Realist synthesis protocol on the effectiveness of a rapid response system in managing mental state deterioration in acute hospital settings
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* Tendayi Bruce Dziruni
* Alison M Hutchinson
* Sandra Keppich-Arnold
* Tracey Bucknall

## Abstract

**Introduction** Patient mental state deterioration impacts patient outcomes, staff and increases costs for healthcare organisations. Mental state is broadly defined to include not only mental health but a broad range of cognitive, emotional and psychological well-being factors. Mental state deterioration is inconsistently identified and managed within acute and tertiary medical settings. This protocol aims to synthesise the evidence to test and refine initial programme theories that outline the functioning of a rapid response system.

**Methods and analysis** This synthesis will be guided by Pawson’s key steps in realist reviews. We will clarify the scope of synthesis through an initial literature search, focusing on understanding the functioning of rapid response system in managing patients presenting with mental state deterioration in acute hospital settings. Initial programme theories will be refined by developing a search strategy to comprehensively search electronic databases for relevant English language peer-reviewed studies. Additionally, we will search the grey literature for sources to supplement theory testing. An abstraction form will be developed to record the characteristics of literature sources. We will use spreadsheets to code and report contextual factors, underlying mechanisms, and outcome configurations.

**Ethics and dissemination** As this study is a realist synthesis protocol, ethics approval is not required. Synthesis findings will be published in a peer-reviewed journal and presented at scientific conferences.

*   Decision Making
*   GENERAL MEDICINE (see Internal Medicine)
*   Health policy
*   Organisation of health services
*   Risk management
*   MENTAL HEALTH

### STRENGTHS AND LIMITATIONS OF THIS STUDY

*   Currently, there are gaps in the existing literature regarding evidence-based early interventions aimed at effectively managing mental state deterioration in general hospital settings.

*   The proposed synthesis will test, refine and identify theories regarding the causal mechanisms underlying the effectiveness of a rapid response team intervention in managing mental state deterioration in acute hospital settings.

*   Through the proposed synthesis, we will gain a deeper understanding of how a rapid response team model would be expected to improve patient outcomes based on a causal context–mechanism–outcome framework. The evidence will provide valuable insights into the effective implementation and impact of the rapid response team intervention.

*   The proposed synthesis cannot comprehensively consider the entire breadth and depth of mental state deterioration due to the scope of the review question, time and resources.

*   The possibility exists that evidence may be missed if the databases selected are not indexed.

## Background

A person’s mental state represents their cognitive and behavioural state and includes factors such as physical health, appearance, emotional state, thought patterns, sensory awareness, orientation, memory, interpretation ability and motor activity.1 2 Indicators of mental state include mood, behaviour, cognition, judgement, memory, thought process and content, insight and judgement.2 Mental state deterioration (MSD) is exacerbated by poor mental health, cognitive impairment and physical health conditions, including delirium, atypical responses to prescribed treatments or intoxication with licit or illicit substances.3 Extrinsic factors like ‘locked doors’ policy, waiting times, clinical practices such as restrictive interventions, specific characteristics of the staff–patient relationship that lead to limit setting, practices around patient and visitor movements, and service expectations are factors that impact MSD.4–6

Previously implemented changes to address and manage MSD in healthcare settings included Code Grey and Code Black standards (a multidisciplinary team response to aggressive behaviour incidents).3 Code Grey is a coordinated clinical and security response across the hospital to actual or potential patient or visitor aggression and violence towards others, which creates a risk to health and safety.7 On the contrary, Code Black is a response to actual or potential aggression or violence involving a weapon (armed threat).8 These standards were introduced in the Victorian healthcare system to promote consistency in responding to occupational violence and aggression incidents.7

There is, however, a continuing trend of MSD occurring in acute hospital settings, which results in poor health outcomes, adverse events and distress for the patient, their families, caregivers and staff.9–11 As an adverse outcome, MSD is also associated with other adverse outcomes such as trauma, clinical aggression and the use of restrictive practices or interventions.12 13 For clinical aggression, the impacts on staff are well documented, including managing unpredictable behaviours, staff injury, sick leave, the effect of perceived risk and emotional distress associated with actual aggression, and the impact on morale, performance and job satisfaction.14–17 The effects on organisations include the cost of sick leave, litigation, decreased staff effectiveness and difficulty recruiting and retaining staff.5 6 18 Organisations are responsible for identifying and implementing interventions to manage and minimise MSD. Moreover, to also provide high-quality care, organisational leaders need to promote a healthy, respectful, safe work environment and employ a skilled, engaged and compassionate workforce.19 The existing body of research around managing clinical aggression in settings such as emergency departments, mental health, and geriatric settings is well established.20–22 However, to date, little attention has been paid on the role of rapid response team in early identification and management of patients presenting with MSD in acute hospital settings. Furthermore, current approaches are inconsistent and MSD rates remain high.3 23 To address this knowledge gap, a tertiary teaching hospital in Melbourne is trialling DIvERT (De-scalation, Intervention, Early, Response, Team) intervention to manage patients presenting with MSD. The proposed synthesis is part of a larger project, a realist evaluation of DIvERT. As an early intervention strategy, DIvERT aims to intervene at the first sign of MSD and mobilise a timely response to ensure that patients receive appropriate and timely care plans and to prevent associated risks from escalating.

### Realist reviews

A realist review is a theory-driven methodology to comprehensively review the literature and apply realist philosophy to synthesise findings.24 Realist programme theories articulate the key components of the programme, the intended outcomes, as well as the contexts that may shape the mechanisms through which the programme contributes to those outcomes.25 The objective of a realist review is to test, refine and refute initial programme theories (IPTs) explained through context–mechanism–outcome (CMO) configurations that consolidate evidence from diverse data sources.26 As the first step in the realist cycle, IPTs are a way of initially theorising the intention of an intervention by classifying and organising assumptions of programme designers.27 The realist approach seeks to address the questions, ‘what works, for whom, in what respects, to what extent, in what contexts, and how?’ instead of ‘does it work’.28 29 The methodology is based on the philosophical paradigm of realism, which positions itself between the positivist and the constructivist paradigms and emphasises the search for alignment between reality and our constructions of reality.30 31 To apply the methodology, researchers must examine the underlying mechanisms that explain ‘how’ the outcomes are produced and the influence of context.31 32

This distinctive understanding of generative causation is the hallmark of the realist approach and supports understanding how programmes and policies generate outcomes through human decisions.24 Achieving this requires uncovering the architecture of programmes and services, the formal and informal resources, and efforts alike.33 The driving forces for the construction are retroduction, the search to unearth causal mechanisms (underpinning causal forces) and ontological depth; reality is stratified, and thus causal evidence transpires at a deeper level of reality.33 34 The causal links between CMOs are the fundamental principles of the realist research methodology.35 The CMO framework is generally summarised as context + mechanism = outcome.29 Table 1 provides a brief overview of CMO.

View this table:
[Table 1](http://bmjopen.bmj.com/content/14/1/e077597/T1)

Table 1 
What are C, M and O?

Research based on realist principles involves developing IPTs, and a realist review tests and refines these theories. IPTs are the testable hypotheses about how, for whom and in what circumstances a programme is thought to work and are a fundamental and prerequisite part of the evaluation methodology.36 IPTs evaluate the original intentions of the programme by theorising, classifying and organising the experiences and assumptions of the programme designers and implementers. In contrast to traditional systematic reviews, realist reviews rely on multiple data sources to test theories rather than using only peer-reviewed sources.37 This use of multiple sources is aligned with the concept of theory triangulation which uses different methods to answer the same question.38 Central to theory triangulation is that processes leading to the same results strengthen research findings.39

### The Australian healthcare system

The Australian healthcare system is complex, the state funds hospitals’ infrastructure and workforce, while the federal government funds the healthcare system’s Medicare (activity). There are different challenges when improvements are introduced; any changes, policies and initiatives need to align with the State Department of Health objectives. Implementation chains go through various routes, from the intervention designers to the various committees that may have to approve the policy and the ward environment in the hands of staff who might have different competing priorities.40 The realist methodology has been selected because it provides the systematic tools for synthesising complexity and the potential to improve service delivery by focusing on granulated contextual analysis to explain how a programme works.24 31

## Methods

The primary stages of a realist review are comparable with those of a standard Cochrane review; however, the substeps involved in completing a realist review may be overlapping and iterative rather than chronological.25 This iteration strengthens the explanation building with primary research examined for its contribution towards IPT development and refinement.31 Figure 1 shows a synopsis of the realist review stages.

![Figure 1](http://bmjopen.bmj.com/https://bmjopen.bmj.com/content/bmjopen/14/1/e077597/F1.medium.gif)

[Figure 1](http://bmjopen.bmj.com/content/14/1/e077597/F1)

Figure 1 
Iterative, non-linear process.

### Stage 1: preliminary programme theory development

As the first key step in realist methodology, IPTs provide a theoretical framework for articulating the assumptions and ideas underlying how and why an intervention or programme is expected to be effective.25 41 Thus, in this stage, we will broadly theorise our intervention for managing MSD, which should also provide a structure for organising synthesis findings.24 35 41 IPTs are progressively refined, tested and added to as the review progresses to other stages. We will complete a preliminary scoping review through purposeful and iterative searching of the peer-reviewed English language literature on existing interventions to manage MSD in acute hospital settings. The following search terms will be used: ‘mental state deterioration’, ‘behavioural disturbances’, ‘acute behavioural disturbances’, ‘violence prevention’, ‘restraint’ and ‘medical response team’, ‘medical emergency teams’, ‘rapid response team’ from the last 10 years. We will also scope the grey literature to support theory development.

From a tentative scope of the literature for theories, we found sufficient literature to support IPT development. Here is what we think we will find, for a rapid response system to be effective, there needs to be organisational changes at distinct levels and CMO will encompass processes of care, therapeutic practices, and organisational supports.42–44

Processes of care relate to the actions and decisions that healthcare staff will take and make collaboratively to recognise, escalate, manage and report deterioration in mental state safely and effectively.

Therapeutic practices will represent the collaborative approaches that healthcare staff adopt through a rapid response system to manage patients presenting with MSD. Some of the mechanisms that lead to outcomes include timely responding to MSD, teamwork, shared decision making, communication, cultural competence, delivering care pathways that acknowledge and respect people’s experience with trauma, safely avoiding restrictive practices and identifying precursors to incidents and prevent recurrences.

Organisational supports describe the underlying, organisational and governance structures that support the healthcare workforce to effectually recognise and manage patients presenting with MSD. The organisational leadership should allocate resources to support the delivery and effective functioning of the systems for managing MSD.

Overall, there is critical role of the organisational leadership in leading the vision, being proactive, accountable and engaged by availing resources for addressing MSD.44–46 According to reviewed sources, there is consensus that changes should include implementing guidelines and rapid response system policies for the local context, which align with relevant national, state, and local policies.5 43 47

The importance of increasing preparedness is highlighted in the literature through tailored education training programmes for addressing MSD.48 49 Accordingly, training modules should be relevant to the core competencies required by all staff working with patients, including allied health.48 Previous research50 established that staff feel more confident about patients’ medical condition than about cognitive, behavioural challenges and mental health problems. Additionally, staff commented that early involvement of a specialist team would be invaluable in managing patients with complex co-morbidities.50 Overall, there is evidence to indicate that training such as on recognising early signs of agitation potentially improves the confidence and clinical skills of staff leading to improved patient outcomes and MSD interventions that represent safe and cost-effective approaches.46

The composition of the rapid response team should include a mix of skills, involving mental health trained staff, doctors, nurses and medical trainees, each with varying levels of operational oversight.51 Therefore, the optimal functioning of rapid response system depends on understanding of roles and responsibilities, liaison between those who call the response team (users), those rostered to respond (response team members), and the intra-interdisciplinary communication and cooperation. Facilitators of optimal effectiveness can be improved through staff training in leading and managing rapid response calls, including the non-technical team leadership skills, knowledge of deterioration indicators, communication skills and encouraging users to voice any ongoing or unresolved clinical concerns during response calls.52 53

The decision to activate the rapid response system is often moderated by justifying the need by seeking affirmation from peers or gathering more clinical data to avoid unnecessary activation.54 Justification requires increasing competencies such that nursing staff are confident in applying clinical reasoning supported by assessment tools, clinical indicators together with clinical experience.54 It is argued that staff who were unsure whether patient met the rapid response criteria questioned themselves if they were doing the ‘right thing’ and the time spent justifying limits the rapid response as an effective early intervention strategy.53 54 Evidence5 12 18 supports implementing process management features including staff using validated screening and risk assessment tools, as prompts about the importance of early recognition and management of MSD to minimise associated risks from escalating.

Several studies5 13 suggest that there is extensive under-reporting of MSD incidents mainly due to cumbersome reporting systems, lengthy digital forms and staff reluctance to report leading to incident data that is not reliable, comparable and often of poor quality for quality improvement and evaluation purposes. Reporting procedures must be simple and user-friendly and staff should be confident that they will receive management support when they report incidents, reinforcing the importance of feedback and feedforward processes.52 55 From the evidence from our brief scope of the literature, we have developed our tentative working IPTs shown in table 2. As the first step in theory refinement, we hope to test, refine and develop other theories through the proposed synthesis.

View this table:
[Table 2](http://bmjopen.bmj.com/content/14/1/e077597/T2)

Table 2 
Tentative initial programme theories

### Stage 2: search for evidence

Stage 2 involves focused and iterative searching based on articulated IPT. Purposive sampling is used to identify specific evidence to test particular hypotheses and to identify primary research studies that will facilitate the refinement of theories.31 There is no finite set of relevant research papers for realist reviews, and the strength-by-numbers approach does not apply. Therefore, a small number of relevant studies on the grounds of rigour does not impact nor reduce the validity and generalisability of synthesis findings.25 33 As highlighted by Saul *et al*,26 searching for evidence involves four stages, which are summarised as follows;

1.  A background search to get a feel for the literature.

2.  Progressive focusing on identifying the programme theories.

3.  A search for empirical evidence to test a subset of the programme theories.

4.  A final search once the synthesis is almost complete.

Literature searches will be carried out in the Excerpta Medica database (EMBASE), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Online Medical Literature Analysis and Retrieval System (MEDLINE), supplemented by citation tracking to identify peer-reviewed articles relevant, first, to MSD and, second, to rapid response teams in the context of acute hospital settings. We will also search the grey literature for government framework documents, health policy directives and theory guidance documents. We aim to evaluate primary research and grey literature for evidence that will contribute conceptually and empirically to test, refine and rebuke our IPT.

The inclusion and exclusion criteria will be continuously refined, considering emerging data. The date range coverage will be for evidence published in the last 10 years, and a search strategy is provided in online supplemental appendix. Before the main search, a preliminary search will be conducted to determine whether the topic has already been examined and to check for broadness, narrowness and alternative terminology. As necessary, the search will be refined and may need to be performed several times until there are no spelling errors or missing terms, and the search returns relevant articles. In realist reviews, searching continues in a cyclical and iterative process that is not exhaustive; however, test saturation can be applied at each searching stage by checking whether anything new has been added to the understanding and whether further searching will add new insight.25 31 On completion of the final search, each database search will be saved, and all searches will be exported to the Endnote reference manager. Details of the final search will be documented in a table.

### Supplementary data

[[bmjopen-2023-077597supp001.pdf]](pending:yes)

### Stage 3: literature selection and appraisal

After initial screening of titles and abstracts, retained sources will be imported into Covidence for further screening. The full-text articles will be screened further by two members of the research team to improve the reliability, objectivity and quality of the screening process. Any disagreements encountered will be resolved through discussion and consensus during team meetings. In accordance with the realist review methodology, the relevance of evidence is determined by whether the evidence addresses the theory under test. Based on the RAMESES (Realist And Meta-narrative Evidence Syntheses: Evolving Standards), rigour will be evaluated by assessing whether specific inferences drawn have sufficient support to make a methodologically substantial influence when testing IPT.24 25 The appraisal of studies will be based on how specific sections of their evidence support a particular programme theory regarding the links between context, mechanism and outcome.56 In other words, we are interested in selecting studies based on the knowledge they contribute to understanding of the CMO configuration framework. Studies should contribute a different component to the rich picture that constitutes the overall synthesis of evidence.57 In the third stage of screening, sources will read in full and screened in Covidence by two members of the research team with regular feedback of potential sources for consideration to the whole team through our team meetings. We will use the TAPUPAS framework (Transparency, Accuracy, Purposivity, Utility, Propriety, Accessibility and Specificity) during the appraisal process for transparency and to provide a reference for judgements about rigour, richness and relevance to justify the selection of sources.58 Using the Covidence software, we will create a PRISMA (Preferred Reporting Items for Systematic review and Meta-Analysis) flow chart which will be downloaded and modified in Microsoft word to meet our synthesis needs.

### Stage 4: data extraction

Since primary studies will use a variety of research methodologies, there is no one-size-fits-all approach when it comes to extraction. Realist reviews assimilate information more by capturing notes and annotation than by extracting data per se.25 We will use Microsoft Excel to create a table of characteristic to organise a summary of key information about literature sources such as the study design, participants, interventions, outcomes and key findings that contribute to our understanding of effective functioning of a rapid response model for managing MSD in acute hospital settings. Additionally, context, mechanism and outcome themes will be extracted and organised using a Microsoft Excel data matrix. Two research team members will complete the extraction of CMO themes which will be discussed and evaluated with the rest of research team in our regular meetings. Based on our review of the literature, which highlighted the role of processes, therapeutic practices and organisational support in thinking about the effectiveness of rapid response teams, we are interested in sources that improve the conceptual richness and contextual thickness of evidence.59 A reviewer is said to change from divergent to convergent thinking during the data extraction phase by switching from CMO framework building to framework testing and from theory construction to theory refinement.24 ,31

### Stage 5: synthesis of evidence

Data synthesis refers to the explanatory pursuit that will lead to an understanding of what it is about interventions for addressing MSD that works, for whom, in what circumstances, in what respect and why.25 Since realist reviews begin with theories and conclude with more refined theories, this phase is intended to translate the analysis of data into refined programme theories.60 In other words, it is making sense of the analysed data using the IPTs, which will produce more refined evidence-based theories. Like figuring out a puzzle to form a causal picture, the aim being to re-articulate the evidence guided by the principles of generative causation. That is, an outcome is generated by a related mechanism triggered in a particular context. Data will be coded using three approaches: deductively using ideas from the initial literature search, inductively drawing conclusions from the data in the literature and reproductively inferring potential CMOs from the literature.24

A Microsoft Excel spreadsheet will be used to code the CMOs based on the IPTs. Demi-regularities will be explored and recorded for their causative mechanisms. A demi-regularity is a partial event regularity that indicates a mechanism is occasionally actualised, but not always, over a particular period of time.61 In line with realist synthesis publication standards, a description of the review team and participation in the analysis and synthesis process will be provided in the final review.24

### Stage 6: dissemination of the findings

The final phase of a realist synthesis is to present refined theories and engage the key stakeholders through meetings for sense-checking, refinement and to prioritise theories to be tested in future research. We have a delegated governance steering committee overseeing DIvERT at our organisation. The committee had oversight on the DIvERT implementation and regularly meets to discuss progress. The research team met with committee at commencement of realist evaluation via Microsoft Team and there has been ad hoc email communication to meet requests for the evaluation needs. We hope to arrange another team meeting with the DIvERT steering committee to discuss our findings when we complete the synthesis. Through this iterative process of stakeholder review and refinement, programme theories are tested and validated as the steering committee are the subject matter experts.25 62 63 Refined theories should be presented to gain a deeper understanding of how intended and unintended outcomes are achieved through the interaction of mechanisms in given contexts.26 Furthermore, refined theories can assist programme designers in identifying the considerations and caveats that should be considered and to support decisions.

This protocol encapsulates the steps that will be adopted to complete this realist review in line with the RAMESES methodological guidelines for realist reviews.24 The proposed review will serve as a foundation for a realist evaluation of an intervention to improve outcomes for MSD in the acute hospital settings. The construction of IPTs will also contribute to scholarly knowledge on the management of MSD which is currently limited.

## Conclusion

The concept of a rapid response team is exciting as it offers a practical and proactive of model of care to improve the quality of care, patient outcomes, manage and minimise risks associated with MSD in acute hospital settings. The proposed synthesis findings will provide a nuanced understanding of the contextual factors that influence the effectiveness of a rapid response team intervention. The knowledge of how a rapid response model works in specific contexts is important to tailor interventions. By highlighting the factors that can lead to a response team model’s success or failure, the proposed synthesis uncovers underlying causal mechanisms, essential to optimising team structures and processes. The findings will offer practical implications for the implementation of rapid response teams for managing MSD, such as guidance on team composition, training, communication strategies and coordination with medical teams. Furthermore, the synthesis will contribute to the advancement of knowledge in mental health by providing a valuable evidence base for shaping mental health policies and clinical practices in acute hospital settings.

## Limitations

Like any other type of review, this proposed synthesis cannot comprehensively consider the entire breadth and depth of MSD due to the scope of the review question, time and resources. Our review is context-related and limited to literature sources published in English. The realist review methodology cannot detail all the context and mechanisms that bring about change; however, we endeavour to practically shed some insight into how an intervention is supposed to work to improve patient care and fill the knowledge gap. Considerations will be taken to explain the strengths and limitations in the final review.

## Ethics statements

### Patient consent for publication

Not applicable.

## Footnotes

*   Twitter @dziruni_tb

*   Contributors TB and SK-A developed the PhD idea, selected the design, TB drafted the first draft of the protocol. TB, SK-A and AMH reviewed and recommended ideas of second draft. All authors contributed to the refining the protocol and were involved in the final review. The final manuscript has been read and approved by the authors.

*   Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

*   Competing interests None declared.

*   Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

*   Provenance and peer review Not commissioned; externally peer reviewed.

*   Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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## References

1.  Craze L, McGeorge P, Holmes D, et al. Recognising and responding to deterioration in mental state: A scoping review. ACSQHC: Sydney, 2014.
    
    

2.  Semple D, Smyth R. *Oxford handbook of psychiatry*. July 2019. [doi:10.1093/med/9780198795551.001.0001](http://dx.doi.org/10.1093/med/9780198795551.001.0001)
    
    

3.  Victorian Auditor-General. Occupational violence against healthcare workers. Melbourne, VIC: Victorian Government Printer, 2015. Available: [https://www.audit.vic.gov.au/sites/default/files/2017-07/20150506-Occ-Violence.pdf?](https://www.audit.vic.gov.au/sites/default/files/2017-07/20150506-Occ-Violence.pdf?)
    
    

4.  Papadopoulos C, Ross J, Stewart D, et al. The antecedents of violence and aggression within psychiatric in-patient settings. Acta Psychiatr Scand 2012;125:425–39. [doi:10.1111/j.1600-0447.2012.01827.x](http://dx.doi.org/10.1111/j.1600-0447.2012.01827.x)
    
    [CrossRef](http://bmjopen.bmj.com/lookup/external-ref?access_num=10.1111/j.1600-0447.2012.01827.x&link_type=DOI) 
    
    [PubMed](http://bmjopen.bmj.com/lookup/external-ref?access_num=22268678&link_type=MED&atom=%2Fbmjopen%2F14%2F1%2Fe077597.atom) 
    
    [Web of Science](http://bmjopen.bmj.com/lookup/external-ref?access_num=000303853700002&link_type=ISI) 

5.  Victorian Auditor General. Occupational violence against healthcare workers. Melbourne, VIC: Victorian Government Printer, 2015. Available: [https://www.audit.vic.gov.au/sites/default/files/2017-07/20150506-Occ-Violence.pdf?](https://www.audit.vic.gov.au/sites/default/files/2017-07/20150506-Occ-Violence.pdf?)
    
    

6.  Queensland. Occupational Violence Prevention in Queensland Health’s Hospital and Health Services: State of Queensland. 2016. Available: [https://www.health.qld.gov.au/\_\_data/assets/pdf\_file/0024/443265/occupational-violence-may2016.pdf](https://www.health.qld.gov.au/__data/assets/pdf_file/0024/443265/occupational-violence-may2016.pdf)
    
    

7.  Department of Health and Human Services. Code grey standards: Victorian state government. 2016. Available: [https://www2.health.vic.gov.au/about/publications/policiesandguidelines/code-grey-standards](https://www2.health.vic.gov.au/about/publications/policiesandguidelines/code-grey-standards)
    
    

8.  Standards Australia Limited. AS 4083-2010 planning for emergencies – Healthcare care facilities: Standards Australia. 2010. Available: [https://www.standards.org.au/standards-catalogue/sa-snz/health/he-026/as--4083-2010](https://www.standards.org.au/standards-catalogue/sa-snz/health/he-026/as--4083-2010)
    
    

9.  Roppolo LP, Morris DW, Khan F, et al. Improving the management of acutely agitated patients in the emergency Department through implementation of project BETA (best practices in the evaluation and treatment of agitation). J Am Coll Emerg Physicians Open 2020;1:898–907. [doi:10.1002/emp2.12138](http://dx.doi.org/10.1002/emp2.12138)
    
    

10. Sim IO, Ahn KM, Hwang EJ. Experiences of psychiatric nurses who care for patients with physical and psychological violence: A phenomenological study. Int J Environ Res Public Health 2020;17:5159. [doi:10.3390/ijerph17145159](http://dx.doi.org/10.3390/ijerph17145159)
    
    

11. Cole R. Reducing restraint use in a trauma center emergency room. Nurs Clin North Am 2014;49:371–81. [doi:10.1016/j.cnur.2014.05.010](http://dx.doi.org/10.1016/j.cnur.2014.05.010)
    
    [CrossRef](http://bmjopen.bmj.com/lookup/external-ref?access_num=10.1016/j.cnur.2014.05.010&link_type=DOI) 
    
    [PubMed](http://bmjopen.bmj.com/lookup/external-ref?access_num=25155536&link_type=MED&atom=%2Fbmjopen%2F14%2F1%2Fe077597.atom) 

12. Digby R, Bushell H, Bucknall TK. Implementing a psychiatric Behaviours of concern emergency team in an acute inpatient psychiatry unit: staff perspectives. Int J Ment Health Nurs 2020;29:888–98. [doi:10.1111/inm.12723](http://dx.doi.org/10.1111/inm.12723)
    
    

13. Davids J, Murphy M, Moore N, et al. Exploring staff experiences: A case for Redesigning the response to aggression and violence in the emergency Department. Int Emerg Nurs 2021;57:101017. [doi:10.1016/j.ienj.2021.101017](http://dx.doi.org/10.1016/j.ienj.2021.101017)
    
    

14. Gates D, Gillespie G, Smith C, et al. Using action research to plan a violence prevention program for emergency departments. J Emerg Nurs 2011;37:32–9. [doi:10.1016/j.jen.2009.09.013](http://dx.doi.org/10.1016/j.jen.2009.09.013)
    
    [PubMed](http://bmjopen.bmj.com/lookup/external-ref?access_num=21237365&link_type=MED&atom=%2Fbmjopen%2F14%2F1%2Fe077597.atom) 

15. Farrell GA, Shafiei T, Chan S-P. Patient and visitor assault on nurses and midwives: an exploratory study of employer ‘protective’ factors. Int J Ment Health Nurs 2014;23:88–96. [doi:10.1111/inm.12002](http://dx.doi.org/10.1111/inm.12002)
    
    

16. Needham I, Abderhalden C, Halfens RJG, et al. Non-somatic effects of patient aggression on nurses: a systematic review. J Adv Nurs 2005;49:283–96. [doi:10.1111/j.1365-2648.2004.03286.x](http://dx.doi.org/10.1111/j.1365-2648.2004.03286.x)
    
    [CrossRef](http://bmjopen.bmj.com/lookup/external-ref?access_num=10.1111/j.1365-2648.2004.03286.x&link_type=DOI) 
    
    [PubMed](http://bmjopen.bmj.com/lookup/external-ref?access_num=15660553&link_type=MED&atom=%2Fbmjopen%2F14%2F1%2Fe077597.atom) 
    
    [Web of Science](http://bmjopen.bmj.com/lookup/external-ref?access_num=000226678200008&link_type=ISI) 

17. Wolf LA, Delao AM, Perhats C. Nothing changes, nobody cares: understanding the experience of emergency nurses physically or verbally assaulted while providing care. J Emerg Nurs 2014;40:305–10. [doi:10.1016/j.jen.2013.11.006](http://dx.doi.org/10.1016/j.jen.2013.11.006)
    
    [PubMed](http://bmjopen.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fbmjopen%2F14%2F1%2Fe077597.atom) 

18. NICE. Violence and aggression: short-term management in mental health, health and community settings: NICE, . 2015Available: [https://www.nice.org.uk/guidance/ng10/resources/violence-and-aggression-shortterm-management-in-mental-health-health-and-community-settings-pdf-1837264712389](https://www.nice.org.uk/guidance/ng10/resources/violence-and-aggression-shortterm-management-in-mental-health-health-and-community-settings-pdf-1837264712389)
    
    

19. WorkSafe. Prevention and management of violence and aggression in health services. 2017. Available: [https://content.api.worksafe.vic.gov.au/sites/default/files/2018-06/ISBN-Prevention-and-management-of-violence-and-aggression-health-services-2017-06.pdf](https://content.api.worksafe.vic.gov.au/sites/default/files/2018-06/ISBN-Prevention-and-management-of-violence-and-aggression-health-services-2017-06.pdf)
    
    

20. Morphet J, Griffiths D, Beattie J, et al. Prevention and management of occupational violence and aggression in Healthcare: A Scoping review. Collegian 2018;25:621–32. [doi:10.1016/j.colegn.2018.04.003](http://dx.doi.org/10.1016/j.colegn.2018.04.003)
    
    

21. Nia Manning S. Managing behaviour that challenges in people with dementia in the emergency Department. Emerg Nurse 2021;29:34–40. [doi:10.7748/en.2020.e2019](http://dx.doi.org/10.7748/en.2020.e2019)
    
    

22. Edward K, Giandinoto J-A, Weiland TJ, et al. Brief interventions to de-escalate disturbances in emergency departments. Br J Nurs 2018;27:322–7. [doi:10.12968/bjon.2018.27.6.322](http://dx.doi.org/10.12968/bjon.2018.27.6.322)
    
    

23. Gaskin C. Recognising Signs of Deterioration in a Person’s Mental State: An Updated Literature Review 2019. 2019. Available: [https://www.safetyandquality.gov.au/sites/default/files/2019-11/recognising\_signs\_of\_deterioration\_in\_a\_persons\_mental\_state\_an\_updated\_literature\_review\_0.pdf](https://www.safetyandquality.gov.au/sites/default/files/2019-11/recognising\_signs\_of\_deterioration\_in\_a\_persons\_mental\_state\_an\_updated_literature_review_0.pdf)
    
    

24. Wong G, Greenhalgh T, Westhorp G, et al. RAMESES publication standards: realist syntheses. BMC Med 2013;11:21. [doi:10.1186/1741-7015-11-21](http://dx.doi.org/10.1186/1741-7015-11-21)
    
    

25. Pawson R, Greenhalgh T, Harvey G, et al. Realist review - a new method of systematic review designed for complex policy interventions. J Health Serv Res Policy 2005;10(1_suppl):21–34. [doi:10.1258/1355819054308530](http://dx.doi.org/10.1258/1355819054308530)
    
    [CrossRef](http://bmjopen.bmj.com/lookup/external-ref?access_num=10.1258/1355819054308530&link_type=DOI) 
    
    [PubMed](http://bmjopen.bmj.com/lookup/external-ref?access_num=16053581&link_type=MED&atom=%2Fbmjopen%2F14%2F1%2Fe077597.atom) 

26. Saul JE, Willis CD, Bitz J, et al. A time-responsive tool for informing policy making: rapid realist review. Implement Sci 2013;8:103. [doi:10.1186/1748-5908-8-103](http://dx.doi.org/10.1186/1748-5908-8-103)
    
    [CrossRef](http://bmjopen.bmj.com/lookup/external-ref?access_num=10.1186/1748-5908-8-103&link_type=DOI) 
    
    [PubMed](http://bmjopen.bmj.com/lookup/external-ref?access_num=24007206&link_type=MED&atom=%2Fbmjopen%2F14%2F1%2Fe077597.atom) 

27. Mukumbang FC, Marchal B, Van Belle S, et al. Using the realist interview approach to maintain theoretical awareness in realist studies. Qualitative Research 2020;20:485–515. [doi:10.1177/1468794119881985](http://dx.doi.org/10.1177/1468794119881985)
    
    

28. Marchal B, van Belle S, van Olmen J, et al. Is realist evaluation keeping its promise? A review of published empirical studies in the field of health systems research. Evaluation 2012;18:192–212. [doi:10.1177/1356389012442444](http://dx.doi.org/10.1177/1356389012442444)
    
    [CrossRef](http://bmjopen.bmj.com/lookup/external-ref?access_num=10.1177/1356389012442444&link_type=DOI) 
    
    [Web of Science](http://bmjopen.bmj.com/lookup/external-ref?access_num=000208898000004&link_type=ISI) 

29. Pawson R, Tilley N. Realistic evaluation: sage. 1997.
    
    

30. Graham AC, McAleer S. An overview of realist evaluation for simulation-based education. Adv Simul (Lond) 2018;3:13. [doi:10.1186/s41077-018-0073-6](http://dx.doi.org/10.1186/s41077-018-0073-6)
    
    

31. Pawson R. Evidence-based policy: A realist perspective: sage. 2006. [doi:10.4135/9781849209120](http://dx.doi.org/10.4135/9781849209120)
    
    

32. Jagosh J. Realist synthesis for public health: building an ontologically deep understanding of how programs work, for whom, and in which contexts. Annu Rev Public Health 2019;40:361–72. [doi:10.1146/annurev-publhealth-031816-044451](http://dx.doi.org/10.1146/annurev-publhealth-031816-044451)
    
    [PubMed](http://bmjopen.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fbmjopen%2F14%2F1%2Fe077597.atom) 

33. Jagosh J. 8th annual CARES summer school for realist methodology training. 2021.
    
    

34. Sayer A. Realism and social science. In: Realism and social science. 1 Oliver’s Yard, 55 City Road, London EC1Y 1SP United Kingdom : SAGE Publications Ltd, 2000. [doi:10.4135/9781446218730](http://dx.doi.org/10.4135/9781446218730)
    
    

35. Pawson R. Evidence-based policy: the promise of realist synthesis. Evaluation 2002;8:340–58. [doi:10.1177/135638902401462448](http://dx.doi.org/10.1177/135638902401462448)
    
    [CrossRef](http://bmjopen.bmj.com/lookup/external-ref?access_num=10.1177/135638902401462448&link_type=DOI) 

36. Westhorp G. Realist impact evaluation: an introduction. 2014: 1–12. Available: [https://cdn.odi.org/media/documents/9138.pdf](https://cdn.odi.org/media/documents/9138.pdf)
    
    

37. Wong G, Westhorp G, Greenhalgh J, et al. Quality and reporting standards, resources, training materials and information for realist evaluation: the RAMESES II project. Health Serv Deliv Res 2017;5:1–108. [doi:10.3310/hsdr05280](http://dx.doi.org/10.3310/hsdr05280)
    
    

38. Michie S, Johnston M, Rothman AJ, et al. Developing an evidence-based online method of linking behaviour change techniques and theoretical mechanisms of action: a multiple methods study. Health Serv Deliv Res 2021;9:1–168. [doi:10.3310/hsdr09010](http://dx.doi.org/10.3310/hsdr09010)
    
    

39. Noble H, Heale R. Triangulation in research, with examples. Evid Based Nurs 2019;22:67–8. [doi:10.1136/ebnurs-2019-103145](http://dx.doi.org/10.1136/ebnurs-2019-103145)
    
    [FREE Full Text](http://bmjopen.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NjoiZWJudXJzIjtzOjU6InJlc2lkIjtzOjc6IjIyLzMvNjciO3M6NDoiYXRvbSI7czoyNjoiL2Jtam9wZW4vMTQvMS9lMDc3NTk3LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

40. Dixon-Woods M, McNicol S, Martin G. Ten challenges in improving quality in Healthcare: lessons from the health foundation’s programme evaluations and relevant literature. BMJ Qual Saf 2012;21:876–84. [doi:10.1136/bmjqs-2011-000760](http://dx.doi.org/10.1136/bmjqs-2011-000760)
    
    [Abstract/FREE Full Text](http://bmjopen.bmj.com/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MzoicWhjIjtzOjU6InJlc2lkIjtzOjk6IjIxLzEwLzg3NiI7czo0OiJhdG9tIjtzOjI2OiIvYm1qb3Blbi8xNC8xL2UwNzc1OTcuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

41. Stolee P, Elliott J, McNeil H, et al. Choosing Healthcare options by involving Canada’s elderly: a protocol for the CHOICE realist synthesis project on engaging older persons in Healthcare decision-making: table 1. BMJ Open 2015;5:e008190. [doi:10.1136/bmjopen-2015-008190](http://dx.doi.org/10.1136/bmjopen-2015-008190)
    
    

42. ACSQHC. National Consensus Statement: Essential elements for recognising and responding to deterioration in a person’s mental state: Australian Commission on Safety and Quality in Health Care. 2017. Available: [https://www.safetyandquality.gov.au/sites/default/files/migrated/National-Consensus-Statement-Essential-elements-for-recognising-and-responding-to-deterioration-in-a-person%E2%80%99s-mental-state-July-2017.pdf](https://www.safetyandquality.gov.au/sites/default/files/migrated/National-Consensus-Statement-Essential-elements-for-recognising-and-responding-to-deterioration-in-a-person%E2%80%99s-mental-state-July-2017.pdf)
    
    

43. Babiarczyk B, Turbiarz A, Tomagová M, et al. Reporting of workplace violence towards nurses in 5 European countries - a cross-sectional study. Int J Occup Med Environ Health 2020;33:325–38. [doi:10.13075/ijomeh.1896.01475](http://dx.doi.org/10.13075/ijomeh.1896.01475)
    
    

44. Lamont S, Brunero S. The effect of a workplace violence training program for generalist nurses in the acute hospital setting: A quasi-experimental study. Nurse Educ Today 2018;68:45–52. [doi:10.1016/j.nedt.2018.05.008](http://dx.doi.org/10.1016/j.nedt.2018.05.008)
    
    

45. Heckemann B, Peter KA, Halfens RJ, et al. Nurse managers: determinants and Behaviours in relation to patient and visitor aggression in general hospitals. A qualitative study. J Adv Nurs 2017;73:3050–60. [doi:10.1111/jan.13366](http://dx.doi.org/10.1111/jan.13366)
    
    

46. Department of Health and. Violence prevention and management standards for development of training and Organisational responses in Victorian health services. Department of Health and Human Services, 2014. Available: [https://www2.health.vic.gov.au/about/publications/researchandreports/Violence-prevention-and-management-standards-for-development-of-training-and-organisational-responses-in-Victorian-Health-Services](https://www2.health.vic.gov.au/about/publications/researchandreports/Violence-prevention-and-management-standards-for-development-of-training-and-organisational-responses-in-Victorian-Health-Services)
    
    

47. Buchell H, Whitecross F, Berry C, et al. Exploring the prevalence and impact of Behaviours of concern and whether a psychiatric behaviour of concern team improves safety. 2018.
    
    

48. Adams J. Assessing the effectiveness of clinical education to reduce the frequency and recurrence of workplace violence. Aust J Adv Nurs 2017;34:6–15.
    
    

49. Ferrara KL, Davis-Ajami ML, Warren JI, et al. De-escalation training to medical–surgical nurses in the acute care setting. Issues Ment Health Nurs 2017;38:742–9. [doi:10.1080/01612840.2017.1335363](http://dx.doi.org/10.1080/01612840.2017.1335363)
    
    [PubMed](http://bmjopen.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fbmjopen%2F14%2F1%2Fe077597.atom) 

50. Griffiths A, Knight A, Harwood R, et al. Preparation to care for confused older patients in general hospitals: a study of UK health professionals. Age Ageing 2014;43:521–7. [doi:10.1093/ageing/aft171](http://dx.doi.org/10.1093/ageing/aft171)
    
    [CrossRef](http://bmjopen.bmj.com/lookup/external-ref?access_num=10.1093/ageing/aft171&link_type=DOI) 
    
    [PubMed](http://bmjopen.bmj.com/lookup/external-ref?access_num=24165310&link_type=MED&atom=%2Fbmjopen%2F14%2F1%2Fe077597.atom) 

51. Sethi SS, Chalwin R. Governance of rapid response teams in Australia and New Zealand. Anaesth Intensive Care 2018;46:304–12. [doi:10.1177/0310057X1804600308](http://dx.doi.org/10.1177/0310057X1804600308)
    
    

52. Jones D, Hicks P, Currey J, et al. Findings of the first ANZICS conference on the role of intensive care in rapid response teams. Anaesth Intensive Care 2015;43:369–79. [doi:10.1177/0310057X1504300314](http://dx.doi.org/10.1177/0310057X1504300314)
    
    

53. Chalwin R, Flabouris A, Kapitola K, et al. Perceptions of interactions between staff members calling, and those responding to, rapid response team activations for patient deterioration. Aust Health Rev 2016;40:364–70. [doi:10.1071/AH15138](http://dx.doi.org/10.1071/AH15138)
    
    

54. Chua WL, See MTA, Legio-Quigley H, et al. Factors influencing the activation of the rapid response system for clinically deteriorating patients by frontline ward Clinicians: a systematic review. Int J Qual Health Care 2017;29:981–98. [doi:10.1093/intqhc/mzx149](http://dx.doi.org/10.1093/intqhc/mzx149)
    
    [PubMed](http://bmjopen.bmj.com/lookup/external-ref?access_num=http://www.n&link_type=MED&atom=%2Fbmjopen%2F14%2F1%2Fe077597.atom) 

55. Somani R, Muntaner C, Hillan E, et al. A systematic review: effectiveness of interventions to de-escalate workplace violence against nurses in Healthcare settings. Saf Health Work 2021;12:289–95. [doi:10.1016/j.shaw.2021.04.004](http://dx.doi.org/10.1016/j.shaw.2021.04.004)
    
    

56. Pawson R. Digging for nuggets: how ‘bad’ research can yield ‘good’ evidence. International Journal of Social Research Methodology 2006;9:127–42. [doi:10.1080/13645570600595314](http://dx.doi.org/10.1080/13645570600595314)
    
    

57. Kastner M, Estey E, Perrier L, et al. Understanding the relationship between the perceived characteristics of clinical practice guidelines and their uptake: protocol for a realist review. Implement Sci 2011;6:69. [doi:10.1186/1748-5908-6-69](http://dx.doi.org/10.1186/1748-5908-6-69)
    
    [CrossRef](http://bmjopen.bmj.com/lookup/external-ref?access_num=10.1186/1748-5908-6-69&link_type=DOI) 
    
    [PubMed](http://bmjopen.bmj.com/lookup/external-ref?access_num=21733160&link_type=MED&atom=%2Fbmjopen%2F14%2F1%2Fe077597.atom) 

58. Pawson R, Boaz A, Grayson L, et al. Knowledge review 3: Types and quality of knowledge in social care. Retrieved from Social Care Institute for Excellence website, 2003. Available: [http://www.scie org uk/publications/knowledgereviews/kr03 pdf](http://www.scie%20org%20uk/publications/knowledgereviews/kr03%20pdf)
    
    

59. Maidment ID, Lawson S, Wong G, et al. Medication management in older people: the MEMORABLE realist synthesis. Health Serv Deliv Res 2020;8:1–128. [doi:10.3310/hsdr08260](http://dx.doi.org/10.3310/hsdr08260)
    
    

60. Mukumbang FC. Retroductive theorizing: A contribution of critical realism to mixed methods research. Journal of Mixed Methods Research 2023;17:93–114. [doi:10.1177/15586898211049847](http://dx.doi.org/10.1177/15586898211049847)
    
    

61. Lawson T. Economics and reality: Routledge. 1997. [doi:10.4324/9780203195390](http://dx.doi.org/10.4324/9780203195390)
    
    

62. Rycroft-Malone J, McCormack B, Hutchinson AM, et al. Realist synthesis: illustrating the method for implementation research. Implement Sci 2012;7:33. [doi:10.1186/1748-5908-7-33](http://dx.doi.org/10.1186/1748-5908-7-33)
    
    [CrossRef](http://bmjopen.bmj.com/lookup/external-ref?access_num=10.1186/1748-5908-7-33&link_type=DOI) 
    
    [PubMed](http://bmjopen.bmj.com/lookup/external-ref?access_num=22515663&link_type=MED&atom=%2Fbmjopen%2F14%2F1%2Fe077597.atom) 

63. Jagosh J, Pluye P, Wong G, et al. Critical reflections on realist review: insights from Customizing the methodology to the needs of Participatory research assessment. Res Synth Methods 2014;5:131–41. [doi:10.1002/jrsm.1099](http://dx.doi.org/10.1002/jrsm.1099)