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Feature - Advancing care

Margarita Corry discusses a resource for developing complex interventions in the healthcare setting

Technological advances allow healthcare providers to deliver their services in new ways. Developing novel ways to provide health or social care in practice is a complex activity that requires researchers to consider a number of different but interconnected phases.

The ‘Complex Interventions’ website –www.complexinterventions.blogspot.ie– is a useful resource for those who are new to the process of developing complex interventions in a healthcare setting. The site gives an overview of what a complex intervention is and the different frameworks and guidelines available for developing one. It uses an example of the development of a nurse-led telephone support intervention for the carers of people with multiple sclerosis to take users through the steps.

On the website, various experts speak on the different aspects of intervention development in a collection of specially-made video interviews. Drawing on nursing practice as an example, these interviews explain: why intervention development and testing is important; the use of theory for intervention development; the role of systematic reviews in intervention development; methods of evaluation such as realist evaluation and the randomised controlled trial; and the value of including an economic evaluation.

The following extracts summarise what you can learn from the interviews:

Prof Debra Moser describes why complex interventions are important. She defines a nursing intervention as one that is not just conducted by a nurse, but in which the intervention has an integral component that relates to nursing. Nursing interventions are designed to test some aspect of nursing practice or systems of care delivery.

Moser argues that much nursing practice has not been tested for effectiveness but may be based on custom. Therefore, nursing interventions need to be tested in order to determine if they do have a positive impact on outcomes, identify ways to best improve outcomes, demonstrate the value of nursing, and make nursing visible.

She points out that ineffective nursing practice can have a negative effect on patient outcomes and can lead to nurses’ dissatisfaction with work processes and frustration that they are not delivering optimum care. This may result in burn out and the delivery of worsening care.

Prof Hugh McKenna describes the types of theories which are sometimes referred to as models or conceptual frameworks. He explains the difference between grand theories, middle range theories and practice theories. He argues that nurses need more practice theories to inform their work.

Practice theories should be used to develop nursing interventions because they are specific, relevant and applicable to every day practice. Meanwhile, grand theories are too broad and remote from specific nursing contexts and have limited usefulness to inform actual practice interventions.

Dr Valerie Smith, from the School of Nursing and Midwifery in TCD, provides guidance on how systematic reviews can inform the development of complex interventions. Along with clarifying the concept, systematic reviews make a unique contribution to the theoretical development of an intervention by specifically focusing and collating evidence on a particular topic using the rigor of a systematic process.

Smith contextualises the use of systematic reviews in complex intervention development by providing examples on how she has used the outcome from such reviews to inform her work in this area.

Prof Alison While explains what virtual healthcare interventions are and highlights the key components and complexity of developing such interventions. She highlights the importance of ensuring that outcomes include both clinical and, where possible, psychosocial outcomes so, where appropriate, practitioners bring about changes in practice.

She provides advice on the practicalities of developing an intervention for the virtual healthcare setting and highlights the importance of testing for feasibility and ensuring cost-effectiveness is considered.

Prof Charles Normand looks at the concept of economic evaluation, key areas to consider and the challenges researchers encounter. He also emphasises that while the principle of economic evaluation is straight forward, actually carrying out an economic evaluation is a technical activity. The challenges researchers face in terms of perspective and measurement are discussed.

Prof Mike Clarke highlights the importance of having a clear definition of the intervention from the outset. Non-randomised study designs may be used to test out the elements of the intervention but once the intervention is defined, the only design that will minimise bias is the randomised control trial. How qualitative research can contribute to our understanding is also explored.

Prof Brendan McCormack examines the concept of realist evaluation and its place in healthcare research. The origins of realist evaluation, its purpose, complexity and how it guides evaluation is explored.

McCormack believes that the exploratory phase of a trial does lend itself to realist work but current guidelines do not give enough attention to context. In realist evaluation ‘context is everything as it drives decision making and what we are trying to achieve’.

McCormack says that the process starts in the real world of practice. He outlines the practical challenges facing the researcher, including challenges in hypothesis generation, knowing when to stop and obtaining funding when doing realist evaluation. Links to useful resources such as published papers and books, websites and particularly helpful courses abound throughout the resource pack on the ‘Complex Interventions’ website.

Margarita Corry is currently completing a Health Research Board research fellowship in the Department of Nursing, TCD

Feature - Advancing care
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