Peter O’Halloran

The use and limitation of realistic evaluation as a tool for evidence-based practice: a critical realist perspective

The use and limitation of realistic evaluation as a tool for evidence-based practice: a critical realist perspective In this paper, we assess realistic evaluations articulation with evidence-based practice (EBP) from the perspective of critical realism. We argue that the adoption by realistic evaluation of a realist causal ontology means that it is better placed to explain complex healthcare interventions than the traditional method used by EBP, the randomized controlled trial (RCT). However, we do not conclude from this that the use of RCTs is without merit, arguing that it is possible to use both methods in combination under the rubric of realist theory. More negatively, we contend that the rejection of critical theory and utopianism by realistic evaluation in favour of the pragmatism of piecemeal social engineering means that it is vulnerable to accusations that it promotes technocratic interpretations of human problems. We conclude that, insofar as realistic evaluation adheres to the ontology of critical realism, it provides a sound contribution to EBP, but insofar as it rejects the critical turn of Bhaskars realism, it replicates the technocratic tendencies inherent in EBP.

Management of long-term sickness absence: a systematic realist review

Purpose The increasing impact and costs of long term sickness absence have been well documented. However, the diversity and complexity of interventions and of the contexts in which these take place makes a traditional review problematic. Therefore, we undertook a systematic realist review to identify the dominant programme theories underlying best practice, to assess the evidence for these theories, and to throw light on important enabling or disabling contextual factors. Method A search of the scholarly literature from 1950 to 2011 identified 5,576 articles, of which 269 formed the basis of the review. Results We found that the dominant programme theories in relation to effective management related to: early intervention or referral by employers; having proactive organisational procedures; good communication and cooperation between stakeholders; and workplace-based occupational rehabilitation. Significant contextual factors were identified as the level of support for interventions from top management, the size and structure of the organisation, the level of financial and organisational investment in the management of long-term sickness absence, and the quality of relationships between managers and staff. Conclusions Consequently, those with responsibility for managing absence should bear in mind the contextual factors that are likely to have an impact on interventions, and do what they can to ensure stakeholders have at least a mutual understanding (if not a common purpose) in relation to their perceptions of interventions, goals, culture and practice in the management of long term sickness absence.

Adolescent Men’s Pregnancy Resolution Choices in Relation to an Unintended Pregnancy: A Comparative Analysis of Adolescent Men in Three Countries

This article investigates adolescent men’s pregnancy resolution choices in Australia, Ireland, and Italy. It addresses two main gaps in the literature: the lack of research on (adolescent) men’s views on unintended pregnancy and pregnancy resolution and the lack of international comparative case studies on men and reproductive choices. Consistent with theories of the transformation of intimacies in society and the growth of individualization, the results suggest that adolescent men are interested in the effect of an unintended pregnancy on their individual biographies as well as the effect on their girlfriend’s health and well-being. However, Australian male adolescents were much more likely to choose abortion than Italian or Irish adolescents, suggesting adolescent males have also internalized country-level debates surrounding abortion. Methodologically, the article demonstrates an innovative approach to data collection using a computer-based interactive drama to facilitate participants’ deliberation and responses. It was shown to engage a large number of adolescent men and is likely to have wider generalizability in developing international comparative research on the topic as well as applications for health promotion.

The Management of Long-Term Sickness Absence in Large Public Sector Healthcare Organisations: A Realist Evaluation Using Mixed Methods

Purpose The success of measures to reduce long-term sickness absence (LTSA) in public sector organisations is contingent on organisational context. This realist evaluation investigates how interventions interact with context to influence successful management of LTSA. Methods Multi-method case study in three Health and Social Care Trusts in Northern Ireland comprising realist literature review, semi-structured interviews (61 participants), Process-Mapping and feedback meetings (59 participants), observation of training, analysis of documents. Results Important activities included early intervention; workplace-based occupational rehabilitation; robust sickness absence policies with clear trigger points for action. Used appropriately, in a context of good interpersonal and interdepartmental communication and shared goals, these are able to increase the motivation of staff to return to work. Line managers are encouraged to take a proactive approach when senior managers provide support and accountability. Hindering factors: delayed intervention; inconsistent implementation of policy and procedure; lack of resources; organisational complexity; stakeholders misunderstanding each other’s goals and motives. Conclusions Different mechanisms have the potential to encourage common motivations for earlier return from LTSA, such as employees feeling that they have the support of their line manager to return to work and having the confidence to do so. Line managers’ proactively engage when they have confidence in the support of seniors and in their own ability to address LTSA. Fostering these motivations calls for a thoughtful, diagnostic process, taking into account the contextual factors (and whether they can be modified) and considering how a given intervention can be used to trigger the appropriate mechanisms.

Online learning versus blended learning of clinical supervisee skills with pre-registration nursing students: A randomised controlled trial

BACKGROUND The World Health Organisation amongst others recognises the need for the introduction of clinical supervision education in health professional education as a central strategy for improving patient safety and patient care. Online and blended learning methods are growing exponentially in use in higher education and the systematic evaluation of these methods will aid understanding of how best to teach clinical supervision. OBJECTIVE The purpose of this study was to test whether undergraduate nursing students who received clinical supervisee skills training via a blended learning approach would score higher in terms of motivation and attitudes towards clinical supervision, knowledge of clinical supervision and satisfaction of learning method, when compared to those students who received an online only teaching approach. DESIGN A post-test-only randomised controlled trial. METHODS Participants were a total of 122 pre-registration nurses enrolled at one United Kingdom university, randomly assigned to the online learning control group (n = 60) or the blended learning intervention group (n = 62). The blended learning intervention group participated in a face-to-face tutorial and the online clinical supervisee skills training app. The online learning control group participated in an online discussion forum and the same online clinical supervisee skills training app. The outcome measures were motivation and attitudes using the modified Manchester Clinical Supervision Scale, knowledge using a 10 point Multiple Choice Questionnaire and satisfaction using a university training evaluation tool. Statistical analysis was performed using independent t-tests to compare the differences between the means of the control group and the intervention group. Thematic analysis was used to analyse responses to open-ended questions. RESULTS All three of our study hypotheses were confirmed. Participants who received clinical supervisee skills training via a blended learning approach scored higher in terms of motivation and attitudes - mean (m) = 85.5, standard deviation (sd) = 9.78, number of participants (n) = 62 - compared to the online group (m = 79.5, sd = 9.69, n = 60) (p = .001). The blended learning group also scored higher in terms of knowledge (m = 4.2, sd = 1.43, n = 56) compared to the online group (m = 3.51, sd = 1.51, n = 57) (p = .015); and in terms of satisfaction (m = 30.89, sd = 6.54, n = 57) compared to the online group (m = 26.49, sd = 6.93, n = 55) (p = .001). Qualitative data supported results. CONCLUSION Blended learning provides added pedagogical value when compared to online learning in terms of teaching undergraduate nurses clinical supervision skills. The evidence is timely given worldwide calls for expanding clinical skills supervision in undergraduate health professional education to improve quality of care and patient safety.

Facilitating Transition from Children's to Adult Services for Young Adults with Life-limiting conditions (TASYL). Programme theory developed from a mixed methods realist evaluation

BACKGROUND Improvements in care and treatment have led to more young adults with life-limiting conditions living beyond childhood, necessitating a transition from childrens to adult services. Given the lack of evidence on interventions to promote transition, it is important that those creating and evaluating interventions develop a theoretical understanding of how such complex interventions may work. OBJECTIVES To develop theory about the interventions, and organisational and human factors that help or hinder a successful transition from childrens to adult services, drawing on the experience, knowledge, and insights of young adults with life-limiting conditions, their parents/carers, and service providers. DESIGN A realist evaluation using mixed methods with four phases of data collection in the island of Ireland. Phase one: a questionnaire survey of statutory and non-statutory organisations providing health, social and educational services to young adults making the transition from childrens to adult services in Northern Ireland and one Health Services Executive area in the Republic of Ireland. Phase two: interviews with eight young adults. Phase three: two focus groups with a total of ten parents/carers. Phase four: interviews with 17 service providers. Data were analysed seeking to explain the impact of services and interventions, and to identify organisational and human factors thought to influence the quality, safety and continuity of care. RESULTS Eight interventions were identified as facilitating transition from childrens to adult services. The inter-relationships between these interventions supported two complementary models for successful transition. One focused on fostering a sense of confidence among adult service providers to manage the complex care of the young adult, and empowering providers to make the necessary preparations in terms of facilities and staff training. The other focused on the young adults, with service providers collaborating to develop an autonomous young adult, whilst actively involving parents/carers. These models interact in that a knowledgeable, confident young adult who is growing in decision-making abilities is best placed to take advantage of services - but only if those services are properly resourced and run by staff with appropriate skills. No single intervention or stakeholder group can guarantee a successful transition. Rather, service providers could work with young adults and their parents/carers to consider desired outcomes, and the range of interventions, in light of the organisational and human resources available in their context. This would allow them to supplement the organisational context where necessary and select interventions that are more likely to deliver outcomes in that context.

49 The use of patient-held records by children and young people managing a health condition: a realist review of the literature

Introduction Patient-held records (PHRs) are proposed to improve communication and coordination of care amongst young people with life-limiting conditions their families and health professionals. However implementation of PHRs has proved difficult due to technical organisational and professional barriers.1 Aims To identify the factors which help or hinder the use of PHRs by young people with life-limiting conditions. Method Systematic realist review. Literature was sourced from six databases: Medline Embase CINAHL PsychInfo The Cochrane Library Science Direct (from 1946 to December Week 1 2016). The web was searched to identify grey literature. Articles were sourced from reference lists of included studies. Data were extracted using a standardised data extraction form. Two reviewers completed data extraction and synthesis. Methodological rigor was assessed using the relevant Critical Appraisal Skills Programme (CASP) tool. Results Nine articles were included each reporting on a different PHR. Young people (and/or parents/carers) with conditions of higher severity requiring ongoing care more medications and frequent appointments with multiple providers were more engaged with the PHR. Service providers need sufficient knowledge about the PHR and organisations need to ensure staff can see the benefits of using the PHR for implementation success. Mechanisms triggered by the PHR included improved self-advocacy and young people becoming empowered to self-manage their condition. Conclusion Clear definitions of which young people would benefit from using a PHR must be established in order to direct resources accordingly. These definitions will help inform which organisations and service providers would see the most reward from PHR implementation. Reference . Archer N, Fevrier-Thomas U, Lokker C, McKibbon KA, Straus SE. Personal health records: A scoping review. Journal of American Medical Information Association2011;18(4):515–522.

“Hip protectors in the elderly: lack of effectiveness or just suboptimal implementation?” A reply to critics

Concerning: 1) Meyer G, Muhlhauser I (2006) Hip protectors in the elderly: lack of effectiveness or just suboptimal implementation? Eur Rev Aging Phys Act 3(2):85–90; and 2) O’Halloran PD, Cran GW, Beringer TRO, Kernohan G, O’Neill C, Orr A, Dunlop L, Murray LJ (2004) A cluster randomised controlled trial to evaluate a policy of making hip protectors available to residents of nursing homes. Age Ageing 33:582–588. doi:10.1093/ageing/afh200