Application of the critical incident technique in refining a realist initial programme theory

Examining sedentary behaviours of adults with intellectual disabilities: A qualitative analysis

Sedentary behaviours among adults with intellectual disabilities have not been well studied. A sedentary lifestyle puts adults with and without disabilities at high risk of developing health conditions and diseases. Current literature revealed few empirical studies on the benefits of reducing sedentary behaviours with respect to the health of adults with intellectual disabilities. This research explored the factors that helped or hindered sedentary behaviours of adults with intellectual disabilities in the Canadian population. Guided by the socio-ecological model, Critical Incident Technique (CIT) was conducted. Five adults with intellectual disabilities from the Province of Ontario were interviewed and 102 critical incidents were collected. Adults with intellectual disabilities identified personal and environmental related factors that led to increased sedentary behaviours; and revealed helpful factors and wish-lists of actions that decreased sedentary lifestyle. Findings may be useful when developing programs aimed to decrease prolonged periods of sedentary behaviours specific to this vulnerable population.

Challenges in teacher-student communication during family medicine residency: A qualitative study

BACKGROUND

Deficiencies in communication among healthcare professionals, recognized by medical educators and healthcare institutions, can negatively impact medical education and clinical practice. Analyzing teacher-resident communication difficulties shed light on this issue and propose practical strategies for its mitigation.

OBJECTIVE

To identify common communication challenges between teacher and residents during Family Medicine residency and to analyze their impact on interactions with peers, the work team, and patients.

DESIGN

Qualitative study, the critical incident technique was used to collect information of interest.

PARTICIPANTS

Seventy teachers, and fifty third-year residents from the Mexican Republic described critical incidents related to their communication experiences during Family Medicine residency.

RESULTS

192 critical incidents were collected (several participants reported more than one incident), comprising 127 reports from teachers, and 65 from residents. Four themes were identified: 1) asymmetric communication, 2) assertive communication, 3) organizational communication, and 4) effective communication. The main challenges identified were abuse of power in communication, lack of communication skills, and the absence of institutional communication channels. These issues significantly impacted learning, work environment, interpersonal relationships, and medical care.

CONCLUSION

This study highlights communication issues within Family Medicine residency in Mexico. The issues detected hindered learning and effective collaboration and negatively impacted the work environment, interpersonal relationships, and the quality of medical care. These findings underscore the urgent need to reorient the medical specialty curriculum towards an approach that includes communication skills.

unDerstandIng the cauSes of mediCation errOrs and adVerse drug evEnts for patients with mental illness in community caRe (DISCOVER): a qualitative study

Background

It is estimated that 237 million medication errors occur in England each year with a significant number occurring in the community. Our understanding of the causes of preventable medication errors and adverse drug events (ADE) affecting patients with mental illness is limited in this setting. Better understanding of the factors that contribute to errors can support the development of theory-driven improvement interventions.

Methods

Remote qualitative semi-structured interviews with 26 community-based healthcare professionals in England and Wales were undertaken between June-November 2022. Recruitment was undertaken using purposive sampling via professional networks. Interviews were guided by the critical incident technique and analysed using the framework method. Any data that involved speculation was not included in the analysis. Independent analysis was carried out by the research team to extract themes guided by the London Protocol.

Results

A total of 43 medication errors and 12 preventable ADEs were discussed, with two ADEs having an unknown error origin. Prescribing errors were discussed most commonly (n = 24), followed by monitoring errors (n = 8). Six contributory factor themes were identified: the individual (staff); the work environment; the teams/interfaces; the organisation and management; the patient; and the task and technology. The individual (staff) factors were involved in just over 80% of all errors discussed. Participants reported a lack of knowledge regarding psychotropic medication and mental illnesses which accompanied diffusion of responsibility. There were difficulties with team communication, particularly across care interfaces, such as ambiguity/brevity of information being communicated and uncertainty concerning roles which created confusion amongst staff. Unique patient social/behavioural contributory factors were identified such as presenting with challenging behaviour and complex lifestyles, which caused difficulties attending appointments as well as affecting overall clinical management.

Conclusion

These findings highlight that the causes of errors are multifactorial with some unique to this patient group. Key areas to target for improvement include the education/training of healthcare professionals regarding neuropharmacology/mental illnesses and enhancing communication across care interfaces. Future research should explore patient perspectives regarding this topic to help develop a holistic picture. These findings can be used to guide future intervention research to ameliorate medication safety challenges for this patient group.

Challenges, coping and support during student placement abroad: A qualitative study

BACKGROUND

During placements abroad, healthcare students are confronted with different personal and professional challenges, related to participation in practice. This study investigates when and how students respond to such challenges, and which coping and support mechanisms students use to overcome these.

METHODS

Twenty-five international students shared their experiences about physiotherapy placement in The Netherlands. Using a critical incident technique, we asked participants to recall events where participation was affected by an unforeseen situation, in or outside the clinic. Further, we explored students' strategies of seeking support within their social network to overcome individual challenges. Two researchers applied thematic analysis to the interview data, following an iterative approach. Team discussions supported focused direction of data collection and analysis, before conceptualizing results.

RESULTS

Participants described a wide range of challenges. The scope and impact level of challenges varied widely, including intercultural differences, language barriers and inappropriate behaviour in the workplace, students' personal context and wellbeing. Mechanisms employed by students to overcome these challenges depended on the type of event (personal or professional), making purposeful use of their available network.

CONCLUSION

Students involve clinical staff, peers, family and friends during placement abroad, to make deliberate use of their support network to overcome challenges in participation, whereas the academic network remains distant. Findings may help reflect on the roles and responsibilities of academic staff and other professionals involved with placements abroad. Healthcare programmes should ensure support before, during and after placement is within students' reach.

Strategies for a safe interhospital transfer with an intubated patient or where readiness for intubation is needed: A critical incidents study

INTRODUCTION

The number of interhospital transports with intubated patients or where intubation readiness is required is increasing in Sweden and globally. Specialist nurses are often responsible for these transports, which involve numerous risks for critically ill patients.

AIM

The aim of this study was to describe nurse anaesthetists' and intensive care nurses' strategies for safe interhospital transports with intubated patients or where intubation readiness is required.

METHOD

A qualitative study was conducted using the critical incident technique. During March and April 2020, 12 semi-structured interviews were conducted with nurse anaesthetists and intensive care nurses. Data were analysed according to the critical incident technique, and a total of 197 critical incidents were identified. The analysis revealed five final strategies for safe interhospital transport.

RESULTS

Participants described the importance of ensuring clear and adequate information transfers between caregivers to obtain vital patient information that enables the nurse in charge to identify risks and problems in advance and create an action plan. Stabilising and optimising the patient's condition before departure and preparing drugs and equipment were other strategies described by the participants, as well as requesting assistance or support if questions or complications arose during transport.

CONCLUSION

Transports with intubated patients or where intubation readiness is required are complex and require systematic patient-safety work to ensure that strategies for increasing patient safety and decreasing risks are visible to the nurses in charge, that they are applied, and that they are, indeed, effective.

A Realist Evaluation of Team Interventions in Acute Hospital Contexts-Use of Two Case Studies to Test Initial Programme Theories

BACKGROUND

Designing and implementing team interventions to improve quality and safety of care in acute hospital contexts is challenging. There is little emphasis in the literature on how contextual conditions impact interventions or how specific active ingredients of interventions impact on team members' reasoning and enact change. This realist evaluation helps to deepen the understanding of the enablers and barriers for effective team interventions in these contexts.

METHODS

Five previously developed initial programme theories were tested using case studies from two diverse hospital contexts. Data were collected from theory driven interviews (n = 19) in an Irish context and from previously conducted evaluative interviews (n = 16) in a US context. Data were explored to unpack the underlying social and psychological drivers that drove both intended and unintended outcomes. Patterns of regularity were identified and synthesised to develop middle-range theories (MRTs).

RESULTS

Eleven MRTs demonstrate how and why intervention resources introduced in specific contextual conditions enact reasoning mechanisms and generate intended and unintended outcomes for patients, team members, the team and organisational leaders. The triggered mechanisms relate to shared mental models; openness, inclusivity and connectedness; leadership and engagement; social identity and intrinsic motivational factors.

CONCLUSIONS

The findings provide valuable information for architects and facilitators of team interventions in acute hospital contexts, as well as help identify avenues for future research. Dataset: The data presented in this study are available on request from the corresponding author. The data are not publicly available due to their sensitive nature and potential identification of participants.

Team interventions in acute hospital contexts: protocol for the evaluation of an initial programme theory using realist methods

Introduction: Literature on multi-disciplinary healthcare team interventions to improve quality and safety of care in acute hospital contexts tends to focus on evaluating the success of the intervention by assessing patient outcomes. In contrast, there is little focus on the team who delivered the intervention, how the team worked to deliver the intervention or the context in which it was delivered. In practice, there is therefore a poor understanding of why some interventions work and are sustained and why others fail. There is little emphasis in the literature on how the team delivering the intervention might impact success or failure.

Given that team is the vehicle through which these interventions are introduced, it is important to understand interventions from their perspectives.

This research seeks to deepen understanding of enablers and barriers for effective team interventions. Using two case studies, we will evaluate previously developed initial programme theories to understand, what worked for whom, in what conditions, why, to what extent and how?

Methods and analysis: A realist evaluation approach will be employed to test the previously formed set of initial programme theories. Two multi-disciplinary acute hospital team interventions in two different geographical and organisational contexts will be identified. In case study 1, a theory based approach to interviewing will be used. In case study 2, interview transcripts obtained using a semi- structured approach for primary research purposes will undergo secondary analysis.

This will enable a more sensitive look at patterns and variations in patterns of multi-disciplinary team interventions. Researchers will first iteratively interrogate each respective dataset to identify the characteristics or resources present within the specific context that influenced how the team intervention worked to produce particular outcomes. Data will then be synthesised across contexts in order to produce middle range theories and thereby more generalisable insights.

Why women die after reaching the hospital: a qualitative critical incident analysis of the 'third delay' in postconflict northern Uganda

OBJECTIVES

To critically explore and describe the pathways that women who require emergency obstetrics and newborn care (EmONC) go through and to understand the delays in accessing EmONC after reaching a health facility in a conflict-affected setting.

DESIGN

This was a qualitative study with two units of analysis: (1) critical incident technique (CIT) and (2) key informant interviews with health workers, patients and attendants.

SETTING

Thirteen primary healthcare centres, one general private-not-for-profit hospital, one regional referral hospital and one teaching hospital in northern Uganda.

PARTICIPANTS

Forty-nine purposively selected health workers, patients and attendants participated in key informant interviews. CIT mapped the pathways for maternal deaths and near-misses selected based on critical case purposive sampling.

RESULTS

After reaching the health facility, a pregnant woman goes through a complex pathway that leads to delays in receiving EmONC. Five reasons were identified for these delays: shortage of medicines and supplies, lack of blood and functionality of operating theatres, gaps in staff coverage, gaps in staff skills, and delays in the interfacility referral system. Shortage of medicines and supplies was central in most of the pathways, characterised by three patterns: delay to treat, back-and-forth movements to buy medicines or supplies, and multiple referrals across facilities. Some women also bypassed facilities they deemed to be non-functional.

CONCLUSION

Our findings show that the pathway to EmONC is precarious and takes too long even after making early contact with the health facility. Improvement of skills, better management of the meagre human resource and availing essential medical supplies in health facilities may help to reduce the gaps in a facility's emergency readiness and thus improve maternal and neonatal outcomes.