483 A realist review of inpatient insulin self-administration policy interventions for people with diabetes in hospital
Authors: Bain A , Babar Z U D , Kavanagh S 
Published: April 2023

Abstract

Introduction
Self-administration of insulin in hospital is recommended by Diabetes UK and NHS Improvement to improve patient outcomes, empower patients to self-care, reduce costs and facilitate better use of resources (1). The availability and use of policies to facilitate self-administration across NHS hospitals varies, therefore further exploration is needed regarding their use (2). As self-administration policies are a ‘complex intervention’, exploration should include elucidation of contextual factors that make the design, implementation, and use of these policies successful.

Aim
To discover what works, for whom, in what circumstances, in relation to the implementation of inpatient insulin self-administration policies.

Methods
A realist review was conducted to produce programme theories that uncovered the contexts and mechanisms by which self-administration policies are likely to be effective. Theories were developed iteratively using a combination of retroductive theorising, literature searching (Fig. 1) and stakeholder group consultation. Literature reviews included all evidence types published in English; references that failed realist quality assessment were excluded. Data were extracted and coded to programme theories to aid development using NVivo. Results were analysed using Normalisation Process Theory and Kanter’s theory of structural empowerment as a conceptual framework. The RAMESES standards were used to guide study conduct and reporting, and the protocol was published in the PROSPERO register. Ethical approval was not required. Stakeholder involvement throughout ensured that results remained grounded in the practical reality experienced by a range of participants and enhanced the usability of actionable findings.
Figure 1: Overview of iterative literature searches and review process.

Results
Ten refined programme theories, presented as context-mechanism-outcome hypotheses resulted from the review Theories involved patient empowerment, shared-decision-making, shared responsibility, equalising power dynamics, correcting misconceptions, staff support and managing anticipated work burden. Contexts that facilitated positive outcomes included assigning a dedicated project lead, requisite governance considerations, multidisciplinary and patient collaboration, as well as clarification of responsibilities.

Conclusion
This review resulted in high-level principles to help guide context-specific organisational change and implementation of insulin self-administration policies for benefit of patient safety and satisfaction. Limitations include the complexity and arduousness of the process, requiring experience in realist theory, current practice, academia and policy implementation.

References
1. Rowse,V. Implementing self-administration of insulin in hospital. Br J Diabetes 2018;18. DOI: https://doi.org/10.15277/bjd.2018.160
2. Bain, A. et. Al. Strategies to reduce insulin prescribing errors in UK hospitals: results from a national survey. Diabet. Med. 2020, 37, 1176– 1184. https://doi.org/10.1111/dme.14209