Commentary: Developing initial programme theories for a realist synthesis on digital clinical consultations in maternity care: contributions from stakeholder involvement

It was great to read this paper about the ARM@DA project (Nottingham University, 2024; A Realist Enquiry into Maternity Care at a Distance). This was a National Institute for Health and Care Research (NIHR)-funded project exploring the rapid shift to remote technologies or ‘digital clinical consultations’ (DC-CON) as they are referred to in this paper, around the time of the COVID-19 pandemic.

This paper is a clear articulation of the first phase of a realist approach. There is enough detail to allow others to follow a similar approach, and the paper offers methodological insights and advice into doing such work in a participatory manner. This first phase was focussed on the generation of Initial Programme Theories (IPT) and composed of three activities: consultation to gather both experience and opinions of DC–CON, a literature review and identification of potential mid-range theories, and finally the articulation of Initial Programme Theories with the focus on context, mechanism and outcome.

For me, the IPTs really come alive when you look at the scenarios. For the reader, they give the practical example of a clinical situation and allow you to understand the application of the Initial Programme Theories in that instance, they also give a great insight into how the IPTs were brought to life for the participants in the research. Realist approaches by their very nature are complex, requiring considerable reflection and creativity on behalf of the researcher (Dalkin et al., 2015) never mind non research trained participants. The scenario approach I feel goes some why to making accessible the IPT for the broader set of stakeholders who, as the paper outlines, deliver great benefits from their involvement.

The IPTs also align to fundamental aspects of midwifery practice as enshrined in the domains of the NMC code namely: prioritise people, practise effectively, preserve safety and promote professionalism and trust (Nursing and Midwifery Council, 2018). This is expressed in the centrality of women and families in the context, quality and safety in the outcomes and most importantly informed consent in the domain of ‘Knowledge, Choice and Fit with Preferences’.

This paper’s contribution to nursing and midwifery practice is to advocate for, and demonstrate, the value of a theory-based approach to delivering digital transformation. The results, at this stage, give a strong steer as to the benefits of involvement of a broad range of stakeholders in this process. The use of creative methods, to enable the meaningful participation of these stakeholders, is to be particularly commended.