http://informahealthcare.com/jic ISSN: 1356-1820 (print), 1469-9567 (electronic) J Interprof Care, 2015; 29(1): 1–2 ! 2015 Informa UK Ltd. DOI: 10.3109/13561820.2015.985883

EDITORIAL

The importance of realist synthesis for the interprofessional field Scott Reeves Centre for Health and Social Care Research, Kingston University & St George’s, University of London, London, UK

Introduction Realist synthesis is an increasingly popular approach in reviewing and synthesising evidence for a range of different interventions and activities in health and social care services. Rather than using the traditional approach in reviewing the literature which tends to focus on reporting outcomes, a realist synthesis focuses on understanding how context affects the mechanisms by which an intervention may (or may not) be effective. As such, the key question posed in this type of review is – what works, for whom, under what circumstances? Given the comprehensive approach taken with a realist synthesis, it is particularly well suited for understanding the nature of complicated educational, practice and/or organisational interventions. Indeed, due to the complexity involved in developing and implementing interprofessional education and practice activities, realist syntheses are a particularly useful approach in the interprofessional field. In this editorial, I describe this emerging method, and argue that realist synthesis work should be employed by colleagues interested in developing a more comprehensive understanding of the nature of interprofessional activities. In developing this argument, I draw upon a series of papers recently published in this journal (Hewitt, Sims, & Harris, 2014; Hewitt, Sims, & Harris, 2015; Sims, Hewitt, & Harris, 2015a,b) describing the first realist synthesis of interprofessional teamwork.

Realist synthesis Over the past decade or so, we have seen a continued growth of activities focused on reviewing and synthesising the research evidence within the health professions education and health service domains. One increasingly popular approach is realist synthesis (Pawson, Greenhalgh, Harvey, & Walshe, 2005). This type of work focuses on understanding and unpacking the mechanisms by which an intervention works, or fails to work. In doing so, a realist synthesis helps provide empirical explanations about effectiveness, rather than making judgments about how what might be effective (e.g. Dixon-Woods, Agarwhal, Jones, Young, & Sutton, 2005; Greenhalgh, Kristjansson, & Robinson, 2007; Wong, Greenhalgh, & Pawson, 2010). An important part of a realist synthesis is exploring how contextual factors may influence identified mechanisms, which in turn may affect the outcomes produced from an intervention. Given the complex nature of health professions education and health services interventions/activities, the realist synthesis approach is Correspondence: Scott Reeves, Kingston University & St George’s, University of London, London, UK. E-mail: S.Reeves@sgul. kingston.ac.uk

particularly suited to these fields. However, despite their potential for the interprofessional field, the bulk of literature synthesis work has employed more traditional systematic, scoping or narrative review methods (e.g. Abu-Rish et al., 2012; Brandt, Lutfiyya, King, & Chioreso, 2014; Lapkin, Levett-Jones, & Gilligan, 2013). To date, the closest we have come to publishing this type of synthesis was a review that employed a realistic evaluation approach to examine the factors that affected reported outcomes from interprofessional education studies (Barr, Koppel, Reeves, Hammick, & Freeth, 2005).

A realist synthesis of interprofessional teamwork In beginning to address this shortfall in the interprofessional literature, Ruth Harris, Gillian Hewitt and Sarah Sims have recently published a series of four Journal of Interprofessional Care papers which provide a fascinating account into the processes and findings from their realistic synthesis of interprofessional teamwork (Hewitt et al., 2014, 2015; Sims et al., 2015a,b). Through a rigorous set of searches, these papers describe how their synthesis of teamwork studies generated a number of key mechanisms that affected this type of collaborative work. A summary of these papers is presented below. In locating the key mechanisms for interprofessional teamwork from their synthesis of the research literature, the authors described how they undertook a two-stage literature search to identify firstly, the mechanisms assumed to be underlying interprofessional teamwork; and secondly, to look for evidence which may support these mechanisms. The initial stage involved a preliminary search aimed at producing evidence of underpinning theories of how/why teams function to generate a list of preliminary mechanisms. Nine tentative mechanisms were produced. This list was expanded to 10 mechanisms after a consultation with the authors’ expert advisory group. In the second stage, a more comprehensive search was conducted to identify evidence which may support the preliminary mechanisms. Evidence was located for all 10. In addition, the authors found evidence for a further three mechanisms. Therefore, in total, the following 13 teamwork mechanisms were produced:  Support and value;  Collaboration and coordination;  Pooling of resources;  Individual learning;  Role blurring;  Efficient, open and equitable communication;  Tactical communication;  Shared responsibility and influence;

2

Editorial

    

Team behavioural norms; Shared responsibility and influence; Critically reviewing performance and decisions; Generating and implementing new ideas; Leadership. Given the increasing attention placed on leadership in health and social care, below I provide some details on what the authors found on this mechanism. Thirty quantitative and qualitative studies were identified. The authors report that many of the studies explored the nature of a leader’s various roles within a team, covering elements such as influencing a team’s culture, values, vision and objectives. It was also found that team leaders often lacked facilitation and communication skills. In addition, a number of different leadership models were found, including notions of shared leadership. It was reported that the main context influencing the leadership mechanism was professional hierarchy – typically physicians were assumed to be the team leader, and there was friction reported if they did not have this role. Interestingly, when other team members supported a hierarchical approach, they too assumed physicians would be team leaders (Sims et al., 2015b). It was also found that clear leadership encouraged teams to develop a collective vision and encouraged interprofessional learning. In contrast, those teams without clear leadership reported a lack of clarity about their shared objectives. Clear leadership was also linked with notions of team innovation and effectiveness, as well as improved interprofessional communication. The authors go on to note that although they found evidence that supported all 13 mechanisms, its strength was variable. Evidence for some of the mechanisms such as support and value, collaboration and coordination, and efficient open and equitable communication was stronger – often because these tended to relate more observable activities involved in interprofessional teamwork. In contrast, the evidence for other mechanisms was more limited (e.g. individual learning, team behavioural norms, shared responsibility and influence, critical reflection and generating new ideas) as these tended to be to less visible or more conceptual in nature (Sims et al., 2015b). In their discussion, the authors go on to acknowledge the wider difficulties with undertaking a realist synthesis on teamwork. They point out that the literature in the interprofessional field is very large, which made it impossible for them follow the full realist synthesis process which also involves searching across disciplinary boundaries to explore how mechanisms operate in other fields (Pawson, Greenhalgh, Harvey, & Walshe, 2004). In addition, it is reported that the authors encountered difficulties in distinguishing between contexts, mechanisms and outcomes. For example, they struggled in identifying whether the notion of innovation was always an independent mechanism or was sometimes an outcome of critical reflection. Nevertheless, in drawing their conclusions about this synthesis, it is stated: This realist synthesis has provided a unique and powerful review of the evidence of interprofessional teamwork. It has provided a means of conceptualising and understanding processes of teamwork to enable the research evidence to be examined in considerable detail. (Sims et al., 2015b) Indeed, as someone who has been involved in the reviewing of the interprofessional evidence for a number of years now, this set of papers provides a unique, detailed and insightful account of the 13 key facilitating and inhibiting mechanisms that affect how interprofessional teams work together in providing care to patients and clients.

J Interprof Care, 2015; 29(1): 1–2

Concluding comments Realist synthesis is a new and emerging approach to reviewing evidence. As noted above, it is an approach which is particularly appropriate for understanding the impact of complex interventions, as it operates on the notion that one needs to understand how interventions work in different contexts and why. Given the complexities involved in the interprofessional field, this approach is particularly advantageous for researchers to adopt. As demonstrated in this set of papers, the use of realist synthesis can provide a very comprehensive account of the nature of interprofessional teamwork. Building upon this work, I would encourage researchers to draw on these findings to help develop more empirical clarity about what works, for whom and in what circumstances for the various interprofessional interventions/ activities used in our field.

Declaration of interest The author declares no conflicts of interest. The author was responsible for the writing and content of this paper.

References Abu-Rish, E., Kim, S., Choe, L., Varpio, L., Malik, E., White, A. . . . Zierler, B. (2012). Current trends in interprofessional education of health sciences students: A literature review. Journal of Interprofessional Care, 26, 444–451. Barr, H., Koppel, I., Reeves, S., Hammick, M., & Freeth, D. (2005). Effective interprofessional education: Argument, assumption and evidence. Oxford: Blackwell. Brandt, B., Lutfiyya, M., King, J.A., & Chioreso, C. (2014). A scoping review of interprofessional collaborative practice and education using the lens of the triple aim. Journal Interprofessional Care, 28, 393–399. Dixon-Woods, M., Agarwhal, S., Jones, D., Young, B., & Sutton, A. (2005). Synthesising qualitative and quantitative evidence: A review of possible methods. Journal of Health Services Research and Policy, 10, 45–53. Greenhalgh, T., Kristjansson, E., & Robinson, V. (2007). Realist review to understand the efficacy of school feeding programmes. British Medical Journal, 335, 858–861. Hewitt, G., Sims, S., & Harris, R. (2014). Using realist synthesis to understand the mechanisms of interprofessional teamwork in health and social care. Journal of Interprofessional Care, 28, 501–506. Hewitt, G., Sims, S., & Harris, R. (2015). Evidence of communication, influence and behavioural norms in interprofessional teams: A realist synthesis. Journal of Interprofessional Care, 29, 1–6 [Epub ahead of print]. Lapkin, S., Levett-Jones, T., & Gilligan, C. (2013). A systematic review of the effectiveness of interprofessional education in health professional programs. Nurse Education Today, 33, 90–102. Pawson, R., Greenhalgh, T., Harvey, G., & Walshe, K. (2004). Realist synthesis: An introduction. RMP methods paper 2/2004. Manchester, UK: ESRC Research Methods Programme, University of Manchester. Pawson, R., Greenhalgh, T., Harvey, G., & Walshe, K. (2005). Realist review – A new method of systematic review designed for complex policy interventions. Journal of Health Services Research and Policy, 10, 21–34. Sims, S., Hewitt, G., & Harris, R. (2015a). Evidence of collaboration, pooling of resources, learning and role blurring in interprofessional healthcare teams: A realist synthesis. Journal of Interprofessional Care, 29, 20–25. Sims, S., Hewitt, G., & Harris, R. (2015 b). Evidence of a shared purpose, critical reflection, innovation and leadership in interprofessional healthcare teams: A realist synthesis. Journal of Interprofessional Care, 29, 1–7. [Epub ahead of print]. Wong, G., Greenhalgh, T., & Pawson, R. (2010). Internet-based medical education: A realist review of what works, for whom and in what circumstances. BMC Medical Education, 10, 12. http://www.biomedcentral.com/1472-6920/10/12.

Copyright of Journal of Interprofessional Care is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

The importance of realist synthesis for the interprofessional field.

The importance of realist synthesis for the interprofessional field. - PDF Download Free
130KB Sizes 2 Downloads 4 Views