Exploring change mechanisms of implementation strategies for providing guideline-adherent care by interprofessional teams in inpatient settings: a realist synthesis.

backgroundWell-designed guideline implementation tools - such as job aids and documentation charts - can facilitate adherence to clinical practice guidelines among health workers and accelerate improvements in quality of care and patient outcomes. However, the mechanisms through which these tools and participatory design processes influence guideline adherence in low- and middle-income country (LMIC) hospitals remain underexplored. This realist synthesis aims to refine a theory explaining how and why these strategies work, and in what contexts, by identifying evidence to support, refute, or expand upon hypothesized explanations in an initial program theory.

methodsWe conducted a realist synthesis, a theory-driven interpretive approach to secondary research integrating empirical data with realist philosophical interpretation. This realist synthesis was conducted in five steps: (1) clarify scope, (2) search for evidence, (3) appraise studies and extract data, (4) synthesize evidence and draw conclusions, and (5) disseminate, implement, and evaluate. A program theory was developed to explain a pilot project to improve adherence to existing guidelines for inpatient care of malnourished children in Kenya. Context, strategy, mechanism, outcome (CSMO) configurations are the units of theory. Evidence was identified through a search of four databases. An appraisal of relevance, richness, and rigor determined inclusion in data extraction. We synthesized our findings to refine the program theory, resulting in a middle-range theory.

resultsWe screened 8697 titles and abstracts and reviewed 112 full-text manuscripts. Data were abstracted from 27 articles. The refined middle-range theory included eight context-strategy-mechanism-outcome configurations. Participatory processes-such as health worker engagement, user testing, and local consensus processes-were found to generate mechanisms including buy-in, tool acceptability, and team identity. Guideline implementation tools contributed through mechanisms such as role clarity, reminders, improved competence, and enhanced communication. Job aid posters and user-friendly documentation tools were particularly valued for making information accessible and supporting patient monitoring. The findings highlight synergies between participatory processes and guideline implementation tools, especially in promoting teamwork.

conclusionsOur middle-range theory describes the how, why, and in what contexts implementation strategies involving participatory processes and guideline implementation tools support clinical guideline adherence among health workers in LMIC hospitals. This refined theory can be utilized to guide implementation efforts, supporting selection and design of implementation strategies that align to context and trigger the generative mechanisms that produce results.