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

BACKGROUND: As realist methodology is still evolving, there is a paucity of guidance on how to conduct theory driven interviews. Realist researchers can therefore struggle to collect interview data that can make a meaningful contribution to refining their initial programme theory. Collecting data to inform realist Inital Programme Theories (IPTs) in healthcare contexts is further compounded due to the healthcare workers' busy work schedules. In this case study of team interventions in acute hospital contexts, we explore the benefits of using the Critical Incident Technique (CIT) in order to build and refine an initial programme theory. We contend that use of the CIT helps to draw on more specific experiences of "Key Informants" and therefore elicits richer and more relevant data for realist enquiry. METHODS: The five steps of the CIT were mapped against realist methods guidance and adapted into an interview framework. Specifications to identify an incident as "critical" were agreed. Probes were embedded in the interview framework to confirm, refine and/or refute previous theories. Seventeen participants were interviewed and recordings were transcribed and imported for analysis into NVivo software. Using RAMESES guidelines, Context-Mechanism-Outcomes configurations were extrapolated from a total of 31 incidents. RESULTS: We found that the CIT facilitated construction of an interview format that allowed participants to reflect on specific experiences of interest. We demonstrate how the CIT strengthened initial programme theory development as it facilitated the reporting of the specifics of team interventions and the contexts and mechanisms characteristic of those experiences. As new data emerged, it was possible to evolve previous theories synthesised from the literature as well as to explore new theories. CONCLUSIONS: Utilising a CIT framework paid dividends in terms of the relevance and usefulness of the data for refining the initial programme theory. Adapting the CIT questioning technique helped to focus the participants on the specifics relating to an incident allowing the interviewers to concentrate on probes to explore theories during the interview process. The CIT interview format therefore achieved its purpose and can be adapted for use within realist methodology.

Team interventions in acute hospital contexts: a systematic search of the literature using realist synthesis.

BACKGROUND: Research on team effectiveness in healthcare has focussed on whether effective teams yield positive outcomes for patients and on the effectiveness of team interventions to improve performance. Limited understanding exists of what works for whom within an effective team, or how and why the context in which the team operates enables team members both as individuals and as a collective to enact behaviours that promote positive outcomes. METHODS: This realist synthesis of the literature explores the relationship between team interventions, underlying teamwork mechanisms generated by those interventions, and the resultant impact on patient outcomes in an acute hospital context. A systematic search of five healthcare and healthcare management academic databases: PubMed, PsychINFO, CINAHL, ABInform, Emerald Management and three grey literature databases: ERIC, OpenDOAR and Open Grey was undertaken. Five experts in the field were also contacted to source relevant literature. Using PRISMA guidelines, relevant studies published between January 2006 and January 2017 were systematically searched by a team of three people. Drawing on realist methodology, data were synthesised using context, mechanism and outcome configurations as the unit of analysis to identify enablers and barriers to effective team interventions. RESULTS: Out of 3347 papers retrieved, 18 were included in the final synthesis. From these, five contextual enablers were identified: an inter-disciplinary focus and flattened hierarchy; effective communication; leadership support and alignment of team goals with organisational goals; credibility of intervention; and appropriate team composition with physician involvement. Ten recurring mechanisms were identified, the most frequently occurring of which was shared responsibility. CONCLUSIONS: The advantage of using realist synthesis to extrapolate data from the literature is that it considers the context and mechanisms that will impact effectiveness of healthcare team interventions. This methodological approach provides a different perspective to other types of syntheses and offers insight as to why certain contextual elements may yield more success than others. Findings therefore tend to have more practical implications. Specificity of detail in terms of how external drivers impact on healthcare team interventions was limited in the articles extracted for analysis. This broader perspective is therefore an important consideration for future research.