The IPT building process was completed using multiple methods and consisted of three phases. In phase one, transferable preliminary IPTs were identified from carefully selected samples of OTDSC literature (n = 35). In phase two, the preliminary IPTs identified were further refined using multiple methods. The findings on the feasibility of the comparative study included results from eight NHS trusts, two feedback events with patient expert advisers (n = 6), and eight expert practitioners (n = 8). In phase three, all the evidence, including that relating to OTDSCs, was considered for developing the taxonomy and the IPTs.
The use of multiple methods that focused on several different actors (such as HCPs, managers from different disciplines and patients) helped to capture different perspectives to understand the following research question: why are OTDSCs happening, in what contexts, and to what extent can they be minimised? The comparative study included eight NHS trusts (phase two), providing various information related to how NHS trusts report and categorise various OTDSCs. Experienced practitioners' feedback provided the opportunity to interact and ask questions directly to understand why and how different types of OTDSCs happen. Similarly, patient feedback events helped the researcher to understand patient perspectives on why and how to minimise OTDSCs caused by DNA and patients failing to provide consent.
The evidence was reviewed and the data collection completed between January 2019 and February 2020 (i.e., before hospitals were affected by the COVID-19 pandemic). During this time, NHS hospitals in England were severely affected by austerity measures, high emergency admissions and delayed discharges.
The literature review involved three types of searches to identify relevant material: conventional database searches, searches of selected websites and supplementary searches. The following three databases were used to search for studies: Scopus, Cochrane and Cinahl Plus. Searches were limited to human studies and papers published in English without limiting them to a time period. Further website searches were carried out using keywords relating to the Social Care Institute for Excellence (SCIE), The King’s Fund, NHS Improvement and the Nuffield Trust. These website searches used the search functions available on the websites concerned.
Several search strategies were developed and revised several times using advice from information specialists. The final version of the search strategy is described in the table below (see Table 1).
Table 1
– Summary of search strategies used for databases
Search query used | “surg*” OR “elective activit*” OR “elective procedure*” OR “operation*” AND “cancel*” OR “terminate*” OR “reschedule*” OR “abandon*” AND “health*” OR “hospital*” OR “acute care” |
Database searched | Web of Science, Scopus, Cochrane, Cinahl Plus, Medline |
Exclusion criteria | Non-human studies Languages other than English |
Purposeful sampling was used to capture studies from a wide range of care settings and research design to develop exploratory and transferable IPTs. The rationale for using a purposeful sample was to embrace the richness and breadth of available literature on OTDSCs. The inclusion criterion was “Could this article provide useful information about transferable patterns or trends that understand or minimise OTDSCs?”. For all the empirical studies (except the evidence review), the quality was appraised using the mixed method appraisal tool (MMAT) (20).
Ethical considerations and registration
The realist review received ethical approval from the University of Manchester and the Health Research Authority in the UK. The realist review protocol is registered with the International Prospective Register for Systematic Reviews (PROSPERO) database [Ref: CRD42019124272].
Data analysis
The traditional CMO (context–mechanism–outcome) heuristic tool developed by Pawson and Tilley was expanded to include “intervention” (I) and “actors” (A) to develop the ICAMO heuristic tool (21). The ICAMO heuristic tool was used to organise and analyse data to identify connections between each component in the tool and provide transferable explanations. The elements of the ICAMO are illustrated in Table 2 with examples related to SSCSs. The definitions of the elements were adopted from Mukumbang et al. (21)
Table 2
– Definitions of the elements included in the ICAMO heuristic tool
Elements included in the ICAMO heuristic tool | Definition | Examples from SSCSs |
Interventions | A combination of programme components designed to produce behaviour changes or improve health status among individuals or group members. | Standardised interventions include pre-assessment tools, clinical protocols, patient interview guides and scheduling tools. |
Context | The salient conditions that are likely to enable or limit the activation of mechanisms. | Various NHS policies (e.g., waiting list targets and austerity measures) and organisational conditions (e.g., high workload and inter-professional collaboration). |
Actors | The individuals, groups and institutions that play a role in implementation and outcomes. | Pre-operative nurses (PONs), doctors, anaesthetists and surgeons. |
Mechanism | Any underlying determinants of social behaviour generated in certain contexts that are hidden and not easily identifiable or measurable but real. | Patients’ trust in the clinical team, compassion among anaesthetists towards patients undergoing surgery. |
Outcomes | Expected (i.e., desired outcomes) or unexpected effects (i.e., undesired outcomes) of interventions. | Individualisation of care related to clinical preparation of patients undergoing surgery (desired outcomes) and individualisation of care related to resource preparation related to undergoing surgery (desired outcomes), OTDSCs, delayed discharges (undesired outcomes). |
The data synthesis was an iterative process consisting of a multi-stepped approach to identifying and organising information. Three steps were followed to analyse data. For each study, the data was extracted into a table consisting of eight columns: reference, title of the study, country, information related to care setting, study design, main findings, and how might and should the intervention influence OTDCSs (i.e., applying “realist logic”). In the first instance, by organising and carefully analysing the data, preliminary IPTs were developed based on three types of OTDSCs: those initiated by patients, clinicians and administrators. Second, data from each type of data collection was analysed separately and summarised. The preliminary IPTs were validated, refined and refuted as the next step. The third step involved attempting to validate the preliminary IPTs using all the information, where multiple evidence is used to refine and validate IPTs.
Findings from the literature
Among the 35 studies, the designs varied, including 17 quantitative descriptives (e.g., incident prevalence studies and survey case reports), nine quantitative non-randomised control designs (e.g., cohort studies, case-control studies and cross-sectional studies), five evidence reviews (e.g., literature reviews, commentaries and editorial pieces), three mixed-method studies and one qualitative study. The 35 studies came from 12 countries, emphasising that OTDSCs are a global problem. Most studies are from the UK (n = 7) and the United States (US) (n = 7).
OTDSC cancellation rates (CRs) exceeding 10% of all scheduled cases have been reported in hospitals in the US (4), Europe (6, 22) and Asia (23, 24). The findings of the heterogenous literature review suggested that OTDSCs are largely preventable (4–6). The studies used various atheoretical and subjective approaches to categorising reasons for OTDSCs(4, 25, 26), which is a significant barrier to developing transferable theories and interventions to minimise them.
The literature suggested that SSSCs use various standardised interventions to minimise different types of OTDSCs. For example, PONs clinically prepared patients for surgery using standardised clinical care planning interventions (e.g., clinical care planning protocols, checklists for care planning and screening tools) (27, 28). Similarly, resources (e.g., theatre time, equipment and professionals) were allocated to patients using standardised scheduling interventions (e.g., standardised scheduling tools, historical use of theatre times) (25). The literature suggested that failure of these standardised interventions leads to different types of OTDSCs. For example, failure of standardised clinical care planning interventions to prepare patients leads to OTDSCs for clinical reasons. In contrast, strengthening standardised clinical care planning interventions can minimise OTDSCs for clinical reasons (4, 29–31).
Patients undergoing surgery with few clinical complications are less likely to experience OTDSCs for clinical reasons (26, 27, 32). Evidence from the UK (14), the US (4) and Singapore (33) suggests that OTDSCs are common among patients from disadvantaged communities (e.g., low-income groups and homeless people). Similarly, a wide range of evidence highlights that patients who undergo surgery with high levels of clinical complications are more likely to report OTDSCs (4, 8). The literature suggests that improving patient-centred care (25, 29) and individualised care minimises OTDSCs. Trust between patients and carers undergoing surgery is vital to minimise OTDSCs related to patient reasons such as DNA or withdrawal of consent for surgery (29). Support for PONs from senior clinicians’ clinical colleagues forms an important context that helps deliver standardised interventions (e.g., pre-assessment protocols, interview guides and scheduling tools) to minimise OTDSCs (25, 26, 28).
Findings from multiple methods
Complex nature of OTDSCs
OTDSCs represent a context-sensitive and complex problem resulting from numerous reasons and with strong links to many interconnected components at macro-level (e.g., NHS waiting list policy, austerity measures and workforce shortages) and meso-level (e.g., workload, high emergency admissions and interruptions), as well as HCPs’ and patients’ perceptions and behaviours. Despite their complexity, OTDSCs are largely preventable. Most reported OTDSCs relate to patients being inadequately prepared for surgery (i.e., failures in pre-operative care).
OTDSCs can bring significant suffering to patients and create significant waste in healthcare delivery systems (HDSs). Most OTDSCs initiated by clinicians and administrators can be understood as a necessary response to minimise patient harm. For example, when clinicians who review patients undergoing surgery believe that a patient is not adequately prepared for surgery, they (mostly anaesthetists) tend to initiate OTDSCs for clinical reasons (i.e., patient unfit for surgery) because they believe undergoing surgery may lead to various patient implications (anaesthetic complications or harm, or delayed recovery).
Two main categories
Despite the complexity of OTDSCs, most can be divided into two categories based on their links to different parts of the scheduled surgical care pathway.
Category one: Failure to identify various clinical, communication and resource allocation needs and manage these needs before admission to surgery tends to be linked to preparing patients for surgery (i.e., pre-operative care). This category includes OTDSCs because of unavailability of resources or because of patients’ failure to attend or follow instructions, or patients being unfit for surgery. For example, failure to manage related clinical factors (e.g., anaemia, allergies, hypertension, medication or lack of diagnostic results) as part of clinical care preparation can lead to patient OTDSCs for clinical reasons. Similarly, failure to allocate resources based on patient clinical needs, such as theatre time or equipment, or specific types of post-operative bed (e.g., day care, inpatient or high dependency beds) might lead to OTDSCs because of unavailability of resources.
Category two: Failure to deliver surgical care because of unavailability of resources can occur. For example, although in pre-operative care resources are allocated based on patient needs in advance, they cannot be delivered because of their unavailability on the day of surgery – resources sometimes end up being reallocated to other patients because of resource prioritisation. For example, post-operative beds supposed to be allocated to scheduled surgical care patients might be prioritised and given to emergency patients. This is described as unavailability of resources (e.g., theatre time or post-operative beds). During the data collection process, OTDSCs resulted from post-operative bed unavailability driven by failure to deliver care (i.e., category two) primarily because of a lack of social care, delayed discharges and high levels of emergency admissions.
Both categories are arguably common. By and large, NHS (15, 26) hospitals’ failures to deliver care are outside the hospitals’ control, because of, for example, infection outbreaks in neighbouring hospitals, high levels of emergency admissions because of a flu outbreak, or critical accidents leading to increased emergency admission levels (e.g., multiple accidents or bomb blasts)(26, 34, 35). In contrast, adequately preparing patients for surgery and improving individual clinical, communication and resource allocation before admission (category one) largely depends on the hospital's ability to do this. These two categories are linked to different parts of the care pathway, and interventions to minimise them also vary. OTDSCs related to category one can be minimised by improving pre-operative care interventions. In contrast, category two OTDSCs can be minimised by improving patient flow and creating protection for scheduled surgical care to be carried out, in the form of, for example, dedicated theatres or post-operative beds (i.e., dedicated day cases or intensive care wards).
Failures in individualisation of care leading to OTDSCs
Patients undergoing surgery have diverse set-up needs (i.e., clinical, social and economic resources) and failure to identify and address important aspects of individual patient needs in preparing patients for surgery leads to different types of OTDSCs. The analysis identifies three aspects of individualisation of care – clinical care planning, communication and resources, related to different types of OTDSCs. Inadequate levels of individualisation of care related to clinical preparation leads to OTDSCs for clinical reasons. For example, when patient individualisation is related to clinical planning (e.g., lack of blood tests, failure to stop anti-coagulation medication and managing co-morbidities), clinicians (usually anaesthetists) responsible for surgery can decide to cancel them on the day of the surgery for clinical reasons to avoid any potential harm or patient safety issues.
Patients undergoing surgery usually feel anxious and have diverse communication needs. Some of their anxiety is related to previous experiences with HCPs (29). Unmet communication needs in preparing patients for surgery before they are admitted leads to OTDSCs for reasons such as DNA, withdrawal of consent or patients requesting time to think about side effects. All these reasons for OTDSCs could be minimised, and patients could be better prepared for surgery if their communication needs were understood and met.
Based on patients’ clinical and socio-economic reasons, they require various resources, such as medication, blood, equipment and post-operative beds, specialised professionals and patient discharge requirements. When hospitals do not have specific resources based on their needs to complete surgery, they are likely to experience OTDSCs because of resource unavailability. After patients are admitted for surgery, administrators (bed and theatre managers) assess their ability to carry out surgery safely based on resource availability and ability to provide intra- and post-operative care. Unavailability of resources for surgery can happen for category one and two reasons: inadequate levels of individualisation of care are related to scheduling resources (e.g., failure to identify specific post-operative beds or specialist professionals) and unavailability of resources on the day of the surgery (e.g., inpatient post-operative beds given to emergency patients).
Different types of decision-makers initiating OTDSCs
Around 30 to 40 actors from various disciplines, including PONs, surgeons, anaesthetists, administrators and support staff, contribute to completing a scheduled care surgery. Most organisations and SSCSs rely on various standardised interventions completed by PONs to prepare patients, involving clinical care planning, communication and scheduling resources. However, because of various inadequacies related to individualisation of care, different categories of actors initiate different OTDSCs.
The analysis identified three main actors responsible for initiating most OTDSCs: clinicians (usually anaesthetists or surgeons) who assess clinical suitability for the surgery, patients undergoing surgery and administrators responsible for resources. For example, an inadequate level of individualisation of care in clinical care planning can lead the clinicians responsible for surgery to decide to cancel the surgery for clinical reasons. Similarly, an inadequate level of individualisation of care relating to resources can lead to OTDSCs being initiated because of administrators’ lack of resources (e.g., post-operative beds and professionals). In contrast, when patients undergoing surgery do not meet their individualised communication needs, patients initiate OTDSCs themselves (for reasons such as DNA and withdrawal of consent for surgery).
NHS policy, standardisation and individualisation of care
Most scheduled care systems increasingly rely on standardised care interventions. Three types of standardised interventions prepare patients for surgery: clinical care planning (e.g., clinical protocol or tool, clinical checklist), communication (interview guide, questionnaire, reminder messages, communication checklist) and scheduling resources (e.g., scheduling tool). Based on local practice, organisations use different terminologies. Sometimes, these interventions are used collectively as pre-assessment tools or protocols. Furthermore, a series of protection interventions (dedicated centres for scheduled care surgery wards and emergency theatres) protect resources allocated to scheduled care patients from patients admitted as emergency patients. Failure to prepare patients and address their individualised care needs before surgery using these interventions provides the context to increase the likeliness of OTDSCs. The ability of standardised interventions to provide individualised care for each patient undergoing surgery is an important context influencing the creation of OTDSCs.
On some occasions, various organisational contexts influenced by NHS policy increase the tension between standardisation and individualisation of care. For example, in response to national policy (e.g., austerity measures and achieving national waiting list targets), NHS hospital managers have increase PON workloads and also limited pre-operative assessment to 15 or 20 minutes to improve waiting list times. PONs from several organisations have had their clinical work interrupted because of high levels of emergency admissions and patient flow problems in hospitals. As a result, PONs have felt exhausted and stressed managing their workloads. All these factors have contributed to failures in preparing patients and addressing their individualised needs, consequently leading to various types of OTDSCs, because, for example, patients are unfit for surgery or have failed to provide consent, or failure to schedule resources (e.g., equipment, post-operative beds and specialist professionals) based on patients’ clinical needs has occurred.
IPT development
The following identified themes for IPTs were thus developed: standardisation and individualisation of care, influence of various policy and organisational contexts related to the role of PONs, and the ability of various actors to initiate OTDSCs. IPTs are like pathways that explain how and why various standardised interventions related to clinical care planning, communication and resources lead to different types of OTDSCs initiated by different actors, such as clinicians, patients and managers. For example, the first IPT explained how standardised clinical care planning interventions failed to individualise care concerning clinical care preparation, leading to OTDSCs for clinical reasons (i.e., because patients are unfit for surgery). The Table 3 provides the details of four IPTs that cover different types of OTDSCs.
Table 3
– Details of four IPTs developed from multiple evidence sources
Title of IPT | IPT overview |
One – Related to OTDSCs because patients are deemed unfit for surgery. | When care is delivered using standardised clinical care planning interventions (i.e., checklists, clinical protocols, pre-assessment tools) to prepare patients for surgery, the ability of PONs (actors) to make confident decisions is negatively influenced by various unfavourable working conditions (meso-contexts). As a result, inadequate levels of individualisation of care in clinical preparation (outcome) leads to OTDSCs because patients are unfit for surgery (main outcome), initiated by clinicians who review patients on the day of surgery. Unfavourable organisational conditions include lack of time to complete clinical consultation, high levels of interruptions to clinical work because of emergencies, high workload and inadequate staffing. |
Two – Related to OTDSCs for reasons such as patient DNA or refusal to undergo surgery. | When care is delivered using standardised communication interventions (i.e., pre-interview protocols, text, communication checklists and follow-up calls), various unfavourable working conditions (meso-contexts) negatively influence the ability of PONs (actors) to communicate with patients. As a result, this leads to an inadequate level of individualisation of care in patient communication (outcome), resulting in development of patient trust in the clinical team and leading to OTDSCs being initiated by patients for reasons such as DNA and withdrawing consent (main outcome). Unfavourable organisational conditions (meso-contexts) involve a lack of time to complete clinical consultation, high levels of interruptions to clinical work for emergencies, high workload and inadequate staffing. |
Three – Related to OTDSCs resulting from resource unavailability: scheduling. | When care is delivered using standardised scheduling interventions (i.e., scheduling tools based on historic theatre time), various unfavourable working conditions negatively influence the ability of PONs (actors) to make confident decisions. As a result, inadequate levels of individualisation of care relating to allocation based on clinical needs lead to OTDSCs by administrators responsible for providing resources (various types of post-operative beds or staffing) because of resource unavailability (main outcome). Unfavourable organisational conditions involve lack of inter- and intra-professional collaboration, high workload and inadequate staffing. |
Four – Related to OTDSCs resulting from resource unavailability: care delivery. | When care is delivered using standardised protection interventions (i.e., dedicated theatres for emergency and ring-fenced beds), the ability of HCPs and administrators (actors) to deliver resources by addressing individual patients’ clinical needs (outcomes) is negatively influenced by various unfavourable working conditions. As a result, an inadequate level of individualisation of care when providing resources based on patients’ clinical needs can lead to OTDSCs initiated by administrators responsible for providing resources (managers responsible for various types of post-operative beds, staffing or equipment) because of resource unavailability (main outcome). Unfavourable organisational conditions (meso-contexts) involve a lack of inter- and intra-professional collaboration, high workload and inadequate staffing. |