Understanding what works, why and in what circumstances in hospice at home services for end-of-life care: Applying a realist logic of analysis to a systematically searched literature review
Abstract:Background: We have undertaken a systematically searched literature review using a realist logic of analysis to help synthesise the diverse range of literature available on hospice at home services. Aim: To find out in the existing literature what features of hospice at home models work best, for whom and under what circumstances. Design: A realist logic of analysis was applied to synthesise the evidence focusing on mechanisms by which an intervention worked (or did not work). An initial programme theory was d… Show more
“…Twelve papers [ 8 , 15 – 25 ], reporting eight studies, were identified which met the inclusion criteria (Fig. 1 ).…”
Section: Resultsmentioning
confidence: 99%
“…Three other papers [ 19 , 21 , 24 ] were based on a Realist evaluation on the sustainability of Lean in paediatric healthcare. All other papers reported individual studies [ 8 , 15 , 17 , 22 , 23 , 25 ]. Fig.…”
Section: Resultsmentioning
confidence: 99%
“…Lewis et al 2019 [ 23 ] Community aged home care organisation Australia Qualitative Realist evaluation To evaluate the embedding of sustainable oral healthcare for older people into routine community aged care practice Multi-level facilitation of oral health for older people resident in care homes 14 interviews, mostly staff within the care organisation plus service consumers Yes 11 Flynn et al 2020 [ 24 ] (FLYNN study) Healthcare organisations Canada Multiphase Realist investigation To present a refined programme theory on the contextual factors and mechanisms that influence the sustainability of (Lean) management initiative in paediatric health care Lean model of healthcare quality and efficiency—philosophy and activities Triangulation of multiphase Realist investigation No 12. Hashem et al 2020 [ 25 ] Hospice at home UK Systematic literature review analysed using Realist logic To determine what features of hospice at home models work best, for whom and under what circumstances Hospice at home 49 papers reviewed, of which 34 contributed evidence to at least one of the eight theory areas Yes …”
Section: Resultsmentioning
confidence: 99%
“…These included lean approaches to healthcare [ 15 , 19 , 21 , 24 ], public and patient involvement in healthcare research [ 16 , 18 , 20 ], oral healthcare for older people in community practice [ 23 ] and chronic kidney disease management in primary care [ 17 ]. Two papers focused on intervention effectiveness: Hashem et al [ 25 ] focused on identifying mechanisms underpinning ‘what works, why and in what circumstances’ in hospice at home services for end-of-life care, and Gillespie et al [ 8 ] conducted a realist synthesis of evidence of implementation interventions to improve adherence to the use of safety checklists in surgery. Only one study reported using the approaches to inform both (strategic) implementation as well as evaluation (understanding), of an intervention: ‘open visiting’ on wards for care of older people in the acute hospital setting [ 22 ].…”
Background
Realist approaches and Normalization Process Theory (NPT) have both gained significant traction in implementation research over the past 10 years. The aim of this study was therefore to explore how the approaches are combined to understand problems of implementation, to determine the degree of complementarity of the two approaches and to provide practical approaches for using them together.
Methods
Systematic review of research studies combining Realist and NPT approaches. Realist methodology is concerned with understanding and explaining causation, that is, how and why policies, programmes and interventions achieve their effects. NPT is a theory of implementation that explains how practices become normalised. Databases searched (January 2020) were ASSIA, CINAHL, Health Research Premium Collection via Proquest (Family Health Database, Health & Medical Collection, Health Management Database, MEDLINE, Nursing & Allied Health Database, Psychology Database, Public Health Database) and PsycARTICLES. Studies were included if the author(s) stated they used both approaches: a scientific Realist perspective applying the principles of Pawson and Tilley’s Realist Evaluation or Pawson’s Realist Synthesis and Normalization Process Theory either solely or in addition to other theories. Two authors screened records; discrepancies were reviewed by a third screener. Data was extracted by three members of the team and a narrative synthesis was undertaken.
Results
Of 245 total records identified, 223 unique records were screened and 39 full-text papers were reviewed, identifying twelve papers for inclusion in the review. These papers represented eight different studies. Extent and methods of integration of the approaches varied. In most studies (6/8), Realist approaches were the main driver. NPT was mostly used to enhance the explanatory power of Realist analyses, informing development of elements of Contexts, Mechanisms and Outcomes (a common heuristic in realist work). Authors’ reflections on the integration of NPT and Realist approaches were limited.
Conclusions
Using Realist and NPT approaches in combination can add explanatory power for understanding the implementation of interventions and programmes. Attention to detailed reporting on methods and analytical process when combining approaches, and appraisal of theoretical and practical utility is advised for advancing knowledge of applying these approaches in research.
Systematic review registration
Not registered.
“…Twelve papers [ 8 , 15 – 25 ], reporting eight studies, were identified which met the inclusion criteria (Fig. 1 ).…”
Section: Resultsmentioning
confidence: 99%
“…Three other papers [ 19 , 21 , 24 ] were based on a Realist evaluation on the sustainability of Lean in paediatric healthcare. All other papers reported individual studies [ 8 , 15 , 17 , 22 , 23 , 25 ]. Fig.…”
Section: Resultsmentioning
confidence: 99%
“…Lewis et al 2019 [ 23 ] Community aged home care organisation Australia Qualitative Realist evaluation To evaluate the embedding of sustainable oral healthcare for older people into routine community aged care practice Multi-level facilitation of oral health for older people resident in care homes 14 interviews, mostly staff within the care organisation plus service consumers Yes 11 Flynn et al 2020 [ 24 ] (FLYNN study) Healthcare organisations Canada Multiphase Realist investigation To present a refined programme theory on the contextual factors and mechanisms that influence the sustainability of (Lean) management initiative in paediatric health care Lean model of healthcare quality and efficiency—philosophy and activities Triangulation of multiphase Realist investigation No 12. Hashem et al 2020 [ 25 ] Hospice at home UK Systematic literature review analysed using Realist logic To determine what features of hospice at home models work best, for whom and under what circumstances Hospice at home 49 papers reviewed, of which 34 contributed evidence to at least one of the eight theory areas Yes …”
Section: Resultsmentioning
confidence: 99%
“…These included lean approaches to healthcare [ 15 , 19 , 21 , 24 ], public and patient involvement in healthcare research [ 16 , 18 , 20 ], oral healthcare for older people in community practice [ 23 ] and chronic kidney disease management in primary care [ 17 ]. Two papers focused on intervention effectiveness: Hashem et al [ 25 ] focused on identifying mechanisms underpinning ‘what works, why and in what circumstances’ in hospice at home services for end-of-life care, and Gillespie et al [ 8 ] conducted a realist synthesis of evidence of implementation interventions to improve adherence to the use of safety checklists in surgery. Only one study reported using the approaches to inform both (strategic) implementation as well as evaluation (understanding), of an intervention: ‘open visiting’ on wards for care of older people in the acute hospital setting [ 22 ].…”
Background
Realist approaches and Normalization Process Theory (NPT) have both gained significant traction in implementation research over the past 10 years. The aim of this study was therefore to explore how the approaches are combined to understand problems of implementation, to determine the degree of complementarity of the two approaches and to provide practical approaches for using them together.
Methods
Systematic review of research studies combining Realist and NPT approaches. Realist methodology is concerned with understanding and explaining causation, that is, how and why policies, programmes and interventions achieve their effects. NPT is a theory of implementation that explains how practices become normalised. Databases searched (January 2020) were ASSIA, CINAHL, Health Research Premium Collection via Proquest (Family Health Database, Health & Medical Collection, Health Management Database, MEDLINE, Nursing & Allied Health Database, Psychology Database, Public Health Database) and PsycARTICLES. Studies were included if the author(s) stated they used both approaches: a scientific Realist perspective applying the principles of Pawson and Tilley’s Realist Evaluation or Pawson’s Realist Synthesis and Normalization Process Theory either solely or in addition to other theories. Two authors screened records; discrepancies were reviewed by a third screener. Data was extracted by three members of the team and a narrative synthesis was undertaken.
Results
Of 245 total records identified, 223 unique records were screened and 39 full-text papers were reviewed, identifying twelve papers for inclusion in the review. These papers represented eight different studies. Extent and methods of integration of the approaches varied. In most studies (6/8), Realist approaches were the main driver. NPT was mostly used to enhance the explanatory power of Realist analyses, informing development of elements of Contexts, Mechanisms and Outcomes (a common heuristic in realist work). Authors’ reflections on the integration of NPT and Realist approaches were limited.
Conclusions
Using Realist and NPT approaches in combination can add explanatory power for understanding the implementation of interventions and programmes. Attention to detailed reporting on methods and analytical process when combining approaches, and appraisal of theoretical and practical utility is advised for advancing knowledge of applying these approaches in research.
Systematic review registration
Not registered.
“…Effective home palliative care teams are characterized by timely, experienced and responsive care, effective symptom management, trusting relationships to build knowledge and capacity in patients and families, anticipatory care, and availability. 6,7 These characteristics are reflected in the London Home Palliative Care Team model through its delivery of active, patient-centered in-home physician care. Patients have regular home visits by our physicians to provide ongoing support for patients' physical and nonphysical symptoms.…”
Background: Limited research has characterized team-based models of home palliative care and the outcomes of patients supported by these care teams. Case presentation: A retrospective case series describing care and outcomes of patients managed by the London Home Palliative Care Team between May 1, 2017 and April 1, 2019. Case management: The London Home Palliative Care (LHPC) Team care model is based upon 3 pillars: 1) physician visit availability 2) active patient-centered care with strong physician in-home presence and 3) optimal administrative organization. Case outcomes: In the 18 month study period, 354 patients received care from the London Home Palliative Care Team. Most significantly, 88.4% ( n = 313) died in the community or at a designated palliative care unit after prearranged direct transfer; no comparable provincial data is available. 21.2% ( n = 75) patients visited an emergency department and 24.6% ( n = 87) were admitted to hospital at least once in their final 30 days of life. 280 (79.1%) died in the community. These values are better than comparable provincial estimates of 62.7%, 61.7%, and 24.0%, respectively. Conclusion: The London Home Palliative Care (LHPC) Team model appears to favorably impact community death rate, ER visits and unplanned hospital admissions, as compared to accepted provincial data. Studies to determine if this model is reproducible could support palliative care teams achieving similar results.
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