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Table 5 Potential theories

From: Modelling successful primary care for multimorbidity: a realist synthesis of successes and failures in concurrent learning and healthcare delivery

  Implementation aspects Intended outcomes
…models for learning Educational alliances [10] •Need to trigger interpersonal connections between trainee and supervisor •Educational alliance – defined as partnership producing just the right amount of responsibility – a balance between support and challenge with professional acting as safety net for patient and trainee
Beacon practices [67] •Need to trigger inter-practice links •Collaborative and extended roles in primary care for professionals
•Contextual infrastructure required
Communities of practice [26,40,48,74,76] •Need to trigger genuine team-working between patients, trainees and professionals •Harnessing of emergent learning from practice and experience
•Trust required between all and relationship building a crucial mechanism for interventions to work •Dynamic approach to care aligned to shared goals
•Studies of actual working practices including during interventions needed •Able to capture in-practice learning and innovation to further develop and improve outcomes (emergent learning)
•Any intervention needs to focus not just on education or decision-support for individuals but also the dynamic system in which they are situated •Reciprocal learning and sharing of best practice through system adjustments to support this
•Development of communities of practice
ExBL [11,77] •Need to trigger ‘virtuous learning cycles’ – participation, balance of support and challenge, graded responsibilities •Practical competence
•State of mind conducive to practice (confidence, motivation, sense of professional identity)
Breakdowns [78] •When a breakdown (a situation where a person is not achieving expected effectiveness) occurs then interventions must trigger reflective learning and an effective response from others •Constructive learning for future practice
•Contextual factors: patient engagement, responsibility matched to authority, tools matched to task, information resources matched to need, values shared between co-participants, expectations matched to capacity
Developmental space [79] •Creation of developmental space to permit learning and development of professional identity – space created through workplace context, personal and professional interactions and emotions such as feeling respected and confident •Mindful learning and development
…models for care delivery Guided Care [66] •Increased staff resources for patient support •Increased satisfaction with communication and increased knowledge of patient clinical characteristics
Patient Centred Medical Home [48,61] •Need to trigger social, psychological and physical assessment •Holistic care developed through patient and professional collaboration
•Need to trigger active patient and professional participation
CARE approach [57] •Need to trigger connections between patients and professionals •Holistic assessment, appropriate responses and patient empowerment
Chronic Illness Care Plans [27] •Need to trigger holistic assessment – requires professionals rethinking their roles •Individualised care plans
The Chronic Care Model [1,25,48,62] •Need to trigger a patient centred approach including relational and management continuity •Holistic care shared between patient and provider
•Need to trigger reciprocal learning •Sharing of best practice
•Contextual factors are community resources and policies
Self-management support five A’s [65] •Need to trigger assessment, appropriate advice, agreement of goals, assistance in behavioural change, and monitoring •Personal action plans for patients and increased purposeful self-management
•Context ‘self-management’ of some sort is inevitable as clinicians are only present for a fraction of a patient’s life
Shared decision-making [80,81] •Need to trigger desire for patient involvement (varies according to reason for encounter) •Appropriate shared decision making
•Mechanism – education of health professionals about sharing decisions alongside patient mediated interventions
…models for both Transformative learning [44-46] •Triggers are lived experiences combined with readiness for change leading to critical reflection, restructuring of meanings and development of new meanings •New rules, ways or guidelines, new behaviours, feelings, beliefs, perspectives, identity
•Learning about self and chronic illness in an iterative and continually changing manner
Response shift [44] •Triggers are lived experiences combined with readiness for change leading to critical reflection, restructuring of meanings and development of new meanings •New rules, ways or guidelines, new behaviours, feelings, beliefs, perspectives, identity
Education centred medical home [47] •Need to trigger legitimate participation of trainees in continuity of patient care •Increased patient support
•Practice based learning experiences