The first step of a realist investigation: Building an initial realist theory of on-the-day surgery cancellations.

Background On-the-day surgery cancellations (OTDSCs) have been a longstanding global problem, bringing significant suffering to patients and carers, and substantial waste across healthcare systems. Any cancellation of a surgery that occurs for any reason on the day of the scheduled surgery is defined as an OTDSC. Despite the high prevalence of OTDSCs, little is known about why they happen and how to minimise them. This article illustrates a method for developing initial programme theories (IPTs), which is the first step in any theory-driven realist investigation, with the aim of understanding why OTDSCs happen and in what contexts, as well as the extent to which they can be minimised. Method We used a multi-method approach consisting of three phases to work towards developing IPTs. Multiple methods were used: literature-related OTDSCs, findings on the feasibility of the comparative study, and feedback from expert practitioners and patients. Results The iterative analysis found that OTDSCs are a complex undesired outcome, influenced by many interconnected “variables”, 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 healthcare professionals’ (HCPs) and patients’ perceptions and behaviours. The study identified that failures in various aspects of individualised care (such as care planning, communication and resource allocation) in preparing for surgery before admission could contribute to different types of OTDSCs. Conclusion As a result of the complex and interconnected nature of OTDSCs and the wide variety of causes, it can be hard to reduce their occurrence. OTDSCs can be minimised by carefully considering various aspects of individualisation of care, such as clinical care planning, communication and resource allocation and delivery when preparing patients to undergo surgery. Providing favourable working conditions and creating effective knowledge transfer between the actors initiating OTDSCs and HCPs who prepare patients for surgery can be critical to minimising most OTDSCs. The study developed a taxonomy and novel theories of understanding OTDSCs with practical implications for policymakers and practitioners.