused on the underlying principles that informed care and interventions and the ways they can be employed to achieve equitable care in general practice. We found that in order to decrease inequalities general practice needs to be connected (i.e. programmes and interventions should be coordinated across the sector), intersectional (i.e. care should account for the fact that people’s experience is affected by many of their characteristics like their gender and socio-economic position), flexible (i.e. care should meet patients’ different needs and preferences), inclusive (i.e. care should not exclude people because of who they are) and community-centred (i.e. working with the people who will receive care when designing and providing it). These five qualities of equitable general practice should be employed to inform action across four different domains of power organisation. In the structural domain action should focus on funding allocation, workforce size and diversity, premises convenience and pre-existing inequalities in the social determinants of health (SDH). In the cultural domain action should focus on integrating an understanding of patient worldviews, beliefs and values, and developing culturally sensitive communication and educational material. Moreover, action in the cultural domain should involve shifting away from designing educational or training interventions outside the social and cultural context of patients. Finally, it should involve tackling biases among general practice staff (clinical and non-clinical). In the disciplinary domain, which involves regulated procedures taking place in the everyday delivery of care, action should focus on how disadvantaged patients are excluded from quality assessment standards, and the effective collection and use of patient socio-demographic information, especially socio-economic status and ethnicity, in risk assessment and quality evaluation. Further, emphasis should be put on invitation methods to prevention services, the working hours of services and the contact time between patients and healthcare staff, continuity of care, as well as on the employment of multidisciplinary care teams and the support of all members of staff to engage in prevention services for disadvantaged patients. Finally, in the interpersonal domain, empathetic and trusting relationships between patients and healthcare staff and personalised communication should be a special focus for services. Further, balanced relationships among staff members across professional hierarchies and mutual respect for each other’s leadership skills is another meaningful area of action. Conclusions Inequalities in general practice result from complex processes and power imbalances across four different domains that include structures, ideas, regulations and bureaucracies, and relationships among individuals and communities. To achieve equity, general practice needs to be connected, intersectional, flexible, inclusive and community-centred and effective action implies: Creating a positive vision for general practice. Policy-makers may find it helpful to work on a positive vision of what equitable general practice looks like. It is recommended that reducing health inequalities remains high in the policy-makers agenda and solutions are planned based on a long-term perspective and the integration of different policy domains, including social policy. This among others requires involving front-line workers in general practice and disadvantaged groups in the development of a health-inequality-related strategy. Making effective use of diversity to promote equity in care outcomes. This among other things could involve tackling structural racism and sexism; inclusion work covering sexual orientation, disability, religion and caring responsibilities; cultivating a less Western-centric organisational culture; including social-sciences and humanities modules in medical training; and increasing cultural competence at the practice level with the recruitment and progression of local clinical and non-clinical staff. Workforce support so that staff are recruited and retained in disadvantaged and remote areas. This can be achieved through providing additional training for less experienced employees; financial and career development incentives in disadvantaged and rural areas; medical school placements; developing a subspecialty related to providing care in highly socio-economically disadvantaged areas; and providing training to nurses, healthcare assistants and administrative staff to improve the overall capacity of practices and also staff experience. Equitable distribution of funding so that it accounts better for differences in need of the served populations. This among other things can take the form of updating the Carr-Hill formula so that it integrates patient socio-economic status and ethnicity and higher patient list weights for practices in disadvantaged areas. Tackling accessibility barriers. This can take the form of co-locating practices with local services such as foodbanks or citizens’ advice offices; locating services close to community landmarks such as schools, libraries and cultural or recreational centres; contributing to the development of community transport options; providing targeted home visits; and remote consultation options. Investing in collecting and disaggregating high-quality data by social/socio-demographic categories, such as socio-economic group, or ethnicity. This among other things could involve securing the necessary time for data collection and update during or around consultation time; making data collection and maintenance a specific part of the professional role of clinical and non-clinical staff; and making the best use of IT resources for the development of accurate and up-to-date patient registers. Increasing continuity of care for long-term conditions and patients with complex health problems and social circumstances. This can be achieved through improving working conditions and providing incentives (e.g. financial, training, social) for staff to remain in their post; focusing on continuity between micro-teams and patients instead of individual general practitioners (GPs) and patients; and involving GP teams in invitations to prevention services. Balancing autonomy to facilitate local community-oriented solutions with standardised care. Local general practices need relative autonomy to decide how to do their work better in terms of reducing inequalities. This can involve increased consultation time for patients with complex needs; translation services specific to the needs of the served population; working hours that work better for the community; and the use of community spaces for the delivery of care and promotion of services. Future research should Prioritise inequalities and apply a health-inequalities perspective to broader research and evaluation work. Systematise evidence on health inequalities and develop platforms which will allow easy and effective access to the evidence. Re-consider the effectiveness of PROGRESS-Plus criteria and their suitability as dimensions of inequality. Integrate and operationalise intersectionality. Use qualitative and mixed-methods approaches to provide detailed information about the transferable evidence-based principles behind specific interventions and upstream drivers of inequalities in SDH. Focus more on conditions intrinsically associated with disadvantage, such as COPD, and specific models of local general practice which are designed to address inequalities. Focus on the cultural domain and explore the interconnection(s) between structural racism, healthcare worker and patient experiences of discrimination, and care outcomes in general practice. Study registration This trial is registered as PROSPERO CRD42020217871. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130694) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 7. See the NIHR Funding and Awards website for further award information.

Background Falls are the most common safety incident reported by acute hospitals. The National Institute of Health and Care Excellence recommends multifactorial falls risk assessment and tailored interventions, but implementation is variable. Aim To determine how and in what contexts multifactorial falls risk assessment and tailored interventions are used in acute National Health Service hospitals in England. Design Realist review and multisite case study. (1) Systematic searches to identify stakeholders’ theories, tested using empirical data from primary studies. Review of falls prevention policies of acute Trusts. (2) Theory testing and refinement through observation, staff interviews (n = 50), patient and carer interviews (n = 31) and record review (n = 60). Setting Three Trusts, one orthopaedic and one older person ward in each. Results Seventy-eight studies were used for theory construction and 50 for theory testing. Four theories were explored. (1) Leadership: wards had falls link practitioners but authority to allocate resources for falls prevention resided with senior nurses. (2) Shared responsibility: a key falls prevention strategy was patient supervision. This fell to nursing staff, constraining the extent to which responsibility for falls prevention could be shared. (3) Facilitation: assessments were consistently documented but workload pressures could reduce this to a tick-box exercise. Assessment items varied. While individual patient risk factors were identified, patients were categorised as high or low risk to determine who should receive supervision. (4) Patient participation: nursing staff lacked time to explain to patients their falls risks or how to prevent themselves from falling, although other staff could do so. Sensitive communication could prevent patients taking actions that increase their risk of falling. Limitations Within the realist review, we completed synthesis for only two theories. We could not access patient records before observations, preventing assessment of whether care plans were enacted. Conclusions (1) Leadership: There should be a clear distinction between senior nurses’ roles and falls link practitioners in relation to falls prevention; (2) shared responsibility: Trusts should consider how processes and systems, including the electronic health record, can be revised to better support a multidisciplinary approach, and alternatives to patient supervision should be considered; (3) facilitation: Trusts should consider how to reduce documentation burden and avoid tick-box responses, and ensure items included in the falls risk assessment tools align with guidance. Falls risk assessment tools and falls care plans should be presented as tools to support practice, rather than something to be audited; (4) patient participation: Trusts should consider how they can ensure patients receive individualised information about risks and preventing falls and provide staff with guidance on brief but sensitive ways to talk with patients to reduce the likelihood of actions that increase their risk of falling. Future work (1) Development and evaluation of interventions to support multidisciplinary teams to undertake, and involve patients in, multifactorial falls risk assessment and selection and delivery of tailored interventions; (2) mixed method and economic evaluations of patient supervision; (3) evaluation of engagement support workers, volunteers and/or carers to support falls prevention. Research should include those with cognitive impairment and patients who do not speak English. Study registration This study is registered as PROSPERO CRD42020184458. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129488) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 5. See the NIHR Funding and Awards website for further award information. Plain language summary Many accidental falls by older people in hospitals could be avoided. There are guidelines to prevent falls, but some hospitals are better at following them than others. This study aimed to find out why. First, we looked at research and hospitals’ falls policies for ideas about what stops falls. With advice from service users, we tested these ideas in four hospitals in England, watching how falls were prevented on wards for older people and people who need bone care, and talking to 50 staff, 28 patients and 3 carers. We found the following: Falls leadership: wards had staff called falls link practitioners who supported falls prevention, but senior nurses, not link practitioners, made the most important decisions. Sharing responsibility: patients with falls risks were monitored to try to stop falls. Because only nursing teams were always present to monitor patients, they had most responsibility for preventing falls. This limited sharing responsibility with other staff. Computer tools: nurses used computers to record prevention work, but high workloads could make this a ‘tick-box’ exercise. Computer tools reminded them to do this, although tools varied. Patients had individual falls plans, but they were also ranked more generally as high or low risk of falling, with ‘high-risk’ patients being monitored. Patient involvement: nursing staff did not have time to explain to patients how to prevent falls, but other staff could have such conversations. Many patients had problems like dementia and found it difficult to follow safety advice, although some could take steps to keep safe, with sensitive staff support. We need to involve patients, carers and different staff in falls prevention. Hospitals could develop computer systems to support this, think how to involve more ward staff, and provide guidance on helpful ways to talk with patients about falls. Scientific summary Background Inpatient falls are the most common safety incident reported by acute hospitals and can cause both physical and non-physical harm. The National Institute of Health and Care Excellence (NICE) guideline on falls in older people recommends a multifactorial falls risk assessment (MFRA) and interventions tailored to address the patient’s identified risk factors for all inpatients aged 65 years and older, or 50–64 years and judged to be at higher risk of falling due to an underlying condition. This approach is estimated to reduce the incidence of inpatient falls by 25–30%. However, there is substantial unexplained variation between hospitals in adherence to this guideline. Objectives Use secondary data to develop a theory that explains what supports and constrains routine use of MFRA and falls prevention interventions. Refine the theory through mixed method data collection across three acute hospital Trusts. Translate the theory into guidance to support MFRA and prevention and, in turn, adherence to the NICE guideline. Methods Throughout the study, we were supported by DW, the lay member of the project management group, and the Lay Research Group (a group of service users and carers who had either fallen themselves or cared for someone who fell in hospital). We first undertook a realist review. In Phase 1, systematic searches were undertaken for commentary-type articles, studies mentioning theories/conceptual models for falls risk assessment, and systematic reviews. Additionally, a search of professional/trade journals and an advanced Google search were undertaken. Titles, abstracts and full texts were screened for relevance. Data about contexts, mechanisms and outcomes were extracted from included papers, and referenced substantive theories were noted. Data were summarised in matrices, used to construct context mechanism outcome configurations (CMOcs). To determine which CMOcs should be taken forward for testing in Phase 2, the Lay Research Group and Study Steering Committee (SSC) (comprised of clinicians, academics, and a lay member, with expertise including falls prevention, risk assessment, patient safety and implementation science) ranked them, giving top rankings to statements they believed most likely to work in practice. The Lay Research Group was also asked to highly rank statements likely to have greatest impact for patients and carers. In Phase 2 of the realist review, systematic searches for the four concepts ranked highly by both the Lay Research Group and SSC were conducted across a range of databases. Titles, abstracts and full texts were screened for relevance. In Phase 3 of the realist review, data extraction was conducted using NVivo, coding sections of manuscripts to facilitate theory testing. Researchers analysed two CMOcs: one focused on implementation – facilitation – and one focused on falls risk reduction – patient participation. Narrative summaries were written and used to refine the initial CMOcs. Included texts were appraised using the mixed methods appraisal tool (MMAT). To assess strength of the body of evidence for the refined CMOcs, we used Grades of Recommendation, Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual). As an additional source of evidence, we undertook an advanced Google search for the policies of 25 acute Trusts regarding falls risk assessment and prevention. We assessed adherence of these policies to the NICE guideline on falls in older people by checking whether a falls risk prediction tool was recommended; whether the approach recommended involved tailoring interventions to patients’ individual risk factors; and by looking for specific elements of the assessments undertaken (such as whether continence and cognitive impairment are assessed), as specified by NICE and captured in the National Audit of Inpatient Falls (NAIF). We then conducted a multisite case study to further refine the theories across three NHS acute Trusts in England. Trusts were selected to ensure variation in key indicators in the NAIF and in health IT, and to include both teaching and district general hospitals. In each Trust, we collected data in one older person ward and one orthopaedic ward. Data were collected through 251.25 hours of ethnographic observations of falls prevention practices, interviews with staff (n = 50), patients (n = 28) and carers (n = 3), and a review of patient clinical records (n = 60). We also received routinely collected data on the number of falls and falls-related harms. The Lay Research Group contributed to the development of the observation protocol and interview topic guides for patients and carers. Observations took place at different times of day, including night shifts, and different days of the week, including weekends. The record review extracted data on (1) whether a falls risk assessment was completed for the patient on admission and within 6 hours; (2) whether a care plan was documented for the patient and if this was completed on a day or night shift; and (3) whether the care plan was updated and if updates were completed on a day or night shift. Qualitative data analysis followed the steps of framework analysis. The Lay Research Group contributed, providing a patient perspective. Descriptive statistics were produced for the record review data, broken down by ward. Narratives were written and used to refine the CMOcs. Online presentations at each case site acted as a form of respondent validation and an opportunity to gather participants’ perspectives on the implications of the research for practice. Findings In the realist review, 78 studies were used for theory construction and 50 for theory testing. Four theory areas were explored: (1) leadership; (2) shared responsibility; (3) facilitation via MFRA tools and (4) patient participation. The leadership theory developed in the theory construction phase of the realist review suggested that where falls prevention is prioritised by organisations, for example, in organisational policy and provision of resources, falls leaders/champions (staff trained and dedicated to supporting delivery of multifactorial falls prevention strategies on their wards, e.g. by offering training and education to new staff) inspire and support delivery of the strategy in a consistent and co-ordinated way, so all eligible patients receive a MFRA and tailored intervention strategies. This theory was tested through the review of Trust policies and multisite case study. The review of Trust policies found organisational-level policies, in the main, reflect NICE guidance. The role of falls link practitioners was identified in all three sites. Link practitioners were expected to act as role models for falls reduction in their clinical areas, and provide advice and education around assessment, intervention and management of patients who had fallen or were at risk of falling. They were also expected to facilitate regular audits of falls management practice on wards and raise any patient safety concerns. However, pressures of work on wards, aggravated by coronavirus disease 2019, meant it was not always possible to fulfil such duties. Similarly, it could be difficult for them to attend the training they were entitled to. Despite these challenges, documentation of the falls risk assessment and care plan was largely consistent across sites. Ultimate responsibility for falls prevention resided with senior nurses (the ward manager or the nurse-in-charge of the shift), who would monitor, remind and support staff to deliver falls prevention practices while also being sensitive to the pressures staff were under. They had authority to make decisions related to allocation of resources, such as which patients should be moved to cohort bays (bays where patients considered to be at high risk of falling were placed, with a staff member always present), and they would escalate patient safety concerns to hospital managers. Formal training about Trusts’ falls prevention policies was provided by organisational teams for new starters on induction. Messaging was also a key strategy, for example, through visual displays and reminders about expectations and policy on wards. The initial theory of shared responsibility suggested that, where there is a culture of learning from errors, if information about patients’ falls risks is effectively communicated between ward staff (e.g. through posters/safety huddles/handovers), staff will develop a sense of shared responsibility for falls prevention and become more vigilant of patients at risk from falls, supporting implementation of multifactorial strategies to prevent falls. This theory was tested through the case study. Undertaking MFRAs was the responsibility of nurses; this documentation was rarely accessed by other professional groups. Instead, communication between professional groups was primarily verbal, both formal, for example, in multidisciplinary team meetings and safety huddles, and informal. Additionally, visual communication tools were used, such as patient bed boards, on which information about patient transfer and mobilisation needs was recorded. Symbols such as a falling leaf were also displayed to identify patients at risk of falling. However, information on bed boards was often variable or incomplete. A key falls prevention strategy across all wards was patient supervision, for example, provision of one-to-one care and use of cohort bays, responsibility for which fell to nursing staff, constraining the extent to which responsibility for falls prevention could be shared among the multidisciplinary team. The initial facilitation theory concerned MFRA tools (including health IT) that reflect best practice recommendations, are relatively quick and easy to use, and easily integrated into existing workflows. The theory stated that, where staff educated about falls risks and prevention practices had access to such tools, they will complete them with patients because they facilitate implementation of recommended practice, helping to ensure all eligible patients receive a comprehensive MFRA and appropriate interventions. This theory was tested through the realist review and case study. Review findings suggested that, where tools are clearly visible to staff in their work routines, they can prompt documentation of a falls risk assessment. Following an assessment, documentation and delivery of interventions can be constrained by changes in patient condition, movement between wards, intervention availability, and communication between different professional groups. Health IT can facilitate delivery of falls prevention practices by automating processes and reducing work for clinicians but can also introduce additional tasks. There was variation across case sites in the number and type of assessment items included in the falls risk assessment tools within the electronic health record (EHR). Nurses perceived the tools as practice prompts, but competing priorities on nurse time could reduce tool use to a tick-box exercise. While all tools identified individual patient risk factors, stratification of patients as high or low risk was used to determine which patients should receive supervision. The initial patient participation theory suggested that, where patients have capacity to engage in the MFRA process, and a patient-centred approach is taken that involves them and their carers, patients will understand their strategy and have the confidence/reassurance to participate in specific interventions, thereby reducing their risk of falling. This theory was tested through the realist review and multisite case study. Review findings suggested that interventions that encourage cognitively intact patients to participate in falls prevention practices are associated with a reduction in falls. However, patient participation in falls prevention strategies can be constrained by patients not wanting to disturb busy nurses by requesting help, not perceiving or believing they are at risk of falls, and not understanding their falls risks. Patient participation is supported by staff who understand patients’ circumstances through meaningful, directed interactions, enabling staff to personalise falls prevention messages to improve patient knowledge, skills and confidence to participate. There is little research examining patient participation interventions with cognitively impaired patients. In the case study, workload pressures meant nursing staff had little time to explain to patients why they were at risk of falling or what they could do to prevent themselves from falling, although other staff could have such conversations and pass information to nurses. Many patients had cognitive impairments, which constrained the extent to which they could participate in interventions. Wards were often not staffed sufficiently for staff to respond to patient needs, leading to patients mobilising alone, although the quality of the interaction between staff and patients (including some cognitively impaired patients) could reduce the likelihood of patients taking actions that increased their risk of falling. Participants in the case site presentations agreed with the analysis. Key themes regarding implications were (1) the need for the lessons learnt to be disseminated to all professional groups, through leaflets and training materials; and (2) the need for leaflets for patients and carers, individualised to patients, providing them with information about their falls risks and how to prevent falls. Limitations A limitation of the review is that we were only able to complete data synthesis for two CMOcs. Limitations of the case study are that our observations focused on nursing staff, as they were most present on the wards, and we were unable to access patient records prior to observations, preventing assessment of whether care plans were enacted. Additionally, we did not manage to recruit patient participants who did not speak English; while we had information sheets translated into the three most spoken non-English languages across the case sites, all patients we met could speak English. Conclusions Implications for practice (1) Leadership: There should be a clear distinction between senior nurses’ roles and falls link practitioners in relation to fall prevention; (2) shared responsibility: Trusts should consider how processes and systems, including EHRs, can be revised to better support a multidisciplinary approach, and alternatives to patient supervision should be considered; (3) facilitation: Trusts should consider how to reduce documentation burden and avoid tick-box responses and ensure that items included in the falls risk assessment tools align with guidance. Falls risk assessment tools and falls care plans should be presented as tools to support practice, rather than something to be audited; (4) patient participation: Trusts should consider how they can ensure patients receive individualised information about risks and preventing falls and provide staff with guidance on brief but sensitive ways to talk with patients to reduce the likelihood of actions that increase their risk of falling. Recommendations for research Future research on falls risk assessment and prevention should include those with cognitive impairment and patients who do not speak the main language of the country in which the research is taking place: development and mixed method and economic evaluation of interventions to support multidisciplinary teams to undertake, and involve patients in, MFRA and selection and delivery of tailored interventions mixed method and economic evaluations of cohort bays and one-to-one care, comparing this to tailored alternatives mixed method and economic evaluations of engagement support workers, volunteers, and/or carers to support falls prevention. Study registration This study is registered on PROSPERO CRD42020184458. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR129488) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 5. See the NIHR Funding and Awards website for further award information.

Abstract Background Hospitals invest in Leadership Development Programs (LDPs) for physicians, assuming they benefit the organization’s performance. Researchers have listed the advantages of LDPs, but knowledge of how and why organization-level outcomes are achieved is missing. Objective To investigate how, why and under which circumstances LDPs for physicians can impact organization-level outcomes. Methods We conducted a realist review, following the RAMESES guidelines. Scientific articles and grey literature published between January 2010 and March 2021 evaluating a leadership intervention for physicians in the hospital setting were considered for inclusion. The following databases were searched: Medline, PsycInfo, ERIC, Web of Science, and Academic Search Premier. Based on the included documents, we developed a LDP middle-range program theory (MRPT) consisting of Context-Mechanism-Outcome configurations (CMOs) describing how specific contexts (C) trigger certain mechanisms (M) to generate organization-level outcomes (O). Results In total, 3904 titles and abstracts and, subsequently, 100 full-text documents were inspected; 38 documents with LDPs from multiple countries informed our MRPT. The MRPT includes five CMOs that describe how LDPs can impact the organization-level outcomes categories ‘culture’, ‘quality improvement’, and ‘the leadership pipeline’: 'Acquiring self-insight and people skills (CMO1)', 'Intentionally building professional networks (CMO2)', 'Supporting quality improvement projects (CMO3)', 'Tailored LDP content prepares physicians (CMO4)', and 'Valuing physician leaders and organizational commitment (CMO5)'. Culture was the outcome of CMO1 and CMO2, quality improvement of CMO2 and CMO3, and the leadership pipeline of CMO2, CMO4, and CMO5. These CMOs operated within an overarching context, the leadership ecosystem, that determined realizing and sustaining organization-level outcomes. Conclusions LDPs benefit organization-level outcomes through multiple mechanisms. Creating the contexts to trigger these mechanisms depends on the resources invested in LDPs and adequately supporting physicians. LDP providers can use the presented MRPT to guide the development of LDPs when aiming for specific organization-level outcomes.

Abstract Background There are meaningful gaps in equitable access to Primary Health Care (PHC), especially for vulnerable populations after widespread reforms in Western countries. The Innovative Models Promoting Access-to-Care Transformation (IMPACT) research program is a Canadian-Australian collaboration that aims to improve access to PHC for vulnerable populations. Relationships were developed with stakeholders in six regions across Canada and Australia where access-related needs could be identified. The most promising interventions would be implemented and tested to address the needs identified. This realist review was conducted to understand how community coalition and outreach (e.g., mobile or pop-up) services improve access for underserved vulnerable residents. Objective To inform the development and delivery of an innovative intervention to increase access to PHC for vulnerable populations. Methods A realist review was conducted in collaboration with the Local Innovative Partnership (LIP) research team and the IMPACT research members who conducted the review. We performed an initial comprehensive systematic search using MEDLINE, EMBASE, PsycINFO, and the Cochrane Library up to October 19, 2015, and updated it on August 8, 2020. Studies were included if they focused on interventions to improve access to PHC using community coalition, outreach services or mobile delivery methods. We included Randomized Controlled Trials (RCTs), and systematic reviews. Studies were screened by two independent reviewers and the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used for data extraction and framework analysis to obtain themes. The LIP research team was also allowed to suggest additional papers not included at screening. Results We included 43 records, comprising 31 RCTs, 11 systematic reviews, and 1 case control study that was added by the LIP research team. We identified three main themes of PHC interventions to promote access for vulnerable residents, including: 1) tailoring of materials and services decreases barriers to primary health care, 2) services offered where vulnerable populations gather increases the “reach” of the interventions, 3) partnerships and collaborations lead to positive health outcomes. In addition, implementation designs and reporting elements should be considered. Conclusion Realist reviews can help guide the development of locally adapted primary health care interventions.

Abstract Background Falls are the most common safety incident reported by acute hospitals. In England national guidance recommends delivery of a multifactorial falls risk assessment (MFRA) and interventions tailored to address individual falls risk factors. However, there is variation in how these practices are implemented. This study aimed to explore the variation by examining what supports or constrains delivery of MFRAs and tailored interventions in acute hospitals. Methods A realist review of literature was conducted with searches completed in three stages: (1) to construct hypotheses in the form of Context, Mechanism, Outcome configurations (CMOc) about how MFRAs and interventions are delivered, (2) to scope the breadth and depth of evidence available in Embase to test the CMOcs, and (3) following prioritisation of CMOcs, to refine search strategies for use in multiple databases. Citations were managed in EndNote; titles, abstracts, and full texts were screened, with 10% independently screened by two reviewers. Results Two CMOcs were prioritised for testing labelled: Facilitation via MFRA tools, and Patient Participation in interventions. Analysis indicated that MFRA tools can prompt action, but the number and type of falls risk factors included in tools differ across organisations leading to variation in practice. Furthermore, the extent to which tools work as prompts is influenced by complex ward conditions such as changes in patient condition, bed swaps, and availability of falls prevention interventions. Patient participation in falls prevention interventions is more likely where patient directed messaging takes individual circumstances into account, e.g., not wanting to disturb nurses by using the call bell. However, interactions that elicit individual circumstances can be resource intensive and patients with cognitive impairment may not be able to participate despite appropriately directed messaging. Conclusions Organisations should consider how tools can be developed in ways that better support consistent and comprehensive identification of patients’ individual falls risk factors and the complex ward conditions that can disrupt how tools work as facilitators. Ward staff should be supported to deliver patient directed messaging that is informed by their individual circumstances to encourage participation in falls prevention interventions, where appropriate. Trial registration PROSPERO: CRD42020184458.

Abstract Background The aim of this study is to 1) explore the experiences of people living with dementia interacting with DFCs and 2) identify factors that influence empower and support people living with dementia to live successfully in DFCs. The main elements of a DFC are related to people; communities; organisations and partnerships. There are over 200 organisations recognised as dementia-friendly in Northern Ireland (NI). This realist evaluation is to understand how DFCs work for people living with dementia, how positive outcomes are achieved, for whom and in what contexts do DFCs work best. Methods A realist evaluation using case study methodology. The process evaluation includes a realist review of the literature, non-participant observation of people living with dementia in their local communities, semi-structured interviews to explore the facilitators and barriers to living well in DFCs and focus groups comprised of people living with dementia, family caregivers and people working in DFCs to support Context- Mechanisms and Outcomes (CMOs). This four-stage realist assessment cycle is used, including iterative rounds of theory development, data gathering, and theory testing. In the end, analysis will reveal context mechanisms that influence how dementia-friendly communities operate and present an initial theory of how people think, which, if adopted, may be able to alter current contexts so that "key" mechanisms are activated to generate desired outcomes. Discussion To give confidence in moving from hypothetical constructions about how DFCs could function to explanations of possible or observable causal mechanisms, the realist evaluation of a complex intervention incorporates a variety of evidence and perspectives. Despite playing a significant role in a person with dementia's everyday life, it appears that little is known about how communities function to achieve intended results. Even though there has been a lot of work to pinpoint the fundamentals and crucial phases of building DFCs, it is still unclear how people living with dementia benefit the most from these communities. This study intends to advance our understanding of how outcomes are produced for people living with dementia by contributing to the underlying theory of DFCs as well as addressing the primary research objectives.

Abstract Aim The purpose of this realist review was to assess what works, for whom and in what context, regarding strategies that influence nurses' behaviour to improve triage quality in emergency departments (ED). Design Realist review protocol. Methods This protocol follows the PRISMA‐P statement and will include any type of study on strategies to improve the triage process in the ED (using recognized and validated triage scales). The included studies were examined for scientific quality using the Mixed Methods Appraisal Tool. The framework for this realist review is based on the Behaviour Change Wheel (BCW) and the context‐mechanism‐outcome (CMO) models. Discussion Nurses and ED decision makers will be informed on the evidence regarding strategies to improve the quality of triage and the factors required to maximize their effectiveness. Research gaps may also be identified to guide future research projects on the adoption of best practices in ED nursing triage.

Background: A third of older people take five or more regular medications (polypharmacy). Conducting medication reviews in primary care is key to identify and reduce/ stop inappropriate medications (deprescribing). Recent recommendations for effective deprescribing include shared-decision making and a multidisciplinary approach. Our aim was to understand when, why, and how interventions for medication review and deprescribing in primary care involving multidisciplinary teams (MDTs) work (or do not work) for older people. Methods: A realist synthesis following the Realist And Meta-narrative Evidence Syntheses: Evolving Standards guidelines was completed. A scoping literature review informed the generation of an initial programme theory. Systematic searches of different databases were conducted, and documents screened for eligibility, with data extracted based on a Context, Mechanisms, Outcome (CMO) configuration to develop further our programme theory. Documents were appraised based on assessments of relevance and rigour. A Stakeholder consultation with 26 primary care health care professionals (HCPs), 10 patients and three informal carers was conducted to test and refine the programme theory. Data synthesis was underpinned by Normalisation Process Theory to identify key mechanisms to enhance the implementation of MDT medication review and deprescribing in primary care. Findings: A total of 2821 abstracts and 175 full-text documents were assessed for eligibility, with 28 included. Analysis of documents alongside stakeholder consultation outlined 33 CMO configurations categorised under four themes: 1) HCPs roles, responsibilities and relationships; 2) HCPs training and education; 3) the format and process of the medication review 4) involvement and education of patients and informal carers. A number of key mechanisms were identified including clearly defined roles and good communication between MDT members, integration of pharmacists in the team, simulation-based training or team building training, targeting high-risk patients, using deprescribing tools and drawing on expertise of other HCPs (e.g., nurses and frailty practitioners), involving patents and carers in the process, starting with 'quick wins', offering deprescribing as 'drug holidays', and ensuring appropriate and tailored follow-up plans that allow continuity of care and management. Conclusion: We identified key mechanisms that could inform the design of future interventions and services that successfully embed deprescribing in primary care. [ABSTRACT FROM AUTHOR]