Understanding how and why de-implementation works in health and care: research protocol for a realist synthesis of evidence.

BACKGROUND: Strategies to improve the effectiveness and quality of health and care have predominantly emphasised the implementation of new research and evidence into service organisation and delivery. A parallel, but less understood issue is how clinicians and service leaders stop existing practices and interventions that are no longer evidence based, where new evidence supersedes old evidence, or interventions are replaced with those that are more cost effective. The aim of this evidence synthesis is to produce meaningful programme theory and practical guidance for policy makers, managers and clinicians to understand how and why de-implementation processes and procedures can work. METHODS AND ANALYSIS: The synthesis will examine the attributes or characteristics that constitute the concept of de-implementation. The research team will then draw on the principles of realist inquiry to provide an explanatory account of how, in what context and for whom to explain the successful processes and impacts of de-implementation. The review will be conducted in four phases over 18 months. Phase 1: develop a framework to map the preliminary programme theories through an initial scoping of the literature and consultation with key stakeholders. Phase 2: systematic searches of the evidence to develop the theories identified in phase 1. Phase 3: validation and refinement of programme theories through stakeholder interviews. Phase 4: formulating actionable recommendations for managers, commissioners and service leaders about what works through different approaches to de-implementation. DISCUSSION: This evidence synthesis will address gaps in knowledge about de-implementation across health and care services and ensure that guidance about strategies and approaches accounts for contextual factors, which may be operating at different organisational and decision-making levels. Through the development of the programme theory, which explains what works, how and under which circumstances, findings from the evidence synthesis will support managers and service leaders to make measured decisions about de-implementation. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017081030.

A qualitative study of migraine involving patient researchers.

BACKGROUND: Migraine is poorly managed in primary care despite a high level of morbidity. The majority of sufferers use non-prescription medications and are reluctant to seek help but the reasons for this are not understood. AIM: The aim of this study was to develop a research partnership between migraine sufferers and healthcare professionals to synthesise tacit and explicit knowledge in the area. Building upon this partnership, a further aim was to explore what it is to suffer with migraine from patients' perspectives in order to inform health service delivery. DESIGN: Qualitative interview study involving healthcare professionals and patient researchers. SETTING: A purposeful sample of eight migraine sufferers who had attended a local intermediate care headache clinic. METHOD: A consensual qualitative approach. RESULTS: Migraine had a high and unrecognised impact on quality of life. 'Handling the beast' was a central metaphor that resonated with the experience of all sufferers who sought to control their problem in different ways. Three major themes were identified: making sense of their problem; actively doing something about it either through self-help or professional advice; being resigned to it. CONCLUSION: Despite a significant impact on the quality of life of migraine sufferers and their families, their needs remain largely unmet. Useful insights can be obtained when patients and professionals work together in true partnership but the time and effort involved should not be underestimated. Further research is needed to identify why there are major deficiencies in delivering care in this common problem.

Nutritional care for adults in hospital.

Despite the fact that up to 40% of hospital patients may be malnourished, many nutritional referrals are inconsistent or inappropriate. Recent research has raised awareness of nutrition, but wide variations remain in the assessment and referral procedures used by hospital trusts. The final best practice statement in our series emerged from the responses of nursing and dietetic staff across Scotland. The statement focuses on five aspects of nutritional care: admission to hospital; nursing management of nutritional care; nutritional screening and documentation; criteria for nutritional referrals, and education and training.