A Realist Review Protocol on the Contribution of a Mental Health First Aider Programme to Staff Health and Wellbeing within an Irish Hospital Network

1. Define the scope of the review and develop initial theories

The development of Candidate Programme Theories (CPTs) in a realist review provides a framework for analysing the causal mechanisms that may generate outcomes within specific contexts (Teeling et al., 2021b). Developing CPTs will involve identifying possible explanations for how the MHFA programme may work, for whom, and under what circumstances. This theoretical mapping will draw on a scoping review of existing literature, expert insights, and early conceptual thinking to form initial hypotheses about how the intervention may operate (Keown et al., 2024).

Realist hunches are initial, theory-informed assumptions about how an intervention might work, for whom, and in what contexts (Pawson, 2013). These early ideas will guide the identification of potential mechanisms and relevant contextual conditions. Academic supervision will support the assessment of these developing ideas, ensuring their plausibility and relevance to the MHFA programme (Wong et al., 2013).

To ensure practical and contextual relevance, a Local Reference Group (LRG) will be convened. The LRG will comprise MHFA trainers, MHFA programme participants, and expert instructors with knowledge of MHFA delivery in acute hospital settings (Wong et al., 2016). Their insights will help refine developing CPTs so that emerging theories remain grounded in real-world experience and practice.

A preliminary scoping of the literature will further support the development of CPTs. Searches will include electronic databases (PubMed, Web of Science, PsycINFO, CINAHL, EMBASE, Cochrane Library), grey literature, and organisational sources such as the MHFA International website, using keywords related to realist review, healthcare staff, staff wellbeing, mental health, and MHFA (Booth, 2016).

Once CPTs have been developed in conjunction with the LRG and the scoping literature, they will be presented to an expert review panel for adjudication. The expert panel will comprise individuals with expertise in realist methodology, mental health intervention research, organisational wellbeing, and MHFA programme delivery. The panel will confirm, refute, or refine the developing CPTs to strengthen their methodological rigour and practical relevance.

Following expert adjudication, the refined CPTs will become the Initial Programme Theories (IPTs). These IPTs will inform the next stages of the review, including refinement of the search strategy, development of inclusion and exclusion criteria, data extraction, and synthesis. As evidence is gathered, the IPTs will be iteratively tested and refined in line with realist principles (Dalkin et al., 2015; Wong et al., 2013).

This process will ensure the development of a coherent set of programme theories that will guide the remainder of the realist review.

2. Develop the search strategy

A comprehensive and theory-informed search strategy will be essential to support the development and refinement of programme theories for this realist review. The search strategy will follow RAMESES guidance, which emphasises iterative, purposive searching aligned with the evolving focus of the review (Wong et al., 2013; Wong et al., 2016).

Searches will be conducted across multiple electronic databases, including PubMed, Web of Science, PsycINFO, CINAHL, EMBASE, and the Cochrane Library. Additional sources will include grey literature, organisational websites such as MHFA International, citation searching, and the reference lists of included studies (Booth, 2016). The support of a university librarian will ensure that search processes are systematic, comprehensive, and appropriately targeted.

A PICO (Population, Intervention, Context, Outcomes) framework will be used to structure the development of search terms and guide inclusion and exclusion criteria (Methley et al., 2014; Schardt et al., 2007). The PICO criteria have been developed based on the research question, preliminary scoping of the literature, and anticipated areas of theoretical interest (Booth, 2016; Pawson, 2013). This approach allows the PICO inclusion and exclusion criteria to be refined as the Candidate Programme Theories (CPTs) are developed and formalised, prior to their adjudication by the Expert Panel and progression to Initial Programme Theories (IPTs). These IPT will then be tested through the realist review to develop final Programme Theories (PTs). The PICO framework (Table 1) will therefore serve as a guide for identifying relevant evidence. It will help ensure that search terms capture literature related to MHFA training, staff wellbeing, contextual influences on psychological support interventions, and implementation processes within acute hospital settings.

These PICO criteria will provide the foundation for identifying potentially relevant evidence. As the Candidate Programme Theories (CPTs) are formalised and progress to Initial Programme Theories (IPTs), the selection of studies and the approach to data extraction will evolve to ensure alignment with the developing programme theories. This iterative refinement of searching and evidence selection is consistent with realist methodology, which emphasises the need for theory-driven and adaptive approaches to evidence gathering (Wong et al., 2013). The next section outlines how studies will be screened and how data will be extracted to support this realist review.

3. Review primary studies and extract data

Documents retrieved will be chosen based on their relevance to the research question and their potential to support the development of IPTs. These documents will form a robust collection of papers, essential for a theory-driven realist review to further refine the IPTs (Greenhalgh et al., 2011). The selection of studies will be guided by the realist criteria of relevance, richness, and rigour (Booth et al., 2013). Relevance is assessed by whether a study can contribute to building or testing a programme theory; richness refers to depth, detail, and complexity of data, which includes deep descriptions, contextual understanding, and multifaceted insights into human experiences rather than surface-level information; and rigour refers to the credibility of the methods used to collect the data (Rycroft-Malone et al., 2016; Wong et al., 2013). These criteria will collectively determine which literature is included in the review.

Data extraction will involve three steps: initial screening by title and abstract, full-text retrieval, and quality appraisal. Titles and abstracts will be reviewed in duplicate by Authors 1 and 2 using predefined criteria. Documents passing this stage will then be adjudicated for richness and rigour by Author 3. Any discrepancies will be resolved through discussion among all three authors, in line with RAMESES guidelines (Wong et al., 2013).

4. Synthesize evidence and develop conclusions

Search results will be imported into Covidence an online software for managing and screening systematic search results which is freely available to staff and students of the University College Dublin. Rayyan is an alternative that is freely available. The analysis and synthesis process will follow the stages outlined by Rycroft-Malone et al. (2012), using an iterative, theory-driven approach appropriate for realist methodology. These stages will include:

Retroductive theorising will be used to synthesise data (Mukumbang et al., 2021). Retroduction involves an iterative cycle of inductive reasoning, deductive reasoning, and abduction to identify the underlying causal forces that may explain how the MHFA programme works (Gilmore et al., 2019). Endnote software will be used to record the references from search results and any additional references included during the review, and the review stages will be revisited as necessary to ensure comprehensive evidence gathering and to support theory saturation. EndNote is freely available to staff and students of the University College Dublin, Zotero is an alternative which is freely available.

5. Refine theory iteratively and disseminate findings

The refined Initial Programme Theories (IPTs) derived from the realist review will undergo iterative evaluation and feedback from the expert panel to ensure accurate interpretation and explanation of the findings (Pawson et al., 2005). This engagement will enhance the robustness, contextual sensitivity, and real-world relevance of the resulting programme theories, reflecting the complexity of MHFA implementation in acute hospital settings (Wong et al., 2016).

The outcomes of the realist review will be reported in accordance with the RAMESES II reporting guidelines (Wong, 2018). Dissemination will include publication in peer-reviewed journals, presentations at healthcare and academic conferences, and engagement with key organisational stakeholders.

This realist review protocol is currently under consideration by the PROSPERO Editorial Committee, and a registration number will be added once approval is confirmed. Ethical approval is not required for this review because it synthesises published literature and involves no primary data collection. Ethical approval will be sought for any subsequent realist evaluation involving new data collection.

Systematic review registration

This protocol is currently undergoing review by the PROSPERO Editorial committee and registration number will be added as soon as available.