Developing a Programme Theory of Leadership for a Virtual Ward Programme: A Realist Synthesis

Background: Virtual Ward (VW) Programmes are innovative acute care service models gaining traction in international health strategy (1,2). Enabled by technology, they offer inpatient care to patients at home that would otherwise be hospitalised. When implemented effectively, they are safe, achieve clinical outcomes similar to traditional inpatient settings, enhance person-centred care, and help reduce the pressure on hospital bed capacity (3,4).

 Recent evidence reviews have emphasised the complexity of implementing and sustaining a VW programme and recommend evaluation research that provides evidence-informed implementation guidance (5-7). Guided by realist science, this paper presents a Programme Theory (PT) of leadership for VW Programmes that will guide local hospital implementation and sustainable scale-up across health systems.

 

Approach: This review employs a realist synthesis method to develop PT (8), offering context, mechanism, and outcome configurations to identify the specific contextual conditions of leadership and related resources necessary for achieving VW programme success. The PT was developed through a systematic retrieval and synthesis of thirty-two primary studies. It was further expanded with qualitative evidence from stakeholders and hospital staff involved in the implementation of the National Virtual Ward Programme in Ireland. An expert panel of relevant policymakers and senior nurse leaders guided the review to ensure the PT was relevant for national and international contexts.

 

Results: This realist review developed a PT of leadership to support the effective implementation of a VW Programme, explaining the critical interplay between political leadership, partnership-led digital innovation leadership, and hospital-led implementation leadership.

 

 

 

Implications: This review presents how effective leadership can be supported and improved to enhance VW programmes. It is relevant to the global healthcare community interested in emerging international policy and practice developments in VW Programmes. It offers PT that is action-oriented and practical, which can inform implementation planning.

 

References

1.National Virtual Ward Programme Ireland HSE; 2024 [Available from: https://www.hse.ie/eng/about/who/strategic-programmes-office-overview/national-virtual-ward-programme/.

2.England N. Virtual wards operational framework England NHS England updated July 2025 [Available from: https://www.england.nhs.uk/long-read/virtual-wards-operational-framework/.

3.Shi C, Dumville J, Rubinstein F, Norman G, Ullah A, Bashir S, et al. Inpatient-level care at home delivered by virtual wards and hospital at home: a systematic review and meta-analysis of complex interventions and their components. BMC Medicine. 2024;22(1):145.

4.Leong MQ, Lim CW, Lai YF. Comparison of Hospital-at-Home models: a systematic review of reviews. BMJ Open. 2021;11(1): e043285.

5.Sunny T, Ravichandran N, Broughan J, McCombe G, Loughman S, McDonald K, et al. Practitioners' perspectives on implementation of acute virtual wards: A scoping review. PLOS Digit Health. 2025;4(5):e0000858.

6.Litchfield I, Lewis R, Delanerolle G, Melyda M, Harper L. Factors Influencing the Implementation of a Multispecialty Virtual Ward Program in the United Kingdom: Qualitative Exploration of Staff Experiences and Perspectives. J Med Internet Res. 2025;27: e75406.

7.Yahya F, Cooper M, Nazar H. Hospital at home (virtual wards): developing a logic model and dark logic model. BMC Health Serv Res. 2025;25(1):714.

8.Dalkin SM, Greenhalgh J, Jones D, Cunningham B, Lhussier M. What’s in a mechanism? Development of a key concept in realist evaluation. Implementation Science. 2015;10(1):49.