Understanding success and failure in multimorbidity: protocol for using realist synthesis to identify how social learning and workplace practices can be optimised.

Abstract

Multimorbidity is increasingly prevalent but, aside from epidemiological work, the impact on associated provision of healthcare and/or education is little understood. For example, it is unclear how or why healthcare interventions meet (or do not meet) people's multiple needs. Professionals working in primary care training sites must reconcile two goals: provision of appropriate individualised healthcare and provision of constructive workplace-based learning for future professionals. Given that professionals, learners and patients may have differing priorities and conceptualisations of success and failure in the absence of cure, achievement of both goals depends on social and cultural mechanisms. This review aims to make sense of how healthcare delivery for, and education about, multimorbidity can be concurrently delivered in primary care through identification of relevant theoretical frameworks. Realist synthesis identifies and makes sense of variable outcomes caused by interaction between mechanisms and contexts. This review will produce a synthesis of social science, education and primary care literature. Our objective is to understand interactivity between models of workplace-based education and models of patient-centred/integrated care with a focus on perceptions of 'success' and 'failure' in multimorbidity. We intend to build a conceptual map and a realist programme theory, populated with evidence from the literature, as the first step towards answering our review question: what is known about how and why concurrent health service delivery and professional medical education interact together to generate outcomes valued by professionals, learners and patients for patients with multimorbidity in primary care? To answer this we are focusing on relationship-based negotiation of needs-based learning and needs-based care as our primary outcome of interest. In this protocol we outline our search strategy and proposed methods of analysis and synthesis of credible and trustworthy data judged to be relevant to our research question. Findings will be submitted for peer-reviewed publication. Identification of how mechanisms of social learning and workplace practices could be optimised to improve quality and utility of patient care in multimorbidity is important. This can inform the future research regarding interventions that will produce a sustainable medical workforce equipped to provide healthcare, when the possibility of cure is absent.