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AbstractGiven the growing older population, the pace of technological development and evolving approaches to patient participation in modern healthcare, in this realist review, we seek to identify enabling factors for and barriers to co-creation of health services with older people, particularly regarding digital health services. Two sub-studies were conducted in seven scholarly databases. Based on qualitative analysis of 17 research articles published between 2011 and 2021, six themes are presented. The findings inform hands-on and practical aspects of co-creation by offering recommendations for fostering constructive interactions between older people and various service stakeholders in the development and implementation of digital healthcare services. [ABSTRACT FROM AUTHOR]

Background: With the continuous development of educational methods, desktop virtual reality technology has gradually attracted widespread attention. Although current research has shown that this technology can promote learning among nursing students, the mechanism and intrinsic factors are not yet clear. This study aims to explore the mechanisms and factors of the application of desktop virtual reality technology in nursing students' education and discuss the possible outcomes. Methods: The realist review accords with the Realist and Meta-narrative Evidence Syntheses-Evolving Standards (RAMESES). The steps are mainly divided into the following three stages: (1) To determine the initial project theory; (2) To screen the published research and grey literature according to the inclusion criteria; (3) To analyze, extract, and synthesize the evidence of the included studies and then come to a conclusion. Data sources: This study included the original research from the following 8 databases from the establishment of the database to November 2024: CNKI, Wanfang Database, CBMdisc, VIP database, Pubmed, Cochrane, Web of Science, Embase. Results: A total of 14 papers were included. Six mechanisms and six Context-Mechanism-Outcome combinations were identified, which explained the favourable factors related to the application of desktop virtual reality technology to the education of nursing students. Mechanisms include (1) personalized education, (2) clinically relevant cases, (3) dynamic visualization, (4) good education conditions, (5) gaming education, and (6) interactive education. Conclusion: This realist review demonstrates the underlying mechanisms, context, and outcomes, which will guide educators in using virtual reality technology to educate nursing students better. [ABSTRACT FROM AUTHOR]

Various programs aimed at fostering the resilience of students have been implemented into healthcare undergraduate and postgraduate educational courses and degree programs. Which of these increase their participants' resilience under which circumstances, for whom and why remains uncertain. A realist review of articles reporting program outcomes as measures of resilience through the use of via validated psychometric surveys was conducted to investigate which contexts favour the development of resilience of healthcare and health sciences students and which mechanisms have to be activated to achieve this outcome. Thirteen Context-Mechanism-Outcome Configurations were synthesised from data presented in 43 articles. These were combined with theories explaining the theoretical and psychological frameworks underpinning programs to develop a program theory of how and why resilience fostering programs work. Contexts which favour the development of resilience were the use of validated psychological frameworks as program foundation, e.g. Cognitive Behavioural Therapy, mindfulness-based training. Expert facilitation, longitudinal integration into curricula, flexible and multi-modal design and delivery, and opportunities for students to apply and practice resilience-building strategies also created favourable contexts. Meeting students' or practitioners' needs activated mechanisms of trust, engagement and recognition of a program's value and real-world benefits. An increase in resilience was achieved by students developing reflective skills, metacognitive awareness and positive habits of mind. The program theory established via a realist review provides guidance on how the individual resilience of healthcare students can be fostered throughout their undergraduate, postgraduate degrees and early practice, potentially supporting them to flourish and remain long-term in their chosen professional roles. [ABSTRACT FROM AUTHOR]

A realist review is a theory-driven approach to synthesizing evidence based on the realist philosophy of science. Realist reviews are conducted to provide the policy and practice community with a rich, detailed and practical understanding of complex social interventions that will likely be of much more use to them when planning and implementing programmes. Robust realist reviews must balance philosophical engagement, methodological rigour and relevance to practice. Nevertheless, they have been criticized for being more philosophically inclined and less methodologically robust, with findings that have little implication for practice. Using the philosophy/epistemology➔ methodology➔ theory➔ practice concept flow, we report how we balanced philosophical principles and practical insights in a recently conducted realist review on participatory practices that impact the benefits of non-communicable disease research and interventions in low- and middle-income countries. If realist reviews are not comprehensible enough for these practitioners, their utility and relevance may suffer from being limited to a specialist cohort of academics. We propose that realist review findings and outputs must be framed and communicated to meaningfully engage practitioners without undertaking translational efforts. [ABSTRACT FROM AUTHOR]

Background: Delivery of health and care services using a combination of remote and/or in-person channels and digital and/or traditional tools (Hybrid Service Delivery, HSD) is increasingly seen as a way of improving quality and affordability, improving access, personalisation and sustainability, and reducing inequalities. Across the voluntary, community and social enterprise sector (VCSE), using a combination of remote and/or in-person channels and digital and/or traditional tools (HSD) has enabled the essential provision of services for people who have learning disabilities and/or autistic (LDA). However, it is unclear how different tools and channels have been used, what worked well or not well, for whom, and in what circumstances. The aim of this realist review is to explore how VCSE organisations can effectively use digital technologies alongside or instead of in-person activity to provide social care services to adults with learning disabilities and/or autism. This review protocol is presented in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocol (PRISMA-P). Methods: We will conduct a participatory realist review. Following realist review methodology, and involving people with LDA and organisations who deliver services to them, we will define the scope of the review/theory development, search for and appraise evidence, extract and synthesise findings, and develop the narrative. Using a developed strategy, electronic databases (Academic Search Complete, CINAHL, MEDLINE, PsycInfo, SCOPUS, Social Science Citation Index and Social Policy and Practice) will be searched. A data extraction table will be used to assist in sifting, sorting and organising relevant information from identified studies. For each proposition statement, relevant data from the identified literature will be synthesised and compared with the proposed theory to develop an understanding of how, why and when hybrid delivery works in different settings with different populations. Discussion: This review aims to collate and synthesise evidence relating to hybrid service delivery in VCSE organisations to provide social care services to LDA adults. By conducting a participatory realist review, we anticipate that the findings will lead to a greater understanding of contextual factors and therefore more relevant recommendations. Systematic review registration: PROSPERO CRD42024457161. [ABSTRACT FROM AUTHOR]

Respite and permanent transition to residential aged care are processes that are designed to support preferences and needs of people living with dementia and their carers as the disease progresses. These services are highly variable in acceptability, accessibility, and availability for the caregiving dyad, often not reflecting a person-centred, co-ordinated and cohesive approach. This study aimed to use a two-phase realist synthesis to explore how respite and permanent transition models of care work in different contexts, through different mechanisms to produce varying outcomes. Phase 1 explored preliminary theories and assumptions of the respite care journey, including (a) identification of systematic reviews and innovative programs, and (b) semi-structured interviews sessions with key stakeholders. Phase 2 involved an iterative scoping review to identify and map the available evidence, with a synthesis designed to unpack underlying program theories of why, for whom and in what circumstances respite/transition models of care works. Phase 1(a) identified ten citations from 126 systematic review abstracts. Fourteen residential care managers participated in a contextual scan – Phase 1(b). Phase 2 expanded this knowledge, identifying a further 13 studies. Three program theories, at the macro, meso and micro level, were elucidated: (1) system-level evidence-based integration, through collaboration and co-ordination; (2) inclusive, quality care, with supportive environmental design; and (3) trust, autonomy, and meaning-making. A novel realist synthesis approach was used to explore respite and permanent transition models of care beyond 'what works'. Importantly, findings at the macro, meso and micro level context, suggest nuance, with a shared decision-making approach, is needed to optimise the ever-changing dementia care journey. [ABSTRACT FROM AUTHOR]

Medium secure mental health units (MSUs) provide a specialised secure environment to assist people recovering from mental illness where less restrictive care has been unsuccessful or been unable to provide safety for the person or the community. Internationally, it has been found that these units can be associated with prolonged admissions, posing ethical and resource issues. Objectives: This 'Realist Review' aimed to investigate the factors associated with length of stay and outcomes of medium secure care to help inform the development of a local secure care pathway. Method: The searches generated a total of 1570 entries across multiple search engines. Following removal of duplicates, application of inclusion/exclusion criteria and selection of articles, a total of 18 were reviewed in detail, including a further five articles obtained from references and the explored grey literature. Results: Several issues influenced not only admission to medium secure units, but also the outcomes. Many articles were retrospective studies relying on administrative data. The realist synthesis provides contextual data to inform program development. Conclusions: The existing literature, though variable in quality, was limited by the varied jurisdictions and contexts. However it may be useful to inform care pathways for the optimal use of medium secure beds. [ABSTRACT FROM AUTHOR]

Abstract Background With the continuous development of educational methods, desktop virtual reality technology has gradually attracted widespread attention. Although current research has shown that this technology can promote learning among nursing students, the mechanism and intrinsic factors are not yet clear. This study aims to explore the mechanisms and factors of the application of desktop virtual reality technology in nursing students’ education and discuss the possible outcomes. Methods The realist review accords with the Realist and Meta-narrative Evidence Syntheses-Evolving Standards (RAMESES). The steps are mainly divided into the following three stages: (1) To determine the initial project theory; (2) To screen the published research and grey literature according to the inclusion criteria; (3) To analyze, extract, and synthesize the evidence of the included studies and then come to a conclusion. Data sources This study included the original research from the following 8 databases from the establishment of the database to November 2024: CNKI, Wanfang Database, CBMdisc, VIP database, Pubmed, Cochrane, Web of Science, Embase. Results A total of 14 papers were included. Six mechanisms and six Context-Mechanism-Outcome combinations were identified, which explained the favourable factors related to the application of desktop virtual reality technology to the education of nursing students. Mechanisms include (1) personalized education, (2) clinically relevant cases, (3) dynamic visualization, (4) good education conditions, (5) gaming education, and (6) interactive education. Conclusion This realist review demonstrates the underlying mechanisms, context, and outcomes, which will guide educators in using virtual reality technology to educate nursing students better.

Abstract Background There is growing interest in the benefits of group models of antenatal care. Although clinical reviews exist, there have been few reviews that focus on the mechanisms of effect of this model. Methods We conducted a realist review using a systematic approach incorporating all data types (including non-research and audiovisual media), with synthesis along Context-Intervention-Mechanism-Outcome (CIMO) configurations. Results A wide range of sources were identified, yielding 100 relevant sources in total (89 written and 11 audiovisual). Overall, there was no clear pattern of ‘what works for whom, in what circumstances’ although some studies have identified clinical benefits for those with more vulnerability or who are typically underserved by standard care. Findings revealed six interlinking mechanisms, including: social support, peer learning, active participation in health, health education and satisfaction or engagement with care. A further, relatively under-developed theory related to impact on professional practice. An overarching mechanism of empowerment featured across most studies but there was variation in how this was collectively or individually conceptualised and applied. Conclusions Mechanisms of effect are amplified in contexts where inequalities in access and delivery of care exist, but poor reporting of populations and contexts limited fuller exploration. We recommend future studies provide detailed descriptions of the population groups involved and that they give full consideration to theoretical underpinnings and contextual factors. Registration The protocol for this realist review was registered in the International Prospective Register of Systematic Reviews (PROSPERO CRD42016036768).

Abstract Background Antimicrobial resistance is a global patient safety priority and inappropriate antimicrobial use is a key contributing factor. Evidence have shown that delayed (back-up) antibiotic prescriptions (DP) are an effective and safe strategy for reducing unnecessary antibiotic consumption but its use is controversial. Methods We conducted a realist review to ask why, how, and in what contexts general practitioners (GPs) use DP. We searched five electronic databases for relevant articles and included DP-related data from interviews with healthcare professionals in a related study. Data were analysed using a realist theory-driven approach – theorising which context(s) influenced (mechanisms) resultant outcome(s) (context-mechanism-outcome-configurations: CMOCs). Results Data were included from 76 articles and 41 interviews to develop a program theory comprising nine key and 56 related CMOCs. These explain the reasons for GPs’ tolerance of risk to different uncertainties and how these may interact with GPs’ work environment, self-efficacy and perceived patient concordance to make using DP as a safety-net or social tool more or less likely, at a given time-point. For example, when a GP uses clinical scores or diagnostic tests: a clearly high or low score/test result may mitigate scientific uncertainty and lead to an immediate or no antibiotic decision; an intermediary result may provoke hermeneutic (interpretation-related) uncertainty and lead to DP becoming preferred and used as a safety net. Our program theory explains how DP can be used to mitigate some uncertainties but also provoke or exacerbate others. Conclusion This review explains how, why and in what contexts GPs are more or less likely to use DP, as well as various uncertainties GPs face which DP may mitigate or provoke. We recommend that efforts to plan and implement interventions to optimise antibiotic prescribing in primary care consider these uncertainties and the contexts when DP may be (dis)preferred over other interventions to reduce antibiotic prescribing. We also recommend the following and have included example activities for: (i) reducing demand for immediate antibiotics; (ii) framing DP as an ‘active’ prescribing option; (iii) documenting the decision-making process around DP; and (iv) facilitating social and system support.

Abstract Background Adult day programs aim to facilitate aging in place by supporting the health and well-being of persons with dementia and providing respite to their caregivers. However, studies on the effects of day programs are inconclusive, and we especially lack insights into the context conditions and mechanisms of day programs that may produce different outcomes for different groups of persons with dementia and their caregivers. Our objective was to conduct a realist review, synthesizing research on day programs to develop program theories explaining how and why day programs do or do not produce positive or negative outcomes for different groups of persons with dementia, and caregivers. Methods We identified 14 literature reviews (including 329 references published between 1975 and 2021) on adult day programs. From this initial pool of studies, we will include those that focused on day program attendees with dementia or meaningful cognitive impairment, and/or their caregivers, and that report how day program contexts (C) and mechanisms (M) bring about outcomes (O) for attendees and caregivers. We will extract CMO statements (i.e., narratives that explain how and why day programs do or do not bring about certain outcomes for whom and under what circumstances). Using additional focused searches, citation mapping, citation tracking, and discussions with our researcher and expert team members, we will identify additional references. CMO statements will be synthesized, transformed into hypotheses, and linked and visualized to form program theories. Using focus groups and the James Lind Alliance Priority Setting Partnership method, we will discuss and prioritize our CMO statements and refine our program theories with 32 experts (older adults, caregivers, Alzheimer societies, caregiver organizations, day program staff and managers, and health system and policy decision makers). Discussion By identifying essential elements and processes of day programs and related knowledge gaps, this study will generate much-needed knowledge to leverage the full potential of day programs so they can provide appropriate care, preventing premature institutionalization, and unnecessary acute and primary care use. This will ultimately improve the quality of life of persons with dementia and their caregivers, alleviate caregiver burden, and reduce social costs. Systematic review registration PROSPERO CRD42024504030

Abstract Background Currently, there are more than 55 million people living with dementia worldwide. Supporting people with dementia to live as independently as possible in their communities is a global public health objective. There is limited research exploring the implementation of such interventions in the community context. The aim of the review was to create and refine programme theory – in the form of context mechanism-outcome configurations – on how the characteristics of dementia-friendly communities (DFCs) as geographical locations interact with their social and organisational contexts to understand what works for whom and why. Methods This realist review sourced literature from 5 electronic databases: Cochrane Library, CINAHL, Medline, Scopus, PsychINFO and Google Scholar, as well as relevant websites such as Alzheimer’s Society to identify grey literature. Methodological rigour was assessed using the Joanna Briggs Institute critical appraisal tool. Results Seven papers were included in this realist review that focused on DFCs in a geographical context The implementation of DFC interventions emerged as a process characterised by two pivotal implementation phases, intricately linked with sub-interventions. The first intervention, termed Hierarchy Commitment (I1a/b), involves the formalisation of agreements by businesses and organizations, along with the implementation of dementia-friendly action plans. Additionally, Educational Resources (I1c) play a significant role in this phase, engaging individuals with dementia and their caregivers in educational initiatives. The second phase, Geographical/Environmental Requirements (I2), encompasses the establishment of effective dementia-friendly signage, accessible meeting places, and community support. Conclusions This realist review highlighted a theoretical framework that might guide the development of dementia-friendly communities to enhance the experiences of individuals with dementia and their caregivers within DFCs. Emphasising the need for a theoretical framework in developing geographical DFCs, the review outlines contextual elements, mechanisms, and outcomes, providing a foundation for future studies. The ultimate goal is to establish a robust body of evidence for the sustainable implementation of dementia-friendly communities, thereby improving the quality of life for those with dementia. Study registration This study is registered as PROSPERO 2022 CRD42022317784.

Although support by experiential peers for individuals with criminal behaviour is increasing, an empirical basis for its effectiveness is lacking. The purpose of this review was to investigate outcomes, mechanisms, and contextual factors of individual support by experiential peers for individuals who display criminal behaviour. We conducted a systematic realist literature review to test and refine our initial programme theory, which included seven mechanisms that may play a role in the desistance-supportive outcomes of experiential peer support. We screened 6,530 scientific papers and eventually included 25 articles focusing on asymmetrical one-on-one support for and by individuals with criminal behaviour. The findings suggest that experiential peers show empathy and have a non-judgmental approach, are considered role models, establish a trusting relationship with clients, offer hope, connect clients to other services, and have a recovery perspective on desistance. We found results indicative of act-desistance, positive personal development and improvements in mental health and personal circumstances, although study results were not consistent. The information on contextual factors was too limited for a robust analysis. Future research should not only focus on objective measures (e.g. absence of criminal behaviour), but also on subjective measures (e.g. hope, self-esteem) and investigate long-term effects. [ABSTRACT FROM AUTHOR]

Indigenous communities, linguists, teachers, and language activists have been developing methods to revitalise endangered languages over several decades. Not only are these methods diverse, they are usually implemented in various ways according to local needs and aspirations. Language revitalisation methods focus on proficiency, but there is also interest in strengthening identity, resilience, and wellbeing. Aside from a handful of successes, programs may not be achieving desired outcomes. One could try to evaluate specific programs. However, we believe that a necessary first step is to examine published literature of revitalisation efforts to develop initial understandings of how they work. In particular, we seek to understand how revitalisation efforts tap into the speech community, how local participation affects outcomes, and how this involvement is supported and sustained by external programs, with a focus on language revitalisation efforts in Australia. We conduct a realist synthesis, and through analysis of 125 pieces of literature, we identify 13 initial theories. In analysing these theories, we identify two major gaps in our understanding of language revitalisation: how revitalisation programs work to strengthen communities and promote commitment. We propose these as significant, under-theorised elements of successful revitalisation which can guide exploration at the level of individual programs. [ABSTRACT FROM AUTHOR]

Background: Adult day programs aim to facilitate aging in place by supporting the health and well-being of persons with dementia and providing respite to their caregivers. However, studies on the effects of day programs are inconclusive, and we especially lack insights into the context conditions and mechanisms of day programs that may produce different outcomes for different groups of persons with dementia and their caregivers. Our objective was to conduct a realist review, synthesizing research on day programs to develop program theories explaining how and why day programs do or do not produce positive or negative outcomes for different groups of persons with dementia, and caregivers. Methods: We identified 14 literature reviews (including 329 references published between 1975 and 2021) on adult day programs. From this initial pool of studies, we will include those that focused on day program attendees with dementia or meaningful cognitive impairment, and/or their caregivers, and that report how day program contexts (C) and mechanisms (M) bring about outcomes (O) for attendees and caregivers. We will extract CMO statements (i.e., narratives that explain how and why day programs do or do not bring about certain outcomes for whom and under what circumstances). Using additional focused searches, citation mapping, citation tracking, and discussions with our researcher and expert team members, we will identify additional references. CMO statements will be synthesized, transformed into hypotheses, and linked and visualized to form program theories. Using focus groups and the James Lind Alliance Priority Setting Partnership method, we will discuss and prioritize our CMO statements and refine our program theories with 32 experts (older adults, caregivers, Alzheimer societies, caregiver organizations, day program staff and managers, and health system and policy decision makers). Discussion: By identifying essential elements and processes of day programs and related knowledge gaps, this study will generate much-needed knowledge to leverage the full potential of day programs so they can provide appropriate care, preventing premature institutionalization, and unnecessary acute and primary care use. This will ultimately improve the quality of life of persons with dementia and their caregivers, alleviate caregiver burden, and reduce social costs. Systematic review registration: PROSPERO CRD42024504030 [ABSTRACT FROM AUTHOR]

Background: There is growing interest in the benefits of group models of antenatal care. Although clinical reviews exist, there have been few reviews that focus on the mechanisms of effect of this model. Methods: We conducted a realist review using a systematic approach incorporating all data types (including non-research and audiovisual media), with synthesis along Context-Intervention-Mechanism-Outcome (CIMO) configurations. Results: A wide range of sources were identified, yielding 100 relevant sources in total (89 written and 11 audiovisual). Overall, there was no clear pattern of 'what works for whom, in what circumstances' although some studies have identified clinical benefits for those with more vulnerability or who are typically underserved by standard care. Findings revealed six interlinking mechanisms, including: social support, peer learning, active participation in health, health education and satisfaction or engagement with care. A further, relatively under-developed theory related to impact on professional practice. An overarching mechanism of empowerment featured across most studies but there was variation in how this was collectively or individually conceptualised and applied. Conclusions: Mechanisms of effect are amplified in contexts where inequalities in access and delivery of care exist, but poor reporting of populations and contexts limited fuller exploration. We recommend future studies provide detailed descriptions of the population groups involved and that they give full consideration to theoretical underpinnings and contextual factors. Registration: The protocol for this realist review was registered in the International Prospective Register of Systematic Reviews (PROSPERO CRD42016036768). [ABSTRACT FROM AUTHOR]

This review identifies which elements of home-based comprehensive sexual health care (home-based CSH) impacted which key populations, under which circumstances. A realist review of studies focused on home-based CSH with at least self-sampling or self-testing HIV and additional sexual health care (e.g., treatment, counseling). Peer-reviewed quantitative and qualitative literature from PubMed, Embase, Cochrane Register of Controlled Trials, and PsycINFO published between February 2012 and February 2023 was examined. The PRISM framework was used to systematically assess the reach of key populations, effectiveness of the intervention, and effects on the adoption, implementation, and maintenance within routine sexual health care. Of 730 uniquely identified records, 93 were selected for extraction. Of these studies, 60% reported actual interventions and 40% described the acceptability and feasibility. Studies were mainly based in Europe or North America and were mostly targeted to MSM (59%; 55/93) (R). Overall, self-sampling or self-testing was highly acceptable across key populations. The effectiveness of most studies was (expected) increased HIV testing. Adoption of the home-based CSH was acceptable for care providers if linkage to care was available, even though a minority of studies reported adoption by care providers and implementation fidelity of the intervention. Most studies suggested maintenance of home-based CSH complementary to clinic-based care. Context and mechanisms were identified which may enhance implementation and maintenance of home-based CSH. When providing the individual with a choice of testing, clear instructions, and tailored dissemination successful uptake of STI and HIV testing may increase. For implementers perceived care and treatment benefits for clients may increase their willingness to implement home-based CSH. Therefore, home-based CSH may determine more accessible sexual health care and increased uptake of STI and HIV testing among key populations. [ABSTRACT FROM AUTHOR]

Background: Currently, there are more than 55 million people living with dementia worldwide. Supporting people with dementia to live as independently as possible in their communities is a global public health objective. There is limited research exploring the implementation of such interventions in the community context. The aim of the review was to create and refine programme theory – in the form of context mechanism-outcome configurations – on how the characteristics of dementia-friendly communities (DFCs) as geographical locations interact with their social and organisational contexts to understand what works for whom and why. Methods: This realist review sourced literature from 5 electronic databases: Cochrane Library, CINAHL, Medline, Scopus, PsychINFO and Google Scholar, as well as relevant websites such as Alzheimer's Society to identify grey literature. Methodological rigour was assessed using the Joanna Briggs Institute critical appraisal tool. Results: Seven papers were included in this realist review that focused on DFCs in a geographical context The implementation of DFC interventions emerged as a process characterised by two pivotal implementation phases, intricately linked with sub-interventions. The first intervention, termed Hierarchy Commitment (I1a/b), involves the formalisation of agreements by businesses and organizations, along with the implementation of dementia-friendly action plans. Additionally, Educational Resources (I1c) play a significant role in this phase, engaging individuals with dementia and their caregivers in educational initiatives. The second phase, Geographical/Environmental Requirements (I2), encompasses the establishment of effective dementia-friendly signage, accessible meeting places, and community support. Conclusions: This realist review highlighted a theoretical framework that might guide the development of dementia-friendly communities to enhance the experiences of individuals with dementia and their caregivers within DFCs. Emphasising the need for a theoretical framework in developing geographical DFCs, the review outlines contextual elements, mechanisms, and outcomes, providing a foundation for future studies. The ultimate goal is to establish a robust body of evidence for the sustainable implementation of dementia-friendly communities, thereby improving the quality of life for those with dementia. Study registration: This study is registered as PROSPERO 2022 CRD42022317784. [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]

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]

In 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.

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

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]

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]

Introduction The last decades have witnessed a series of initiatives in the United Kingdom (UK) to enhance patient access to quality care including access to medicine without compromising patient’s safety. Pharmacist independent prescribing is one of the initiatives introduced in 2006 with the intention of making more effective use of the skills and competencies of health professionals. Community pharmacy has a key role in the NHS long-term plan since pharmacies offer convenient and accessible sources of healthcare advice for the public. This role is more evident with the introduction of prescribing for all qualified pharmacists at the point of registration starting 2026. This realist review aims to explore how does independent prescribing in community pharmacy works, for whom, in what circumstances and how. Method and analysis Realist research seeks to explore and explain complex social interventions by utilising programme theories providing causal explanations of outcomes in terms of context-mechanism-outcome configurations. INTEGRATE will progress through six stages. In the first stage, we will partner with Patient, Public, Involvement and Engagement Group (PPIE) and Practitioner Stakeholder Group (SG), to further scrutinise the review’s focus. In stage 2, we will develop initial programme theories for what makes independent prescribing effective in community pharmacy, for whom, in what circumstances and how. In the third stage, we will conduct literature searches to gather secondary data that will help refine our initial programme theories. In stage 4, we will select and appraise identified articles by screening titles, abstracts and full texts against inclusion and exclusion criteria. In stage 5, we will extract, document and code relevant data, followed by realist analysis with contributions from the PPIE and SG. Stage 6 focuses on refining programme theories and identifying key mechanisms that lead to desired outcomes. PROSPERO registration: CRD42023468451

Background Child health programmes in the United Kingdom offer every child and their family an evidence-based programme to support child health and development. During the COVID-19 pandemic, health visiting services in many areas were reduced to a partial service, with significant variability between and within the four United Kingdom countries. This study investigated the impact of the pandemic on health visiting services and developed recommendations for policy and practice. Objectives Conduct a realist review of relevant literature. Engage with key stakeholders in policy, practice and research across the United Kingdom. Identify recommendations for improving the organisation and delivery of health visiting services, with a focus on services being equitable, effective and efficient. Review methods The realist review followed Pawson’s five iterative steps and involved key stakeholder representatives at every step. We searched five electronic databases and references of included articles, as well as relevant organisational websites, to find quantitative, qualitative, mixed-methods and grey literature related to health visiting services in the United Kingdom during the COVID-19 pandemic. An assessment of their relevance to our initial programme theory determined inclusion in the review. Data were extracted, organised and presented as draft context, mechanism and outcome configurations. These were iteratively refined through meetings with 6 people with lived experience of caring for babies during the pandemic and 23 professional stakeholders. Context, mechanism and outcome configurations were then translated into findings and recommendations. Results One hundred and eighteen documents contributed to the review and collectively revealed the far-reaching, uneven and enduring impact of the COVID-19 pandemic on babies and families. Data uncovered significant concerns of families and practitioners amidst the pandemic, along with the service’s corresponding actions. These concerns and responses underscored the critical importance of fostering and sustaining trusting relationships between health visitors and families, as well as conducting holistic assessments for early intervention. Although we found minimal evidence of decision-making within organisational/managerial levels, the data illustrated the diverse and complex nature of health visiting work and the need for flexibility and resourcefulness. Limitations The primary limitation of this review was a lack of specific evidence from the United Kingdom nations other than England. There was also a lack of data focusing on changes during the COVID-19 pandemic at a local management level. Conclusions The needs of babies, children and families, and the delivery of services to support them, were not prioritised in the early phase of the pandemic response. Our data show that the health visiting service was concerned with maintaining visibility of all children, and especially supporting families with a new baby. Health visiting services adapted in numerous ways to respond to these concerns. Implications for policy and practice are presented, identified from our analysis and discussions with stakeholders. Future work The RReHOPE study is part of a jigsaw of evidence, which will provide a much stronger evidence base for future policy and practice. This realist review presents several areas for future research, including how health visiting is organised at local management level; how to optimise limited resources; factors affecting differing uptake in different regions; and analysis of the effectiveness of health visiting using large cohort studies. Funding This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme under award number NIHR134986. Plain language summary Health visiting services are a core part of child health programmes in the United Kingdom. Health visitors provide support to all new babies and families, helping every child to have the best start in life. The COVID-19 pandemic disrupted these services, changing the support families received. Our project aimed to understand how health visiting services across the United Kingdom adapted during the pandemic, and how this affected families and health visiting teams. We reviewed the literature on health visiting during the pandemic using an approach called ‘realist review’. We studied 118 documents that gave us useful information about how health visiting services changed. Findings were grouped into three themes: health visiting contacts, health visiting connections and the health visiting workforce. When pandemic restrictions made it harder for health visitors to conduct their usual assessments, they were concerned about missed needs among families. While remote contacts were sometimes useful, face-to-face interactions were seen as crucial for building trust and understanding family contexts. Disruptions in community services and in connections between different services affected how families accessed wider support. They also made it harder for health visitors to do their job. The pandemic placed greater workload and stress on health visitors. Our recommendations emphasise that when health visitors meet with families it is a chance to learn about their needs, offer all-around support and connect them with other helpful services. We suggest there should be enough staff and time to provide these services, especially via face-to-face home visits. More research is needed on how health visiting services are organised and delivered in different places, and the implications for staff and families. Health visiting has a vital role to play, particularly during and after a pandemic, in keeping children healthy and safe. Our findings can be used to inform policy, practice and future research.

ABSTRACT Background Sedentary office work and work‐related stress increase the risk of metabolic syndrome. Workplace‐based education interventions for promoting prevention are gaining popularity due to their positive impact on managing metabolic syndrome. We conducted this realist review to understand the contextual factors and mechanisms that contribute to the effectiveness of these interventions and how they interact to produce outcomes. Method We conducted a comprehensive search of five main databases (PubMed, Web of Science, ProQuest, Scopus and PsycINFO) and Google Scholar, as well as references of included articles. We included all studies published until 12 January 2023, reporting the effects of workplace lifestyle education interventions on metabolic syndrome. Using a realist review approach, we identified and evaluated middle‐range theories to develop a context–mechanism–outcome configuration. Results We identified 6883 titles for screening, of which 15 studies were included in this realist review. This realist review has identified strong social support networks, workplace influence, involvement of worksite managers and cultural relevance as contextual factors that contribute to the effectiveness of workplace‐based education interventions for managing metabolic syndrome in low‐ and middle‐income countries, which may not be as prominent in developed countries. Conclusion The review concludes that while developing and implementing healthy lifestyle policies in the workplace, policymakers and researchers should consider social support, workplace influences, manager participation and cultural relevance.

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: 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.

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]

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 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 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 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.

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 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.