Why do acute healthcare staff behave unprofessionally towards each other and how can these behaviours be reduced? A realist review.

Background: Unprofessional behaviour in healthcare systems can negatively impact staff well-being, patient safety and organisational costs. Unprofessional behaviour encompasses a range of behaviours, including incivility, microaggressions, harassment and bullying. Despite efforts to combat unprofessional behaviour in healthcare settings, it remains prevalent. Interventions to reduce unprofessional behaviour in health care have been conducted - but how and why they may work is unclear. Given the complexity of the issue, a realist review methodology is an ideal approach to examining unprofessional behaviour in healthcare systems. Aim: To improve context-specific understanding of how, why and in what circumstances unprofessional behaviours between staff in acute healthcare settings occur and evidence of strategies implemented to mitigate, manage and prevent them. Methods: Realist synthesis methodology consistent with realist and meta-narrative evidence syntheses: evolving standards reporting guidelines. Data sources: Literature sources for building initial theories were identified from the original proposal and from informal searches of various websites. For theory refinement, we conducted systematic and purposive searches for peer-reviewed literature on databases such as EMBASE, Cumulative Index to Nursing and Allied Health Literature and MEDLINE databases as well as for grey literature. Searches were conducted iteratively from November 2021 to December 2022. Results: Initial theory-building drew on 38 sources. Searches resulted in 2878 titles and abstracts. In total, 148 sources were included in the review. Terminology and definitions used for unprofessional behaviours were inconsistent. This may present issues for policy and practice when trying to identify and address unprofessional behaviour. Contributors of unprofessional behaviour can be categorised into four areas: (1) workplace disempowerment, (2) organisational uncertainty, confusion and stress, (3) (lack of) social cohesion and (4) enablement of harmful cultures that tolerate unprofessional behaviours. Those at most risk of experiencing unprofessional behaviour are staff from a minoritised background. We identified 42 interventions in the literature to address unprofessional behaviour. These spanned five types: (1) single session (i.e. one-off), (2) multiple sessions, (3) single or multiple sessions combined with other actions (e.g. training session plus a code of conduct), (4) professional accountability and reporting interventions and (5) structured culture-change interventions. We identified 42 reports of interventions, with none conducted in the United Kingdom. Of these, 29 interventions were evaluated, with the majority (n = 23) reporting some measure of effectiveness. Interventions drew on 13 types of behaviour-change strategy designed to, for example: change social norms, improve awareness of unprofessional behaviour, or redesign the workplace. Interventions were impacted by 12 key dynamics, including focusing on individuals, lack of trust in management and non-existent logic models. Conclusions: Workplace disempowerment and organisational barriers are primary contributors to unprofessional behaviour. However, interventions predominantly focus on individual education or training without addressing systemic, organisational issues. Effectiveness of interventions to improve staff well-being or patient safety is uncertain. We provide 12 key dynamics and 15 implementation principles to guide organisations. Future work: Interventions need to: (1) be tested in a United Kingdom context, (2) draw on behavioural science principles and (3) target systemic, organisational issues. Limitations: This review focuses on interpersonal staff-to-staff unprofessional behaviour, in acute healthcare settings only and does not include non-intervention literature outside the United Kingdom or outside of health care. Study registration: This study was prospectively registered on PROSPERO CRD42021255490. The record is available from: www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR131606) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 25. See the NIHR Funding and Awards website for further award information.

For this study, we asked: how, why and in what situations can unprofessional behaviour between healthcare staff working in acute care (usually hospitals) be reduced, managed and prevented? We wanted to research how people understand unprofessional behaviour, explore the circumstances leading to unprofessional behaviour and understand how existing approaches to addressing unprofessional behaviour worked (or did not work) across staff groups and acute healthcare organisations. We used a literature review method called a 'realist review', which differs from other review methods. A realist review focuses on understanding not only if interventions work but how and why they work, and for whom. This allowed us to analyse a wider range of relevant international literature ­ not only academic papers. We found 148 sources, which were relevant either because they described unprofessional behaviour or because they provided information on how to address unprofessional behaviour. Definitions of unprofessional behaviour varied, making it difficult to settle on one description. For example, unprofessional behaviour may involve incivility, bullying, harassment and/or microaggressions. We examined what might contribute to unprofessional behaviour and identified factors including uncertainty in the working environment. We found no United Kingdom-based interventions and only one from the United States of America that sought to reduce unprofessional behaviour towards minority groups. Strategies often tried to encourage staff to speak up, provide ways to report unprofessional behaviour or set social standards of behaviour. We also identified factors that may make it challenging for organisations to successfully select, implement and evaluate an intervention to address unprofessional behaviour. We recommend a system-wide approach to addressing unprofessional behaviour, including assessing the context and then implementing multiple approaches over a long time (rather than just once), because they are likely to have greater impact on changing culture. We are producing an implementation guide to support this process. Interventions need to enhance staff ability to feel safe at work, work effectively and support those more likely to experience unprofessional behaviour.

How can interventions more directly address drivers of unprofessional behaviour between healthcare staff?

Unprofessional behaviours (UBs) between healthcare staff are widespread and have negative impacts on patient safety, staff well-being and organisational efficiency. However, knowledge of how to address UBs is lacking. Our recent realist review analysed 148 sources including 42 reports of interventions drawing on different behaviour change strategies and found that interventions insufficiently explain their rationale for using particular strategies. We also explored the drivers of UBs and how these may interact. In our analysis, we elucidated both common mechanisms underlying both how drivers increase UB and how strategies address UB, enabling the mapping of strategies against drivers they address. For example, social norm-setting strategies work by fostering a more professional social norm, which can help tackle the driver 'reduced social cohesion'. Our novel programme theory, presented here, provides an increased understanding of what strategies might be effective to adddress specific drivers of UB. This can inform logic model design for those seeking to develop interventions addressing UB in healthcare settings.

Integration of primary care and palliative care services to improve equality and equity at the end-of-life: Findings from realist stakeholder workshops.

BACKGROUND: Inequalities in access to palliative and end of life care are longstanding. Integration of primary and palliative care has the potential to improve equity in the community. Evidence to inform integration is scarce as research that considers integration of primary care and palliative care services is rare. AIM: To address the questions: 'how can inequalities in access to community palliative and end of life care be improved through the integration of primary and palliative care, and what are the benefits?' DESIGN: A theory-driven realist inquiry with two stakeholder workshops to explore how, when and why inequalities can be improved through integration. Realist analysis leading to explanatory context(c)-mechanism(m)-outcome(o) configurations(c) (CMOCs). FINDINGS: A total of 27 participants attended online workshops (July and September 2022): patient and public members (n = 6), commissioners (n = 2), primary care (n = 5) and specialist palliative care professionals (n = 14). Most were White British (n = 22), other ethnicities were Asian (n = 3), Black African (n = 1) and British mixed race (n = 1). Power imbalances and racism hinder people from ethnic minority backgrounds accessing current services. Shared commitment to addressing these across palliative care and primary care is required in integrated partnerships. Partnership functioning depends on trusted relationships and effective communication, enabled by co-location and record sharing. Positive patient experiences provide affirmation for the multi-disciplinary team, grow confidence and drive improvements. CONCLUSIONS: Integration to address inequalities needs recognition of current barriers. Integration grounded in trust, faith and confidence can lead to a cycle of positive patient, carer and professional experience. Prioritising inequalities as whole system concern is required for future service delivery and research.

Drivers of unprofessional behaviour between staff in acute care hospitals: a realist review.

BACKGROUND: Unprofessional behaviours (UB) between healthcare staff are rife in global healthcare systems, negatively impacting staff wellbeing, patient safety and care quality. Drivers of UBs include organisational, situational, team, and leadership issues which interact in complex ways. An improved understanding of these factors and their interactions would enable future interventions to better target these drivers of UB. METHODS: A realist review following RAMESES guidelines was undertaken with stakeholder input. Initial theories were formulated drawing on reports known to the study team and scoping searches. A systematic search of databases including Embase, CINAHL, MEDLINE and HMIC was performed to identify literature for theory refinement. Data were extracted from these reports, synthesised, and initial theories tested, to produce refined programme theories. RESULTS: We included 81 reports (papers) from 2,977 deduplicated records of grey and academic reports, and 28 via Google, stakeholders, and team members, yielding a total of 109 reports. Five categories of contributor were formulated: (1) workplace disempowerment; (2) harmful workplace processes and cultures; (3) inhibited social cohesion; (4) reduced ability to speak up; and (5) lack of manager awareness and urgency. These resulted in direct increases to UB, reduced ability of staff to cope, and reduced ability to report, challenge or address UB. Twenty-three theories were developed to explain how these contributors work and interact, and how their outcomes differ across diverse staff groups. Staff most at risk of UB include women, new staff, staff with disabilities, and staff from minoritised groups. UB negatively impacted patient safety by impairing concentration, communication, ability to learn, confidence, and interpersonal trust. CONCLUSION: Existing research has focused primarily on individual characteristics, but these are inconsistent, difficult to address, and can be used to deflect organisational responsibility. We present a comprehensive programme theory furthering understanding of contributors to UB, how they work and why, how they interact, whom they affect, and how patient safety is impacted. More research is needed to understand how and why minoritised staff are disproportionately affected by UB. STUDY REGISTRATION: This study was registered on the international database of prospectively registered systematic reviews in health and social care (PROSPERO): https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490 .

Interventions to address unprofessional behaviours between staff in acute care: what works for whom and why? A realist review.

BACKGROUND: Unprofessional behaviour (UB) between staff encompasses various behaviours, including incivility, microaggressions, harassment, and bullying. UB is pervasive in acute healthcare settings and disproportionately impacts minoritised staff. UB has detrimental effects on staff wellbeing, patient safety and organisational resources. While interventions have been implemented to mitigate UB, there is limited understanding of how and why they may work and for whom. METHODS: This study utilised a realist review methodology with stakeholder input to improve understanding of these complex context-dependent interventions. Initial programme theories were formulated drawing upon scoping searches and reports known to the study team. Purposive systematic searches were conducted to gather grey and published global literature from databases. Documents were selected if relevant to UB in acute care settings while considering rigour and relevance. Data were extracted from these reports, synthesised, and initial theories tested, to produce refined programme theories. RESULTS: Of 2977 deduplicated records, 148 full text reports were included with 42 reports describing interventions to address UB in acute healthcare settings. Interventions drew on 13 types of behaviour change strategies and were categorised into five types of intervention (1) single session (i.e. one off); (2) multiple session; (3) single or multiple sessions combined with other actions (e.g. training sessions plus a code of conduct); (4) professional accountability and reporting programmes and; (5) structured culture change interventions. We formulated 55 context-mechanism-outcome configurations to explain how, why, and when these interventions work. We identified twelve key dynamics to consider in intervention design, including importance of addressing systemic contributors, rebuilding trust in managers, and promoting a psychologically safe culture; fifteen implementation principles were identified to address these dynamics. CONCLUSIONS: Interventions to address UB are still at an early stage of development, and their effectiveness to reduce UB and improve patient safety is unclear. Future interventions should incorporate knowledge from behavioural and implementation science to affect behaviour change; draw on multiple concurrent strategies to address systemic contributors to UB; and consider the undue burden of UB on minoritised groups. STUDY REGISTRATION: This study was registered on the international database of prospectively registered systematic reviews in health and social care (PROSPERO): https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255490 .

Modelling lifecycles of inter-organizational collaborations in healthcare: a systematic review and best-fit framework synthesis.

PURPOSE: Inter-organisational collaboration (IOC) across healthcare settings has been put forward as a solution to mounting financial and sustainability challenges. Whilst ingredients for successful IOC have been explored, there remains limited understanding of the development of IOCs over time. DESIGN/METHODOLOGY/APPROACH: The authors systematically reviewed the literature to identify models applied to IOCs in healthcare across databases such as Healthcare Management Information Consortium (HMIC) and MEDLINE, identifying 2,763 titles and abstracts with 26 final papers included. The authors then used a "best fit" framework synthesis methodology to synthesise fourteen models of IOC in healthcare and the wider public sector to formulate an applied composite model describing the process through which collaborations change over time. This synthesis comprised extracting stages and behaviours from included models, selecting an a priori framework upon which to code these stages and behaviours and then re-coding them to construct a new composite model. FINDINGS: Existing models often did not consider that organisations may undergo many IOCs in the organisations' lifetime nor included "contemplation" stages or those analogous to "dissolution", which might negatively impact papers using such models. The formulated' composite model utilises a life-cycle design comprising five non-linear phases, namely Contemplating, Connecting, Planning, Implementation and Maintenance or Dissolution and incorporates dynamic elements from Complex Adaptive Systems thinking to reflect the dynamic nature of collaborations. ORIGINALITY/VALUE: This is the first purpose-built model of the lifecycles of IOCs in healthcare. The model is intended to inform implementers, evaluators and researchers of IOCs alike.

Towards achieving interorganisational collaboration between health-care providers: a realist evidence synthesis.

Background: Interorganisational collaboration is currently being promoted to improve the performance of NHS providers. However, up to now, there has, to the best of our knowledge, been no systematic attempt to assess the effect of different approaches to collaboration or to understand the mechanisms through which interorganisational collaborations can work in particular contexts. Objectives: Our objectives were to (1) explore the main strands of the literature about interorganisational collaboration and to identify the main theoretical and conceptual frameworks, (2) assess the empirical evidence with regard to how different interorganisational collaborations may (or may not) lead to improved performance and outcomes, (3) understand and learn from NHS evidence users and other stakeholders about how and where interorganisational collaborations can best be used to support turnaround processes, (4) develop a typology of interorganisational collaboration that considers different types and scales of collaboration appropriate to NHS provider contexts and (5) generate evidence-informed practical guidance for NHS providers, policy-makers and others with responsibility for implementing and assessing interorganisational collaboration arrangements. Design: A realist synthesis was carried out to develop, test and refine theories about how interorganisational collaborations work, for whom and in what circumstances. Data sources: Data sources were gathered from peer-reviewed and grey literature, realist interviews with 34 stakeholders and a focus group with patient and public representatives. Review methods: Initial theories and ideas were gathered from scoping reviews that were gleaned and refined through a realist review of the literature. A range of stakeholder interviews and a focus group sought to further refine understandings of what works, for whom and in what circumstances with regard to high-performing interorganisational collaborations. Results: A realist review and synthesis identified key mechanisms, such as trust, faith, confidence and risk tolerance, within the functioning of effective interorganisational collaborations. A stakeholder analysis refined this understanding and, in addition, developed a new programme theory of collaborative performance, with mechanisms related to cultural efficacy, organisational efficiency and technological effectiveness. A series of translatable tools, including a diagnostic survey and a collaboration maturity index, were also developed. Limitations: The breadth of interorganisational collaboration arrangements included made it difficult to make specific recommendations for individual interorganisational collaboration types. The stakeholder analysis focused exclusively on England, UK, where the COVID-19 pandemic posed challenges for fieldwork. Conclusions: Implementing successful interorganisational collaborations is a difficult, complex task that requires significant time, resource and energy to achieve the collaborative functioning that generates performance improvements. A delicate balance of building trust, instilling faith and maintaining confidence is required for high-performing interorganisational collaborations to flourish. Future work: Future research should further refine our theory by incorporating other workforce and user perspectives. Research into digital platforms for interorganisational collaborations and outcome measurement are advocated, along with place-based and cross-sectoral partnerships, as well as regulatory models for overseeing interorganisational collaborations. Study registration: The study is registered as PROSPERO CRD42019149009. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 6. See the NIHR Journals Library website for further project information.

How can the collaboration between health-care providers be improved? There are continuing concerns about poor patient care across the NHS. One of the ways in which governments have tried to solve these issues is by getting services to work together, rather than separately, to solve any problems. The aim of our review is to learn about how, why and when different approaches to working together ­ which we call interorganisational collaboration ­ can be used to improve the performance of NHS providers. We reviewed published evidence and carried out interviews with NHS staff. We also carried out interviews and a focus group with patient and public representatives. Our review finds that interorganisational collaborations can work well when a series of elements are in place, which includes the need to build trust between everyone involved. Having a belief in the collaboration is also needed to help inspire others to get involved. To try and reduce possible problems, setting priorities and having clear methods to show how improvements can be achieved are important, as well as having an agreed contract in place to ensure that any conflicts are resolved. If done well, collaboration can improve resource allocation, coordination, communication and shared learning about best practice. Our review provides valuable evidence of how different approaches to interorganisational collaboration can be used by NHS providers to work together to improve services in different situations. Our review provides different options for organisations to reflect on how well they are collaborating, which includes the involvement of key stakeholders, such as patients, the public and communities.

Knowledge of Nutrition and Physical Activity Guidelines is Not Associated with Physical Function in Dutch Older Adults Attending a Healthy Ageing Public Engagement Event.

Purpose: Evidence-based guidelines on nutrition and physical activity are used to increase knowledge in order to promote a healthy lifestyle. However, actual knowledge of guidelines is limited and whether it is associated with health outcomes is unclear. Participants and Methods: This inception cohort study aimed to investigate the association of knowledge of nutrition and physical activity guidelines with objective measures of physical function and physical activity in community-dwelling older adults attending a public engagement event in Amsterdam, The Netherlands. Knowledge of nutrition and physical activity according to Dutch guidelines was assessed using customized questionnaires. Gait speed and handgrip strength were proxies of physical function and the Minnesota Leisure Time Physical Activity Questionnaire was used to assess physical activity in minutes/week. Linear regression analysis, stratified by gender and adjusted for age, was used to study the association between continuous and categorical knowledge scores with outcomes. Results: In 106 older adults (mean age=70.1 SD=6.6, years) who were highly educated, well-functioning, and generally healthy, there were distinct knowledge gaps in nutrition and physical activity which did not correlate with one another (R2=0.013, p=0.245). Knowledge of nutrition or physical activity guidelines was not associated with physical function or physical activity. However, before age-adjustment nutrition knowledge was positively associated with HGS in males (B= 0.64 (95% CI: 0.05, 1.22)) and having knowledge above the median was associated with faster gait speed in females (B=0.10 (95% CI: 0.01, 0.19)). Conclusion: Our findings may represent a ceiling effect of the impact knowledge has on physical function and activity in the this high performing and educated population and that there may be other determinants of behavior leading to health status such as attitude and perception to consider in future studies.

Why do acute healthcare staff engage in unprofessional behaviours towards each other and how can these behaviours be reduced? A realist review protocol.

INTRODUCTION: Unprofessional behaviours encompass many behaviours including bullying, harassment and microaggressions. These behaviours between healthcare staff are problematic; they affect people's ability to work, to feel psychologically safe at work and speak up and to deliver safe care to patients. Almost a fifth of UK National Health Service staff experience unprofessional behaviours in the workplace, with higher incidence in acute care settings and for staff from minority backgrounds. Existing analyses have investigated the effectiveness of strategies to reduce these behaviours. We seek to go beyond these, to understand the range and causes of such behaviours, their negative effects and how mitigation strategies may work, in which contexts and for whom. METHODS AND ANALYSIS: This study uses a realist review methodology with stakeholder input comprising a number of iterative steps: (1) formulating initial programme theories drawing on informal literature searches and literature already known to the study team, (2) performing systematic and purposive searches for grey and peer-reviewed literature on Embase, CINAHL and MEDLINE databases as well as Google and Google Scholar, (3) selecting appropriate documents while considering rigour and relevance, (4) extracting data, (5) and synthesising and (6) refining the programme theories by testing the theories against the newly identified literature. ETHICS AND DISSEMINATION: Ethical review is not required as this study is a secondary research. An impact strategy has been developed which includes working closely with key stakeholders throughout the project. Step 7 of our project will develop pragmatic resources for managers and professionals, tailoring contextually-sensitive strategies to reduce unprofessional behaviours, identifying what works for which groups. We will be guided by the 'Evidence Integration Triangle' to implement the best strategies to reduce unprofessional behaviours in given contexts. Dissemination will occur through presentation at conferences, innovative methods (cartoons, videos, animations and/or interactive performances) and peer-reviewed journals. PROSPERO REGISTRATION NUMBER: CRD42021255490.

The prevalence of frailty and pre-frailty among geriatric hospital inpatients and its association with economic prosperity and healthcare expenditure: A systematic review and meta-analysis of 467,779 geriatric hospital inpatients.

BACKGROUND: Frailty is a common and clinically significant condition among geriatric populations. Although well-evidenced pooled estimates of the prevalence of frailty exist within various settings and populations, presently there are none assessing the overall prevalence of frailty among geriatric hospital inpatients. The purpose of this review was to systematically search and analyse the prevalence of frailty among geriatric hospital inpatients within the literature and examine its associations with national economic indicators. METHODS: Systematic searches were conducted on Ovid, Web of Science, Scopus, CINAHL Plus, and the Cochrane Library, encompassing all literature published prior to 22 November 2018, supplemented with manual reference searches. Included studies utilised a validated operational definition of frailty, reported the prevalence of frailty, had a minimum age ≥ 65 years, attempted to assess the whole ward/clinical population, and occurred among hospital inpatients. Two reviewers independently extracted data and assessed study quality. RESULTS: Ninety-six studies with a pooled sample of 467,779 geriatric hospital inpatients were included. The median critical appraisal score was 8/9 (range 7-9). The pooled prevalence of frailty, and pre-frailty, among geriatric hospital inpatients was 47.4% (95% CI 43.7-51.1%), and 25.8% (95% CI 22.0-29.6%), respectively. Significant differences were observed in the prevalence of frailty stratified by age, prevalent morbidity, ward type, clinical population, and operational definition. No significant differences were observed in stratified analyses by sex or continent, or significant associations between the prevalence of frailty and economic indicators. CONCLUSIONS: Frailty is highly prevalent among geriatric hospital inpatients. High heterogeneity exists within this setting based on various clinical and demographic characteristics. Pooled estimates reported in this review place the prevalence of frailty among geriatric hospital inpatients between that reported for community-dwelling older adults and older adults in nursing homes, outlining an increase in the relative prevalence of frailty with progression through the healthcare system.

Collaboration over competition? Regulatory reform and inter-organisational relations in the NHS amidst the COVID-19 pandemic: a qualitative study.

BACKGROUND: In 2021, during the COVID-19 pandemic, England's Department of Health and Social Care (DHSC) released a White Paper outlining proposed legislative reform of the National Health Service (NHS). Key to the proposals is the shift from relationships between providers based on competition, to cooperation, as the central driver of improved performance and quality. Against this background we explore potential regulatory barriers and enablers to collaboration identified by key NHS stakeholders and assess whether the proposed policy changes are likely to deliver the desired improvement in collaborative relationships, in the context of challenges experienced during the COVID-19 pandemic. METHODS: We conducted 32 semi-structured interviews with 30 key stakeholders, taking place during the COVID-19 pandemic from Jan 2020 to May 2021. Participants were selected for their expertise regarding collaboration and were recruited purposively. Interviews were conducted online with the use of video conferencing software. The interviews were thematically analysed to identify themes. Proposals contained in the DHSC White Paper helped to structure the thematic analysis, interpretation, and reporting of the results. RESULTS: Requirements to compete to provide services, regulatory ability to block collaborative arrangements, lack of collaboration between providers and Clinical Commissioning Groups, and current lack of data sharing were found to hamper collaborative efforts. These issues often negatively affected collaborative relations by increasing bureaucracy and prompted leaders to attempt to avoid future collaborations. Other barriers included opaque accountability arrangements, and erosion of trust in regulators. The COVID-19 pandemic was found to foster collaboration between organisations, but some changes mandated by the new legislation may stifle further collaboration. CONCLUSIONS: Many of the proposed legislative changes in the White Paper would help to remove existing barriers to service integration and collaboration identified by stakeholders. However, the proposed shift in the concentration of power from NHS England to the DHSC may exacerbate historically low levels of trust between providers and regulators. Many of the proposed changes fail to address endemic NHS policy issues such as chronic understaffing. Further dialogue is needed at all levels of the health and social care system to ensure future legislative changes meet the needs of all stakeholders.

How, when, and why do inter-organisational collaborations in healthcare work? A realist evaluation.

BACKGROUND: Inter-organisational collaborations (IOCs) in healthcare have been viewed as an effective approach to performance improvement. However, there remain gaps in our understanding of what helps IOCs function, as well as how and why contextual elements affect their implementation. A realist review of evidence drawing on 86 sources has sought to elicit and refine context-mechanism-outcome configurations (CMOCs) to understand and refine these phenomena, yet further understanding can be gained from interviewing those involved in developing IOCs. METHODS: We used a realist evaluation methodology, adopting prior realist synthesis findings as a theoretical framework that we sought to refine. We drew on 32 interviews taking place between January 2020 and May 2021 with 29 stakeholders comprising IOC case studies, service users, as well as regulatory perspectives in England. Using a retroductive analysis approach, we aimed to test CMOCs against these data to explore whether previously identified mechanisms, CMOCs, and causal links between them were affirmed, refuted, or revised, and refine our explanations of how and why interorganisational collaborations are successful. RESULTS: Most of our prior CMOCs and their underlying mechanisms were supported in the interview findings with a diverse range of evidence. Leadership behaviours, including showing vulnerability and persuasiveness, acted to shape the core mechanisms of collaborative functioning. These included our prior mechanisms of trust, faith, and confidence, which were largely ratified with minor refinements. Action statements were formulated, translating theoretical findings into practical guidance. CONCLUSION: As the fifth stage in a larger project, our refined theory provides a comprehensive understanding of the causal chain leading to effective collaborative inter-organisational relationships. These findings and recommendations can support implementation of IOCs in the UK and elsewhere. Future research should translate these findings into further practical guidance for implementers, researchers, and policymakers.

Objective and subjective measurement of sedentary behavior in human adults: A toolkit.

OBJECTIVES: Objectives: Human biologists are increasingly interested in measuring and comparing physical activities in different societies. Sedentary behavior, which refers to time spent sitting or lying down while awake, is a large component of daily 24 hours movement patterns in humans and has been linked to poor health outcomes such as risk of all-cause and cardiovascular mortality, independently of physical activity. As such, it is important for researchers, with the aim of measuring human movement patterns, to most effectively use resources available to them to capture sedentary behavior. METHODS: This toolkit outlines objective (device-based) and subjective (self-report) methods for measuring sedentary behavior in free-living contexts, the benefits and drawbacks to each, as well as novel options for combined use to maximize scientific rigor. Throughout this toolkit, emphasis is placed on considerations for the use of these methods in various field conditions and in varying cultural contexts. RESULTS: Objective measures such as inclinometers are the gold-standard for measuring total sedentary time but they typically cannot capture contextual information or determine which specific behaviors are taking place. Subjective measures such as questionnaires and 24 hours-recall methods can provide measurements of time spent in specific sedentary behaviors but are subject to measurement error and response bias. CONCLUSIONS: We recommend that researchers use the method(s) that suit the research question; inclinometers are recommended for the measurement of total sedentary time, while self-report methods are recommended for measuring time spent in particular contexts of sedentary behavior.

When trust, confidence, and faith collide: refining a realist theory of how and why inter-organisational collaborations in healthcare work.

BACKGROUND: Health systems are facing unprecedented socioeconomic pressures as well as the need to cope with the ongoing strain brought about by the COVID-19 pandemic. In response, the reconfiguration of health systems to encourage greater collaboration and integration has been promoted with a variety of collaborative shapes and forms being encouraged and developed. Despite this continued interest, evidence for success of these various arrangements is lacking, with the links between collaboration and improved performance often remaining uncertain. To date, many examinations of collaborations have been undertaken, but use of realist methodology may shed additional light on how and why collaboration works, and whom it benefits. METHODS: This paper seeks to test initial context-mechanism-outcome configurations (CMOCs) of interorganisational collaboration with the view to producing a refined realist theory. This phase of the realist synthesis used case study and evaluation literature; combined with supplementary systematic searches. These searches were screened for rigour and relevance, after which CMOCs were extracted from included literature and compared against existing ones for refinement, refutation, or affirmation. We also identified demi-regularities to better explain how these CMOCs were interlinked. RESULTS: Fifty-one papers were included, from which 338 CMOCs were identified, where many were analogous. This resulted in new mechanisms such as 'risk threshold' and refinement of many others, including trust, confidence, and faith, into more well-defined constructs. Refinement and addition of CMOCs enabled the creation of a 'web of causality' depicting how contextual factors form CMOC chains which generate outputs of collaborative behaviour. Core characteristics of collaborations, such as whether they were mandated or cross-sector, were explored for their proposed impact according to the theory. CONCLUSION: The formulation of this refined realist theory allows for greater understanding of how and why collaborations work and can serve to inform both future work in this area and the implementation of these arrangements. Future work should delve deeper into collaborative subtypes and the underlying drivers of collaborative performance. REVIEW REGISTRATION: This review is part of a larger realist synthesis, registered at PROSPERO with ID CRD42019149009 .

Why do some inter-organisational collaborations in healthcare work when others do not? A realist review.

BACKGROUND: Inter-organisational collaboration is increasingly prominent within contemporary healthcare systems. A range of collaboration types such as alliances, networks, and mergers have been proposed as a means to turnaround organisations, by reducing duplication of effort, enabling resource sharing, and promoting innovations. However, in practice, due to the complexity of the process, such efforts are often rife with difficulty. Notable contributions have sought to make sense of this area; however, further understanding is needed in order to gain a better understanding of why some inter-organisational collaborations work when others do not, to be able to more effectively implement collaborations in the future. METHODS: Realist review methodology was used with the intention of formulating context-mechanism-outcome configurations (CMOCs) to explain how inter-organisational collaborations work and why, combining systematic and purposive literature search techniques. The systematic review encompassed searches for reviews, commentaries, opinion pieces, and case studies on HMIC, MEDLINE, PsycINFO, and Social Policy and Practice databases, and further searches were conducted using Google Scholar. Data were extracted from included studies according to relevance to the realist review. RESULTS: Fifty-three papers were included, informing the development of programme theories of how, why, and when inter-organisational collaborations in healthcare work. Formulation of our programme theories incorporated the concepts of partnership synergy and collaborative inertia and found that it was essential to consider mechanisms underlying partnership functioning, such as building trust and faith in the collaboration to maximise synergy and thus collaborative performance. More integrative or mandated collaboration may lean more heavily on contract to drive collaborative behaviour. CONCLUSION: As the first realist review of inter-organisational collaborations in healthcare as an intervention for improvement, this review provides actionable evidence for policymakers and implementers, enhancing understanding of mechanisms underlying the functioning and performing of inter-organisational collaborations, as well as how to configure the context to aid success. Next steps in this research will test the results against further case studies and primary data to produce a further refined theory. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019149009.

A novel behavioural INTErvention to REduce Sitting Time in older adults undergoing orthopaedic surgery (INTEREST): results of a randomised-controlled feasibility study.

BACKGROUND: Osteoarthritis is a prevalent condition in older adults that causes many patients to require a hip or knee replacement. Reducing patients' sedentariness prior to surgery may improve physical function and post-operative outcomes. METHODS: We conducted a pragmatic randomised-controlled feasibility study with 2:1 allocation into intervention or usual care groups. The intervention, based on Self-Determination Theory, involved techniques to reduce sedentary behaviour, including motivational interviewing, setting of behavioural goals, and more. The primary outcome was feasibility, assessed using mixed methods. We included exploratory measures to inform a future definitive trial, such as ActivPal3 accelerometry to measure movement, the Short Physical Performance Battery (SPPB), Basic Psychological Needs, and cardiometabolic biomarkers. Assessments were at baseline, 1-week pre-surgery, and 6-week post-surgery. RESULTS: We recruited 35 participants aged ≥ 60 years approximately 8 weeks before hip or knee arthroplasty. Participant uptake rate was 14.2%, and retention rate 85.7%. Participants were very satisfied with the study which was found to be feasible with some modifications. Exploratory within-group comparisons found that the intervention has potential to improve SPPB by 0.71 points from baseline to pre-surgery, a clinically significant increase, and reduce sedentary time by up to 66 min d-1. CONCLUSION: In this older surgical population, it is feasible to use behavioural techniques to displace sedentary time to activity and to conduct a trial spanning the period of surgical intervention. This may improve physical function and surgical outcomes. The INTEREST intervention is now ready for evaluation in a full-scale randomised-controlled trial. REGISTRATION: This trial was registered on Clinicaltrials.gov on 13/11/2018. ID: NCT03740412.

Frailty Levels In Geriatric Hospital paTients (FLIGHT)-the prevalence of frailty among geriatric populations within hospital ward settings: a systematic review protocol.

INTRODUCTION: Frailty is a common and clinically significant condition in geriatric populations, associated with adverse health outcomes such as hospitalisation, disability and mortality. Although there are systematic reviews/meta-analyses assessing the prevalence of frailty in community-dwelling older adults, nursing home residents, and cancer and general surgery patients, there are none assessing the overall prevalence of frailty in geriatric hospital inpatients. METHODS AND ANALYSIS: This review will systematically search and analyse the prevalence of frailty within geriatric hospital inpatients within the literature. A search will be employed on the platforms of Ovid, Web of Science and databases of Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus, SCOPUS and the Cochrane Library. Any observational or experimental study design which utilises a validated operational definition of frailty, reports the prevalence of frailty, has a minimum age ≥65 years, attempts to assess the whole ward/clinical population and occurs in hospital inpatients, will be included. Title and abstract and full-text screenings will be conducted by three reviewers. Methodological quality of eligible studies will be assessed using the Joanna Briggs Institute critical appraisal tool. Data extraction will be performed by two reviewers. If sufficient data are available, a meta-analysis synthesising pooled estimates of the prevalence of frailty and pre-frailty, as well as the prevalence of frailty stratified by age, sex, operational frailty definition, prevalent morbidities, ward type and location, among older hospitalised inpatients will be conducted. Clinical heterogeneity will be assessed by two reviewers. Statistical heterogeneity will be assessed through a Cochran Q test, and an I 2 test performed to assess its magnitude. ETHICS AND DISSEMINATION: Ethical approval was not required as primary data will not be collected. Findings will be disseminated through publication in peer reviewed open access scientific journals, public engagement events, conference presentations and social media. PROSPERO REGISTRATION NUMBER: 79202.

Perceptions and Factors Influencing Eating Behaviours and Physical Function in Community-Dwelling Ethnically Diverse Older Adults: A Longitudinal Qualitative Study.

Ethnic minorities have a high prevalence of non-communicable diseases relating to unhealthy lifestyle practices. Several factors have been identified as influencing unhealthy lifestyle practices among this population; however, there is little evidence about how these factors differ among a heterogeneous sample living in a super-diverse city. This study aimed to: (1) identify and compare factors influencing eating behaviours and physical function among ethnic older minorities living in Birmingham, United Kingdom; and (2) understand how these factors and their association with healthy eating and physical function changed over 8-months. An in-depth interviewing approach was used at baseline (n = 92) and after 8-months (n = 81). Interviews were transcribed verbatim and analysed using directed content analysis. Healthy eating was viewed as more important than, and unrelated to, physical function. Personal, social and cultural/environmental factors were identified as the main factors influencing eating behaviours and physical function, which differed by ethnicity, age, and sex. At 8-month interviews, more men than women reported adverse changes. The study provides unique and useful insights regarding perceived eating behaviours and physical function in a relatively large and diverse sample of older adults that can be used to design new, and adapt existing, culturally-tailored community interventions to support healthy ageing.

A novel behavioural INTErvention to REduce Sitting Time in older adults undergoing orthopaedic surgery (INTEREST): protocol for a randomised controlled feasibility study.

BACKGROUND: Osteoarthritis is a highly prevalent condition in older adults, that causes many sufferers to require a hip or knee replacement in order to improve their quality of life and reduce pain. Individuals waiting for hip or knee replacements are often highly sedentary; thus, it is pertinent to assess whether reducing their sedentariness prior to surgery may aid in improving post-operative outcomes. METHODS/DESIGN: The study will be a randomised controlled feasibility trial design, with 2:1 randomisation into an intervention and usual care group respectively. A target of 45 patients aged 60 years or older waiting for elective hip and knee replacements will be recruited from Russells Hall Hospital, Dudley, UK, approximately 8-10 weeks before surgery. The intervention, informed by Self-Determination Theory (SDT), will be composed of multiple behaviour change techniques, namely, motivational interviewing, feedback on current objectively measured sedentary behaviour and activity, goal-setting, environmental modification, self-monitoring, and social support. Assessments will occur at baseline, 1 week pre-surgery, and 6 weeks post-surgery. The primary outcome will be the feasibility of intervention delivery and of the trial procedures, assessed quantitatively based on rates of recruitment, retention, measures-completion, and intervention fidelity assessment, and with mixed-methods assessment of acceptability, practicality, adaption, satisfaction, and safety. Exploratory outcomes will include physical function, cardiometabolic biomarkers, measurement of SDT constructs, and both objective and subjective measurement of physical activity and sedentariness. The study will last up to 18 weeks per participant. No formal between-group comparisons are planned, but the variance in within-group changes and differences between groups in outcome measures will be explored and reported with 95% confidence intervals. DISCUSSION: This is the first study assessing the feasibility of an intervention to reduce sedentary behaviour in older adults with mobility limitations, and the first to assess whether such a reduction could work in a prehabilitative context prior to surgery. The results of this study will help inform the design of a definitive randomised controlled trial. TRIAL REGISTRATION: This trial is registered on Clinicaltrials.gov. Registration number: NCT03740412. Date of registration: 13/11/2018.

Interventions targeting sedentary behavior in non-working older adults: a systematic review.

Sedentary behavior has been found to be associated with negative health outcomes independently of physical activity in older adults. This systematic review collates interventions to reduce sedentary behavior in non-working older adults, assessing whether they are effective, feasible, and safe. A systematic search identified 2560 studies across five databases. Studies were included where participants were ≥60 years on average with none younger than 45, and participants did not work >2 days per week. A total of six studies were identified, three of which included control groups, while the other three were repeated-measures pre-post designs. Only one study randomised participants. The overall level of quality of included studies was poor. A narrative synthesis was conducted, as the level of heterogeneity in outcomes and outcome reporting were too high for a meta-analysis to be performed. The narrative synthesis suggested that interventions have the potential to reduce sitting time in non-working older adults. Included studies reported feasible and safe implementations of their interventions in most samples, except for one subsample from a study of people in sheltered housing. Objectively measured reductions in sitting time were between 3.2% and 5.3% of waking time, or up to 53.9 min per day. Future studies should employ more rigorous designs to assess the effects of reducing sedentary behavior on health and physical function, and should include follow-ups to measure the duration of behavior change.