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

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Mental Health First Aid (MHFA) training is an evidence-based programme designed to support early recognition of mental distress, provide initial reassurance, and facilitate signposting to appropriate help. Its specific contribution to staff wellbeing within acute hospital environments, however, remains underexplored. This paper presents a protocol for a realist review that will examine how why, and in what contexts an MHFA programme may support staff health and wellbeing within an Irish hospital network. Methods This protocol for a realist review will follow RAMESES standards to examine the contribution of MHFA training to staff health and wellbeing. The review will proceed through five stages: (1) clarifying the scope of the review; (2) developing initial programme theories; (3) searching for evidence; (4) extracting and synthesising data using realist logic; and (5) refining the programme theories. An expert panel will be convened to support the development and refinement of the programme theories as the review progresses. Conclusions This realist review protocol will guide the development of context–mechanism–outcome (CMO) configurations to explain how MHFA training may operate within different hospital contexts. The resulting programme theories may contribute to organisational strategy, leadership practice, and policy decisions aimed at improving staff wellbeing in acute hospital settings. 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HRB Open Res 2026, 9 :7 ( https://doi.org/10.12688/hrbopenres.14318.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Study Protocol A Realist Review Protocol on the Contribution of a Mental Health First Aider Programme to Staff Health and Wellbeing within an Irish Hospital Network [version 1; peer review: 1 approved, 1 approved with reservations] Dolores Donegan 1 , Sean Paul Teeling https://orcid.org/0000-0002-4102-7280 1-3 , Martin McNamara https://orcid.org/0000-0001-7257-9654 1,3 Dolores Donegan 1 , Sean Paul Teeling https://orcid.org/0000-0002-4102-7280 1-3 , Martin McNamara https://orcid.org/0000-0001-7257-9654 1,3 PUBLISHED 09 Jan 2026 Author details Author details 1 UCD School of Nursing and Midwifery and Health Systems, University College Dublin, Ireland, Dublin, Ireland 2 Centre for Person-Centered Practice Research, Queen Margaret University School of Health Sciences, Musselburgh, Scotland, EH21 6UU, UK 3 UCD Centre for Interdisciplinary Research, Education and Innovation in Health Systems, School of Nursing, Midwifery & Health Systems, University College Dublin., Dublin, D04 V1W8, Ireland Dolores Donegan Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Sean Paul Teeling Roles: Conceptualization, Formal Analysis, Funding Acquisition, Investigation, Methodology, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Martin McNamara Roles: Formal Analysis, Methodology, Supervision, Validation, Visualization, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Background Staff mental health and wellbeing are growing concerns in acute hospital settings, where increased workload, emotional demand, and organisational pressures contribute to stress, burnout, and reduced psychological safety. Mental Health First Aid (MHFA) training is an evidence-based programme designed to support early recognition of mental distress, provide initial reassurance, and facilitate signposting to appropriate help. Its specific contribution to staff wellbeing within acute hospital environments, however, remains underexplored. This paper presents a protocol for a realist review that will examine how why, and in what contexts an MHFA programme may support staff health and wellbeing within an Irish hospital network. Methods This protocol for a realist review will follow RAMESES standards to examine the contribution of MHFA training to staff health and wellbeing. The review will proceed through five stages: (1) clarifying the scope of the review; (2) developing initial programme theories; (3) searching for evidence; (4) extracting and synthesising data using realist logic; and (5) refining the programme theories. An expert panel will be convened to support the development and refinement of the programme theories as the review progresses. Conclusions This realist review protocol will guide the development of context–mechanism–outcome (CMO) configurations to explain how MHFA training may operate within different hospital contexts. The resulting programme theories may contribute to organisational strategy, leadership practice, and policy decisions aimed at improving staff wellbeing in acute hospital settings. READ ALL READ LESS Keywords Realist Review Protocol, Hospital Staff, Mental Health First Aid, Staff Wellbeing, Healthcare Workers. Corresponding Author(s) Sean Paul Teeling ( [email protected] ) Close Corresponding author: Sean Paul Teeling Competing interests: No competing interests were disclosed. Grant information: Health Research Board Ireland [CES-2024-037] The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2026 Donegan D et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Donegan D, Teeling SP and McNamara M. A Realist Review Protocol on the Contribution of a Mental Health First Aider Programme to Staff Health and Wellbeing within an Irish Hospital Network [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2026, 9 :7 ( https://doi.org/10.12688/hrbopenres.14318.1 ) First published: 09 Jan 2026, 9 :7 ( https://doi.org/10.12688/hrbopenres.14318.1 ) Latest published: 03 Apr 2026, 9 :7 ( https://doi.org/10.12688/hrbopenres.14318.2 )  There is a newer version of this article available. Suppress this message for one day. Introduction Mental health is described by the ( WHO, 2019 ) as a state of mental well-being that enables people to cope with the stresses of life, realise their abilities, learn well and work well, and contribute to their community. It has intrinsic and instrumental value and is integral to our well-being. Increasing demands on hospitals have led to concerns around the working conditions and wellbeing of staff ( Kinman & Teoh, 2018 ). Healthcare staff typically access mental health support through an Employee Assistance Programme (EAP), a work-based service that helps staff and organizations with personal, work-related, and psychosocial issues. Workplace stress “particularly among frontline staff” is the number one issue raised by healthcare staff within the EAP ( Lynch, 2023 ). Mental ill health imposes significant economic burdens, manifesting in various ways such as elevated expenses due to absenteeism and staff turnover, as well as heighted pressure on healthcare service ( Cook et al. , 2024 ). Friends and family may notice early signs of mental illness but often don't know how to help, resulting in delayed access to treatment. Programmes such as Mental Health First Aid (MHFA) offer evidence-based knowledge and skills to enhance engagement and prompt support. Insufficient focus on preventative initiatives has been posited as an explanation for sustained mental ill health prevalence rates in several countries, despite increased mental health expenditure and service provision ( Jorm et al. , 2017 ; Meadows et al. , 2019 ). Delays in seeking care can exacerbate mental ill health conditions leading to worse outcomes and reduced quality of life ( Ahad et al. , 2023 ). Through MHFA training the whole hospital community can assist formal mental health services in early intervention for mental health disorders ( Kitchener & Jorm, 2008 p. 59) MHFA programmes are internationally recognised, evidence-based, accredited training courses designed to inform individuals about how to support someone experiencing mental ill health. This study aims to identify which aspects of the MHFA programme benefit whom, under what conditions, and how best to enhance hospital staff wellbeing. Use of realist inquiry Realist inquiry aims to understand “what works, for whom, under what circumstances, and why ( Pawson et al. , 2005 ; Pawson, 2006 ; Teeling et al. , 2021a ; Teeling et al. , 2021b ). Realist inquiry goes beyond exploring surface-level inputs and outputs by discerning how the resources of a specific intervention evoke and interact with stakeholders’ psychosocial responses, and mechanisms (M) that trigger intervention outcomes (O) in specific contexts (C) ( de Brun et al. , 2020 ). Researchers develop a Context-Mechanism-Outcome (CMO) hypothesis to predict which mechanisms operate in different contexts and the resulting outcomes ( Dalkin et al. , 2015 ). This configuration is ideal for exploring the context-sensitivity of the impact of a MHFA programme on staff health and wellbeing a hospital network. This realist review protocol seeks to understand how, why, for whom, and under what circumstances the MHFA programme can influence workplace culture and promote staff wellbeing in an acute hospital network. While existing evidence highlights the potential benefits of MHFA programme, its effectiveness is likely shaped by contextual factors, such as organisational culture, leadership support, and workforce dynamics. ( Kitchener & Jorm, 2008 ). By exploring the mechanisms through which MHFA operates and the conditions that enable or hinder its success, this research seeks to provide a nuanced understanding of its impact. The research question guiding the realist review described in this protocol is How, why, for whom, and under what circumstances does the MHFA programme influence workplace culture and promote staff wellbeing in acute hospital settings? The RAMESES guidelines provide standards to improve the rigour and comparability of realist and meta-narrative reviews ( Greenhalgh et al. , 2015 ). A five-stage structured methodology consistent with the RAMESES guidelines has been developed ( Wong et al. , 2017 ) which has been utilised to inform this review: 1. Define the scope of the review and develop initial theories. 2. Develop the search strategy. 3. Review primary studies and extract data. 4. Synthesise evidence and develop conclusions. 5. Refine theory iteratively and disseminate findings. 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. Table 1. PICO (Population, Intervention, Context, Outcomes) framework. PICO Element Key Concept Inclusion / Exclusion Criteria Population Healthcare Staff (Acute Hospitals) Inclusion: Acute Hospital Staff who have participated in MHFA training. Exclusion: Acute Hospital Staff who have not participated in MHFA training. Intervention MHFA Training Intervention Inclusion: Acute hospitals implementing the MHFA training Intervention. Exclusion: All other acute hospital staff training interventions not involving MHFA. Context Time Inclusion: Publications 2012–2026. Limiting the search will filter out irrelevant information, making it easier to find high-quality resources that directly address the research. Language Inclusion: Publications in English. Setting Inclusion: Acute hospital settings participating in MHFA training for two years or more. Exclusion: Non-acute healthcare organisations (e.g., Primary Care, community services, specialist mental health services). Outcomes Sustained implementation of MHFA programme Inclusion: % of staff who have completed the MHFA programme. Inclusion: % of staff that completed and are actively implementing the programme. Staff Wellbeing Inclusion: Documented impact of the MHFA programme on healthcare workers’ wellbeing. Staff Absenteeism Inclusion: Documented changes in the organisation’s absenteeism rates associated with MHFA implementation. Staff Health Checks Profiles Inclusion: Documented changes in Staff Health Check profiles associated with MHFA implementation. 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: Organising extracted data into evidence tables; Theming by individual reviewers; Comparing reviewers’ themes for each article and developing chains of inference from the identified themes; Linking chains of inference across articles and tracking how evidence contributes to emerging theory; Formulating hypotheses represented as linked context–mechanism–outcome (CMO) chains. 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. Conclusion The realist review outlined in this protocol aims to explore how, why, for whom, and under what circumstances the MHFA programme may influence workplace culture and promote staff wellbeing in acute hospital settings. By adopting a critical realist approach and utilising realist inquiry, this review will seek to: Determine for whom the MHFA programme works or does not work, and why; Identify the contexts in which the MHFA programme may be effective or ineffective, and the reasons for these variations; Uncover the mechanisms through which the MHFA programme may achieve its intended outcomes in specific contexts; Evaluate the anticipated and unanticipated outcomes of the MHFA programme for staff health and wellbeing. This approach will support the identification not only of potentially effective strategies, but also of the underlying causal processes and contextual conditions that shape their success, providing a robust framework for understanding mechanisms in complex organisational environments ( Pawson & Tilley, 1997 ). It is anticipated that the findings from the realist review described in this protocol will contribute to understanding how MHFA training may support the wellbeing and mental health of staff working in acute hospital settings. Systematic review registration This protocol is currently undergoing review by the PROSPERO Editorial committee and registration number will be added as soon as available. Data availability statement Underlying data No data are associated with this article Extended data Donegan et al. (2025) . Prisma-P 2015 Checklist for realist review protocol: A Realist Review Protocol on the Contribution of a Mental Health First Aider Programme to Staff Health and Wellbeing within an Irish Hospital Network. figshare. Journal contribution. https://doi.org/10.6084/m9.figshare.30815501.v1 Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0) Reporting guidelines The Realist Review will be informed by the RAMESES (Realist and Meta-narrative Evidence Synthesis: Evolving Standards) project. Acknowledgments We acknowledge the anticipated valuable contributions of those who have agreed to participate in our local reference groups and expert panels, whose insights and expertise will be instrumental in guiding and refining this research. Faculty Opinions recommended References Ahad AA, Sanchez-Gonzalez M, Junquera P: Understanding and addressing mental health stigma across cultures for improving psychiatric care: a narrative review. Cureus. 2023; 15 (5): e39549. PubMed Abstract | Publisher Full Text | Free Full Text Booth A: Searching for qualitative research for inclusion in systematic reviews: a structured methodological review. 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Reference Source Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 09 Jan 2026 ADD YOUR COMMENT Comment Author details Author details 1 UCD School of Nursing and Midwifery and Health Systems, University College Dublin, Ireland, Dublin, Ireland 2 Centre for Person-Centered Practice Research, Queen Margaret University School of Health Sciences, Musselburgh, Scotland, EH21 6UU, UK 3 UCD Centre for Interdisciplinary Research, Education and Innovation in Health Systems, School of Nursing, Midwifery & Health Systems, University College Dublin., Dublin, D04 V1W8, Ireland Dolores Donegan Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Sean Paul Teeling Roles: Conceptualization, Formal Analysis, Funding Acquisition, Investigation, Methodology, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Martin McNamara Roles: Formal Analysis, Methodology, Supervision, Validation, Visualization, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information Health Research Board Ireland [CES-2024-037] The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (2) version 2 Revised Published: 03 Apr 2026, 9:7 https://doi.org/10.12688/hrbopenres.14318.2 version 1 Published: 09 Jan 2026, 9:7 https://doi.org/10.12688/hrbopenres.14318.1 Copyright © 2026 Donegan D et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics VIEWS $counts.viewCount downloads Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Donegan D, Teeling SP and McNamara M. A Realist Review Protocol on the Contribution of a Mental Health First Aider Programme to Staff Health and Wellbeing within an Irish Hospital Network [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2026, 9 :7 ( https://doi.org/10.12688/hrbopenres.14318.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 09 Jan 2026 Views 0 Cite How to cite this report: Lavelle M. Reviewer Report For: A Realist Review Protocol on the Contribution of a Mental Health First Aider Programme to Staff Health and Wellbeing within an Irish Hospital Network [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2026, 9 :7 ( https://doi.org/10.21956/hrbopenres.15761.r53376 ) The direct URL for this report is: https://hrbopenresearch.org/articles/9-7/v1#referee-response-53376 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 17 Feb 2026 Mary Lavelle , Queen's University Belfast, Belfast, Northern Ireland, UK Approved with Reservations VIEWS 0 https://doi.org/10.21956/hrbopenres.15761.r53376 This manuscript presents a protocol for a realist review examining how, why, and in what contexts Mental Health First Aid (MHFA) programmes may support staff health and wellbeing within a hospital network. The rationale for undertaking a realist approach is ... Continue reading READ ALL This manuscript presents a protocol for a realist review examining how, why, and in what contexts Mental Health First Aid (MHFA) programmes may support staff health and wellbeing within a hospital network. The rationale for undertaking a realist approach is clearly articulated and well justified. There are some points that require further clarification, which I have summarised below. The title refers specifically to the contribution of the programme within an Irish Hospital Network, yet the proposed review does not appear to be limited to Irish settings. This may create some ambiguity about the scope of the review. Different terms are used throughout the manuscript when referring to the primary outcome, including “staff health and wellbeing,” “staff wellbeing,” and, in the conclusion, “workplace culture.” It would strengthen the protocol to define more precisely the core outcome(s) of interest and to use consistent terminology throughout. If workplace culture is intended as a key outcome, this should be made explicit earlier in the manuscript. Alternatively, if workplace culture is being conceptualised as a contextual factor or mechanism within the realist framework, this should be clearly articulated. Relatedly, in Table 1 (PICO), the outcomes section appears relatively narrow and does not include reference to workplace culture. Could the PICO be too rigid for this type of review? If workplace culture is a central concept within the review, consideration should be given to whether it should be incorporated into the eligibility criteria and reflected explicitly within the outcomes (or context/mechanism) component of the framework. Overall, greater conceptual coherence between the title, stated aims, search strategy, and conclusion would strengthen the clarity and rigour of the protocol. Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Partly Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests: No competing interests were disclosed. Reviewer Expertise: Mental Health research, both qualitative and quantitative methods. I have not conducted a realist review. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Lavelle M. Reviewer Report For: A Realist Review Protocol on the Contribution of a Mental Health First Aider Programme to Staff Health and Wellbeing within an Irish Hospital Network [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2026, 9 :7 ( https://doi.org/10.21956/hrbopenres.15761.r53376 ) The direct URL for this report is: https://hrbopenresearch.org/articles/9-7/v1#referee-response-53376 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 03 Apr 2026 Sean Paul Teeling , UCD School of Nursing and Midwifery and Health Systems, University College Dublin, Ireland, Dublin, Ireland 03 Apr 2026 Author Response Dear Dr Lavelle, Thank you for taking the time to review the protocol and for the thoughtful and constructive comments provided. Your observations were particularly helpful in strengthening the ... Continue reading Dear Dr Lavelle, Thank you for taking the time to review the protocol and for the thoughtful and constructive comments provided. Your observations were particularly helpful in strengthening the clarity of the title, improving conceptual consistency across the manuscript, and refining the framing of the PICO to better reflect the explanatory focus of the review. In response to your observation that the title referred to an Irish Hospital Network while the review itself was not restricted to Ireland, the title and related sections of the manuscript have been revised to remove this ambiguity. The title now focuses on staff wellbeing within a hospital network rather than specifying a national context. This better reflects the scope of the realist review, which draws on international evidence to develop programme theories. The subsequent realist evaluation phase of the wider study will be conducted within Irish hospital sites; however, the review itself is not geographically restricted. Related terminology within the abstract has also been revised to ensure consistency, including replacing “Staff Health and Wellbeing” with “Staff Wellbeing” and removing the reference to an “Irish Hospital Network” (Title section, Page 1; Abstract). Your comment regarding inconsistent terminology across the manuscript was also extremely helpful. The protocol has been revised to ensure consistent use of the term “staff wellbeing” throughout the title, aims, search strategy and conclusion. In addition, “workplace culture” is now positioned more clearly as a contextual influence that may shape how programme mechanisms operate within organisational settings rather than being presented as a standalone outcome. These revisions strengthen conceptual alignment across the protocol and improve clarity regarding the key concepts underpinning the review. Finally, we appreciate your observation that the original PICO appeared overly rigid and did not sufficiently capture the role of workplace culture. In response, the PICO has been revised to better reflect the explanatory orientation of realist methodology. Culture is now positioned within the context component of the framework, recognising its influence on how programme mechanisms may operate in organisational environments. Outcomes are also conceptualised in a layered manner rather than through predefined metric thresholds, allowing for consideration of proximal, intermediate and distal outcomes. The text has also been revised to clarify that study inclusion will be guided by theory development and explanatory relevance rather than by predefined performance indicators (see Line 125). All revisions have been highlighted in yellow in the revised manuscript, and the relevant line numbers have been provided above to assist in locating the changes. Your comments have been extremely helpful in strengthening the conceptual clarity and methodological coherence of the protocol. Dear Dr Lavelle, Thank you for taking the time to review the protocol and for the thoughtful and constructive comments provided. Your observations were particularly helpful in strengthening the clarity of the title, improving conceptual consistency across the manuscript, and refining the framing of the PICO to better reflect the explanatory focus of the review. In response to your observation that the title referred to an Irish Hospital Network while the review itself was not restricted to Ireland, the title and related sections of the manuscript have been revised to remove this ambiguity. The title now focuses on staff wellbeing within a hospital network rather than specifying a national context. This better reflects the scope of the realist review, which draws on international evidence to develop programme theories. The subsequent realist evaluation phase of the wider study will be conducted within Irish hospital sites; however, the review itself is not geographically restricted. Related terminology within the abstract has also been revised to ensure consistency, including replacing “Staff Health and Wellbeing” with “Staff Wellbeing” and removing the reference to an “Irish Hospital Network” (Title section, Page 1; Abstract). Your comment regarding inconsistent terminology across the manuscript was also extremely helpful. The protocol has been revised to ensure consistent use of the term “staff wellbeing” throughout the title, aims, search strategy and conclusion. In addition, “workplace culture” is now positioned more clearly as a contextual influence that may shape how programme mechanisms operate within organisational settings rather than being presented as a standalone outcome. These revisions strengthen conceptual alignment across the protocol and improve clarity regarding the key concepts underpinning the review. Finally, we appreciate your observation that the original PICO appeared overly rigid and did not sufficiently capture the role of workplace culture. In response, the PICO has been revised to better reflect the explanatory orientation of realist methodology. Culture is now positioned within the context component of the framework, recognising its influence on how programme mechanisms may operate in organisational environments. Outcomes are also conceptualised in a layered manner rather than through predefined metric thresholds, allowing for consideration of proximal, intermediate and distal outcomes. The text has also been revised to clarify that study inclusion will be guided by theory development and explanatory relevance rather than by predefined performance indicators (see Line 125). All revisions have been highlighted in yellow in the revised manuscript, and the relevant line numbers have been provided above to assist in locating the changes. Your comments have been extremely helpful in strengthening the conceptual clarity and methodological coherence of the protocol. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 03 Apr 2026 Sean Paul Teeling , UCD School of Nursing and Midwifery and Health Systems, University College Dublin, Ireland, Dublin, Ireland 03 Apr 2026 Author Response Dear Dr Lavelle, Thank you for taking the time to review the protocol and for the thoughtful and constructive comments provided. Your observations were particularly helpful in strengthening the ... Continue reading Dear Dr Lavelle, Thank you for taking the time to review the protocol and for the thoughtful and constructive comments provided. Your observations were particularly helpful in strengthening the clarity of the title, improving conceptual consistency across the manuscript, and refining the framing of the PICO to better reflect the explanatory focus of the review. In response to your observation that the title referred to an Irish Hospital Network while the review itself was not restricted to Ireland, the title and related sections of the manuscript have been revised to remove this ambiguity. The title now focuses on staff wellbeing within a hospital network rather than specifying a national context. This better reflects the scope of the realist review, which draws on international evidence to develop programme theories. The subsequent realist evaluation phase of the wider study will be conducted within Irish hospital sites; however, the review itself is not geographically restricted. Related terminology within the abstract has also been revised to ensure consistency, including replacing “Staff Health and Wellbeing” with “Staff Wellbeing” and removing the reference to an “Irish Hospital Network” (Title section, Page 1; Abstract). Your comment regarding inconsistent terminology across the manuscript was also extremely helpful. The protocol has been revised to ensure consistent use of the term “staff wellbeing” throughout the title, aims, search strategy and conclusion. In addition, “workplace culture” is now positioned more clearly as a contextual influence that may shape how programme mechanisms operate within organisational settings rather than being presented as a standalone outcome. These revisions strengthen conceptual alignment across the protocol and improve clarity regarding the key concepts underpinning the review. Finally, we appreciate your observation that the original PICO appeared overly rigid and did not sufficiently capture the role of workplace culture. In response, the PICO has been revised to better reflect the explanatory orientation of realist methodology. Culture is now positioned within the context component of the framework, recognising its influence on how programme mechanisms may operate in organisational environments. Outcomes are also conceptualised in a layered manner rather than through predefined metric thresholds, allowing for consideration of proximal, intermediate and distal outcomes. The text has also been revised to clarify that study inclusion will be guided by theory development and explanatory relevance rather than by predefined performance indicators (see Line 125). All revisions have been highlighted in yellow in the revised manuscript, and the relevant line numbers have been provided above to assist in locating the changes. Your comments have been extremely helpful in strengthening the conceptual clarity and methodological coherence of the protocol. Dear Dr Lavelle, Thank you for taking the time to review the protocol and for the thoughtful and constructive comments provided. Your observations were particularly helpful in strengthening the clarity of the title, improving conceptual consistency across the manuscript, and refining the framing of the PICO to better reflect the explanatory focus of the review. In response to your observation that the title referred to an Irish Hospital Network while the review itself was not restricted to Ireland, the title and related sections of the manuscript have been revised to remove this ambiguity. The title now focuses on staff wellbeing within a hospital network rather than specifying a national context. This better reflects the scope of the realist review, which draws on international evidence to develop programme theories. The subsequent realist evaluation phase of the wider study will be conducted within Irish hospital sites; however, the review itself is not geographically restricted. Related terminology within the abstract has also been revised to ensure consistency, including replacing “Staff Health and Wellbeing” with “Staff Wellbeing” and removing the reference to an “Irish Hospital Network” (Title section, Page 1; Abstract). Your comment regarding inconsistent terminology across the manuscript was also extremely helpful. The protocol has been revised to ensure consistent use of the term “staff wellbeing” throughout the title, aims, search strategy and conclusion. In addition, “workplace culture” is now positioned more clearly as a contextual influence that may shape how programme mechanisms operate within organisational settings rather than being presented as a standalone outcome. These revisions strengthen conceptual alignment across the protocol and improve clarity regarding the key concepts underpinning the review. Finally, we appreciate your observation that the original PICO appeared overly rigid and did not sufficiently capture the role of workplace culture. In response, the PICO has been revised to better reflect the explanatory orientation of realist methodology. Culture is now positioned within the context component of the framework, recognising its influence on how programme mechanisms may operate in organisational environments. Outcomes are also conceptualised in a layered manner rather than through predefined metric thresholds, allowing for consideration of proximal, intermediate and distal outcomes. The text has also been revised to clarify that study inclusion will be guided by theory development and explanatory relevance rather than by predefined performance indicators (see Line 125). All revisions have been highlighted in yellow in the revised manuscript, and the relevant line numbers have been provided above to assist in locating the changes. Your comments have been extremely helpful in strengthening the conceptual clarity and methodological coherence of the protocol. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Desmet K. Reviewer Report For: A Realist Review Protocol on the Contribution of a Mental Health First Aider Programme to Staff Health and Wellbeing within an Irish Hospital Network [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2026, 9 :7 ( https://doi.org/10.21956/hrbopenres.15761.r53127 ) The direct URL for this report is: https://hrbopenresearch.org/articles/9-7/v1#referee-response-53127 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 09 Feb 2026 Karel Desmet , Ghent University, Ghent, Flanders, Belgium; General Hospital Ostend, Ostend, Belgium Approved VIEWS 0 https://doi.org/10.21956/hrbopenres.15761.r53127 Thank you for submitting this manuscript, which addresses a highly relevant topic in a rapidly evolving healthcare landscape. The protocol paper presents a valuable contribution to the field and is well-structured. The focus on mechanisms, contextual contingencies, and implementation processes ... Continue reading READ ALL Thank you for submitting this manuscript, which addresses a highly relevant topic in a rapidly evolving healthcare landscape. The protocol paper presents a valuable contribution to the field and is well-structured. The focus on mechanisms, contextual contingencies, and implementation processes is well aligned with the complexity of workplace mental health interventions. However, several clarifications and expansions could be strengthened to enhance its precision, clarity, methodological coherence and readability. The authors convincingly justify the use of realist inquiry. The emphasis on context–mechanism–outcome (CMO) configurations and retroductive theorising appropriately reflects the complexity of MHFA as a social and organisational intervention rather than a simple training “dose–response” model. The intention to move beyond effectiveness questions toward explanatory theory building is a clear strength. The integration of local stakeholders (Local Reference Group and expert panel) is particularly valuable and consistent with realist principles of theory refinement through practitioner knowledge. Is it possible to add more information about the MFA trainers, participants and expert trainers. For a non-UK reader this is not clear. Please add some more information about the experts to enhance validity and relevance. Some terms could be defined more precisely. For instance, ‘staff wellbeing’ is used broadly. Clarifying whether this refers to psychological wellbeing, burnout, mental distress, organizational outcomes, or a combination would sharpen the analytical focus. Although realist reviews are not outcome-centric in the traditional sense, the protocol lists several operational indicators (e.g., absenteeism rates, health checks, percentage trained). These metrics risk framing MHFA in primarily instrumental or managerial terms. It may be helpful to: distinguish between proximal outcomes (e.g., confidence to provide peer support, stigma reduction), intermediate outcomes (e.g., help-seeking behaviour, psychological safety), distal organisational outcomes (e.g., absenteeism, retention). This layered outcome logic could strengthen the program theory and prevent conflating mechanisms with endpoints. The use of a PICO structure to guide searching is understandable for transparency, but it sits somewhat uneasily with realist logic. PICO tends to imply intervention–outcome testing (and pragmatically used for systematic reviews), whereas realist synthesis is theory-led and mechanism-focused. Consider clarifying inclusion decisions more theory-driven. Without this clarification, the criteria (e.g., limiting to staff who participated MHFA, or requiring certain outcomes) may inadvertently exclude conceptually rich studies that inform mechanisms but do not report predefined metrics. Restricting settings to ‘acute hospitals participating in MHFA training for two years or more’ may unintentionally narrow the explanatory potential of the review. Realist reviews often benefit from conceptual heterogeneity, including studies from adjacent contexts that illuminate mechanisms. The authors might reflect on whether: shorter implementations, other healthcare or organisational settings, or broader workplace MHFA applications could provide transferable insights into mechanisms. A slightly more permissive approach could enrich theory development. The description of synthesis is appropriate but could be made more explicit. For example: How will CMO configurations be documented (software, templates, coding framework)? Will coding be double-checked or discussed collaboratively? How will disagreements about inferred mechanisms be resolved? Providing these operational details would enhance methodological transparency. The protocol mentions “realist hunches,” CPTs, and IPTs, which is consistent with realist language. However, the process could be described more concretely. A brief illustrative example of a potential CMO hypothesis (even hypothetical) would help readers unfamiliar with realist work to understand how theories will be articulated and refined. Minor suggestions: Ensure consistent terminology (MHFA programme vs training vs intervention). Check citation formatting and typographical accuracy. Avoid over-assertive claims about “evidence-based” status unless clearly specified. Consider a short reflexivity statement describing the team’s positioning, particularly given local implementation links. Overall, this is a thoughtful and promising study that is likely to make a meaningful contribution to both implementation science and mental health research. with modest refinements the protocol will provide a robust foundation for a high-quality realist review. Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: mental health research I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Desmet K. Reviewer Report For: A Realist Review Protocol on the Contribution of a Mental Health First Aider Programme to Staff Health and Wellbeing within an Irish Hospital Network [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2026, 9 :7 ( https://doi.org/10.21956/hrbopenres.15761.r53127 ) The direct URL for this report is: https://hrbopenresearch.org/articles/9-7/v1#referee-response-53127 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 03 Apr 2026 Sean Paul Teeling , UCD School of Nursing and Midwifery and Health Systems, University College Dublin, Ireland, Dublin, Ireland 03 Apr 2026 Author Response Dear Dr Desmet Sincere thanks for the constructive suggestions provided. These comments were extremely helpful in strengthening the clarity and methodological transparency of the study. In response, several revisions have ... Continue reading Dear Dr Desmet Sincere thanks for the constructive suggestions provided. These comments were extremely helpful in strengthening the clarity and methodological transparency of the study. In response, several revisions have been made throughout the manuscript. Additional detail has been added to clarify the composition and roles of both the Local Reference Group and the Expert Panel. These sections now outline the inclusion of MHFA programme participants, accredited MHFA instructors involved in programme delivery, and staff responsible for organisational wellbeing initiatives within hospital settings, alongside academic researchers with recognised expertise in realist methodology and organisational wellbeing (Lines 81–84; 93–98). The introduction has also been revised to provide a clearer definition of staff wellbeing within hospital contexts, specifying that it refers to psychological wellbeing and related workplace experiences such as burnout-related strain, psychological safety, mental distress and perceived organisational support. Workplace culture is clarified as a contextual influence that may shape how programme mechanisms operate, rather than as a standalone outcome (Lines 11–16). In response to your observation that outcomes were framed too narrowly in managerial or metric-driven terms, the outcomes section has been revised to distinguish between proximal, intermediate and distal outcomes. This layered structure supports realist programme theory development by recognising that interventions may produce different types of outcomes across stages of implementation and organisational influence (Lines 125; 127–132). Your observation regarding the rigidity of the original PICO structure was also particularly helpful. The manuscript now clarifies that PICO is used only to structure the initial search strategy and that the review will follow an iterative, theory-led searching process consistent with realist methodology, allowing further purposive searches to explore emerging contextual and mechanistic explanations as programme theories develop (Lines 133–138). In addition, the restriction to acute hospital settings has been relaxed to allow inclusion of studies from adjacent healthcare contexts where they provide transferable explanatory insight relevant to hospital staff wellbeing (Line 125). To further support methodological clarity, a brief illustrative Context–Mechanism–Outcome example has been added to the introduction to demonstrate how provisional programme theories may be articulated and refined during the review process (Lines 43–47). Finally, a reflexivity statement has been included in the methods section outlining the research team’s background in healthcare improvement and organisational wellbeing research and describing the reflexive processes that will be used to support interpretive rigour, including team discussion, expert panel adjudication and stakeholder engagement during programme theory refinement (Lines 203–214). All revisions have been highlighted in yellow in the revised manuscript and the relevant line numbers have been provided above to assist the reviewer in locating the changes. We are grateful for your constructive feedback, which has helped strengthen the explanatory focus and methodological coherence of the protocol and ensures that the review is positioned to generate programme theories that can inform how and under what conditions MHFA may contribute to staff wellbeing across healthcare settings. Dear Dr Desmet Sincere thanks for the constructive suggestions provided. These comments were extremely helpful in strengthening the clarity and methodological transparency of the study. In response, several revisions have been made throughout the manuscript. Additional detail has been added to clarify the composition and roles of both the Local Reference Group and the Expert Panel. These sections now outline the inclusion of MHFA programme participants, accredited MHFA instructors involved in programme delivery, and staff responsible for organisational wellbeing initiatives within hospital settings, alongside academic researchers with recognised expertise in realist methodology and organisational wellbeing (Lines 81–84; 93–98). The introduction has also been revised to provide a clearer definition of staff wellbeing within hospital contexts, specifying that it refers to psychological wellbeing and related workplace experiences such as burnout-related strain, psychological safety, mental distress and perceived organisational support. Workplace culture is clarified as a contextual influence that may shape how programme mechanisms operate, rather than as a standalone outcome (Lines 11–16). In response to your observation that outcomes were framed too narrowly in managerial or metric-driven terms, the outcomes section has been revised to distinguish between proximal, intermediate and distal outcomes. This layered structure supports realist programme theory development by recognising that interventions may produce different types of outcomes across stages of implementation and organisational influence (Lines 125; 127–132). Your observation regarding the rigidity of the original PICO structure was also particularly helpful. The manuscript now clarifies that PICO is used only to structure the initial search strategy and that the review will follow an iterative, theory-led searching process consistent with realist methodology, allowing further purposive searches to explore emerging contextual and mechanistic explanations as programme theories develop (Lines 133–138). In addition, the restriction to acute hospital settings has been relaxed to allow inclusion of studies from adjacent healthcare contexts where they provide transferable explanatory insight relevant to hospital staff wellbeing (Line 125). To further support methodological clarity, a brief illustrative Context–Mechanism–Outcome example has been added to the introduction to demonstrate how provisional programme theories may be articulated and refined during the review process (Lines 43–47). Finally, a reflexivity statement has been included in the methods section outlining the research team’s background in healthcare improvement and organisational wellbeing research and describing the reflexive processes that will be used to support interpretive rigour, including team discussion, expert panel adjudication and stakeholder engagement during programme theory refinement (Lines 203–214). All revisions have been highlighted in yellow in the revised manuscript and the relevant line numbers have been provided above to assist the reviewer in locating the changes. We are grateful for your constructive feedback, which has helped strengthen the explanatory focus and methodological coherence of the protocol and ensures that the review is positioned to generate programme theories that can inform how and under what conditions MHFA may contribute to staff wellbeing across healthcare settings. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 03 Apr 2026 Sean Paul Teeling , UCD School of Nursing and Midwifery and Health Systems, University College Dublin, Ireland, Dublin, Ireland 03 Apr 2026 Author Response Dear Dr Desmet Sincere thanks for the constructive suggestions provided. These comments were extremely helpful in strengthening the clarity and methodological transparency of the study. In response, several revisions have ... Continue reading Dear Dr Desmet Sincere thanks for the constructive suggestions provided. These comments were extremely helpful in strengthening the clarity and methodological transparency of the study. In response, several revisions have been made throughout the manuscript. Additional detail has been added to clarify the composition and roles of both the Local Reference Group and the Expert Panel. These sections now outline the inclusion of MHFA programme participants, accredited MHFA instructors involved in programme delivery, and staff responsible for organisational wellbeing initiatives within hospital settings, alongside academic researchers with recognised expertise in realist methodology and organisational wellbeing (Lines 81–84; 93–98). The introduction has also been revised to provide a clearer definition of staff wellbeing within hospital contexts, specifying that it refers to psychological wellbeing and related workplace experiences such as burnout-related strain, psychological safety, mental distress and perceived organisational support. Workplace culture is clarified as a contextual influence that may shape how programme mechanisms operate, rather than as a standalone outcome (Lines 11–16). In response to your observation that outcomes were framed too narrowly in managerial or metric-driven terms, the outcomes section has been revised to distinguish between proximal, intermediate and distal outcomes. This layered structure supports realist programme theory development by recognising that interventions may produce different types of outcomes across stages of implementation and organisational influence (Lines 125; 127–132). Your observation regarding the rigidity of the original PICO structure was also particularly helpful. The manuscript now clarifies that PICO is used only to structure the initial search strategy and that the review will follow an iterative, theory-led searching process consistent with realist methodology, allowing further purposive searches to explore emerging contextual and mechanistic explanations as programme theories develop (Lines 133–138). In addition, the restriction to acute hospital settings has been relaxed to allow inclusion of studies from adjacent healthcare contexts where they provide transferable explanatory insight relevant to hospital staff wellbeing (Line 125). To further support methodological clarity, a brief illustrative Context–Mechanism–Outcome example has been added to the introduction to demonstrate how provisional programme theories may be articulated and refined during the review process (Lines 43–47). Finally, a reflexivity statement has been included in the methods section outlining the research team’s background in healthcare improvement and organisational wellbeing research and describing the reflexive processes that will be used to support interpretive rigour, including team discussion, expert panel adjudication and stakeholder engagement during programme theory refinement (Lines 203–214). All revisions have been highlighted in yellow in the revised manuscript and the relevant line numbers have been provided above to assist the reviewer in locating the changes. We are grateful for your constructive feedback, which has helped strengthen the explanatory focus and methodological coherence of the protocol and ensures that the review is positioned to generate programme theories that can inform how and under what conditions MHFA may contribute to staff wellbeing across healthcare settings. Dear Dr Desmet Sincere thanks for the constructive suggestions provided. These comments were extremely helpful in strengthening the clarity and methodological transparency of the study. In response, several revisions have been made throughout the manuscript. Additional detail has been added to clarify the composition and roles of both the Local Reference Group and the Expert Panel. These sections now outline the inclusion of MHFA programme participants, accredited MHFA instructors involved in programme delivery, and staff responsible for organisational wellbeing initiatives within hospital settings, alongside academic researchers with recognised expertise in realist methodology and organisational wellbeing (Lines 81–84; 93–98). The introduction has also been revised to provide a clearer definition of staff wellbeing within hospital contexts, specifying that it refers to psychological wellbeing and related workplace experiences such as burnout-related strain, psychological safety, mental distress and perceived organisational support. Workplace culture is clarified as a contextual influence that may shape how programme mechanisms operate, rather than as a standalone outcome (Lines 11–16). In response to your observation that outcomes were framed too narrowly in managerial or metric-driven terms, the outcomes section has been revised to distinguish between proximal, intermediate and distal outcomes. This layered structure supports realist programme theory development by recognising that interventions may produce different types of outcomes across stages of implementation and organisational influence (Lines 125; 127–132). Your observation regarding the rigidity of the original PICO structure was also particularly helpful. The manuscript now clarifies that PICO is used only to structure the initial search strategy and that the review will follow an iterative, theory-led searching process consistent with realist methodology, allowing further purposive searches to explore emerging contextual and mechanistic explanations as programme theories develop (Lines 133–138). In addition, the restriction to acute hospital settings has been relaxed to allow inclusion of studies from adjacent healthcare contexts where they provide transferable explanatory insight relevant to hospital staff wellbeing (Line 125). To further support methodological clarity, a brief illustrative Context–Mechanism–Outcome example has been added to the introduction to demonstrate how provisional programme theories may be articulated and refined during the review process (Lines 43–47). Finally, a reflexivity statement has been included in the methods section outlining the research team’s background in healthcare improvement and organisational wellbeing research and describing the reflexive processes that will be used to support interpretive rigour, including team discussion, expert panel adjudication and stakeholder engagement during programme theory refinement (Lines 203–214). All revisions have been highlighted in yellow in the revised manuscript and the relevant line numbers have been provided above to assist the reviewer in locating the changes. We are grateful for your constructive feedback, which has helped strengthen the explanatory focus and methodological coherence of the protocol and ensures that the review is positioned to generate programme theories that can inform how and under what conditions MHFA may contribute to staff wellbeing across healthcare settings. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 09 Jan 2026 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 2 (revision) 03 Apr 26 read read Version 1 09 Jan 26 read read Karel Desmet , Ghent University, Ghent, Belgium; General Hospital Ostend, Ostend, Belgium Mary Lavelle , Queen's University Belfast, Belfast, UK Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Lavelle M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 21 Apr 2026 | for Version 2 Mary Lavelle , Queen's University Belfast, Belfast, Northern Ireland, UK 0 Views copyright © 2026 Lavelle M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The authors have clearly considered the feedback provided and have improved the clarity of the manuscript. I am happy to approve this manuscript at this stage. Competing Interests No competing interests were disclosed. Reviewer Expertise Mental Health research, both qualitative and quantitative methods. I have not conducted a realist review. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Lavelle M. Peer Review Report For: A Realist Review Protocol on the Contribution of a Mental Health First Aider Programme to Staff Health and Wellbeing within an Irish Hospital Network [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2026, 9 :7 ( https://doi.org/10.21956/hrbopenres.15879.r54456) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://hrbopenresearch.org/articles/9-7/v2#referee-response-54456 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Desmet K. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 07 Apr 2026 | for Version 2 Karel Desmet , Ghent University, Ghent, Flanders, Belgium; General Hospital Ostend, Ostend, Belgium 0 Views copyright © 2026 Desmet K. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The authors are to be commended for the rigor and diligence demonstrated throughout the revision process. Their responses are consistently comprehensive and well-articulated, reflecting a thorough engagement with the comments. Moreover, the revisions made to the manuscript are both appropriate and substantively improve its clarity and scholarly contribution. The authors also demonstrate a commendable level of critical reflection, carefully considering the implications of the feedback and transparently justifying their choices. Overall, this iterative process has clearly strengthened the manuscript. Competing Interests No competing interests were disclosed. Reviewer Expertise mental health research I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Desmet K. Peer Review Report For: A Realist Review Protocol on the Contribution of a Mental Health First Aider Programme to Staff Health and Wellbeing within an Irish Hospital Network [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2026, 9 :7 ( https://doi.org/10.21956/hrbopenres.15879.r54455) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://hrbopenresearch.org/articles/9-7/v2#referee-response-54455 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Lavelle M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 17 Feb 2026 | for Version 1 Mary Lavelle , Queen's University Belfast, Belfast, Northern Ireland, UK 0 Views copyright © 2026 Lavelle M. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This manuscript presents a protocol for a realist review examining how, why, and in what contexts Mental Health First Aid (MHFA) programmes may support staff health and wellbeing within a hospital network. The rationale for undertaking a realist approach is clearly articulated and well justified. There are some points that require further clarification, which I have summarised below. The title refers specifically to the contribution of the programme within an Irish Hospital Network, yet the proposed review does not appear to be limited to Irish settings. This may create some ambiguity about the scope of the review. Different terms are used throughout the manuscript when referring to the primary outcome, including “staff health and wellbeing,” “staff wellbeing,” and, in the conclusion, “workplace culture.” It would strengthen the protocol to define more precisely the core outcome(s) of interest and to use consistent terminology throughout. If workplace culture is intended as a key outcome, this should be made explicit earlier in the manuscript. Alternatively, if workplace culture is being conceptualised as a contextual factor or mechanism within the realist framework, this should be clearly articulated. Relatedly, in Table 1 (PICO), the outcomes section appears relatively narrow and does not include reference to workplace culture. Could the PICO be too rigid for this type of review? If workplace culture is a central concept within the review, consideration should be given to whether it should be incorporated into the eligibility criteria and reflected explicitly within the outcomes (or context/mechanism) component of the framework. Overall, greater conceptual coherence between the title, stated aims, search strategy, and conclusion would strengthen the clarity and rigour of the protocol. Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Partly Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests No competing interests were disclosed. Reviewer Expertise Mental Health research, both qualitative and quantitative methods. I have not conducted a realist review. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 03 Apr 2026 Sean Paul Teeling, UCD School of Nursing and Midwifery and Health Systems, University College Dublin, Ireland, Dublin, Ireland Dear Dr Lavelle, Thank you for taking the time to review the protocol and for the thoughtful and constructive comments provided. Your observations were particularly helpful in strengthening the clarity of the title, improving conceptual consistency across the manuscript, and refining the framing of the PICO to better reflect the explanatory focus of the review. In response to your observation that the title referred to an Irish Hospital Network while the review itself was not restricted to Ireland, the title and related sections of the manuscript have been revised to remove this ambiguity. The title now focuses on staff wellbeing within a hospital network rather than specifying a national context. This better reflects the scope of the realist review, which draws on international evidence to develop programme theories. The subsequent realist evaluation phase of the wider study will be conducted within Irish hospital sites; however, the review itself is not geographically restricted. Related terminology within the abstract has also been revised to ensure consistency, including replacing “Staff Health and Wellbeing” with “Staff Wellbeing” and removing the reference to an “Irish Hospital Network” (Title section, Page 1; Abstract). Your comment regarding inconsistent terminology across the manuscript was also extremely helpful. The protocol has been revised to ensure consistent use of the term “staff wellbeing” throughout the title, aims, search strategy and conclusion. In addition, “workplace culture” is now positioned more clearly as a contextual influence that may shape how programme mechanisms operate within organisational settings rather than being presented as a standalone outcome. These revisions strengthen conceptual alignment across the protocol and improve clarity regarding the key concepts underpinning the review. Finally, we appreciate your observation that the original PICO appeared overly rigid and did not sufficiently capture the role of workplace culture. In response, the PICO has been revised to better reflect the explanatory orientation of realist methodology. Culture is now positioned within the context component of the framework, recognising its influence on how programme mechanisms may operate in organisational environments. Outcomes are also conceptualised in a layered manner rather than through predefined metric thresholds, allowing for consideration of proximal, intermediate and distal outcomes. The text has also been revised to clarify that study inclusion will be guided by theory development and explanatory relevance rather than by predefined performance indicators (see Line 125). All revisions have been highlighted in yellow in the revised manuscript, and the relevant line numbers have been provided above to assist in locating the changes. Your comments have been extremely helpful in strengthening the conceptual clarity and methodological coherence of the protocol. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Lavelle M. Peer Review Report For: A Realist Review Protocol on the Contribution of a Mental Health First Aider Programme to Staff Health and Wellbeing within an Irish Hospital Network [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2026, 9 :7 ( https://doi.org/10.21956/hrbopenres.15761.r53376) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://hrbopenresearch.org/articles/9-7/v1#referee-response-53376 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Desmet K. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 09 Feb 2026 | for Version 1 Karel Desmet , Ghent University, Ghent, Flanders, Belgium; General Hospital Ostend, Ostend, Belgium 0 Views copyright © 2026 Desmet K. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Thank you for submitting this manuscript, which addresses a highly relevant topic in a rapidly evolving healthcare landscape. The protocol paper presents a valuable contribution to the field and is well-structured. The focus on mechanisms, contextual contingencies, and implementation processes is well aligned with the complexity of workplace mental health interventions. However, several clarifications and expansions could be strengthened to enhance its precision, clarity, methodological coherence and readability. The authors convincingly justify the use of realist inquiry. The emphasis on context–mechanism–outcome (CMO) configurations and retroductive theorising appropriately reflects the complexity of MHFA as a social and organisational intervention rather than a simple training “dose–response” model. The intention to move beyond effectiveness questions toward explanatory theory building is a clear strength. The integration of local stakeholders (Local Reference Group and expert panel) is particularly valuable and consistent with realist principles of theory refinement through practitioner knowledge. Is it possible to add more information about the MFA trainers, participants and expert trainers. For a non-UK reader this is not clear. Please add some more information about the experts to enhance validity and relevance. Some terms could be defined more precisely. For instance, ‘staff wellbeing’ is used broadly. Clarifying whether this refers to psychological wellbeing, burnout, mental distress, organizational outcomes, or a combination would sharpen the analytical focus. Although realist reviews are not outcome-centric in the traditional sense, the protocol lists several operational indicators (e.g., absenteeism rates, health checks, percentage trained). These metrics risk framing MHFA in primarily instrumental or managerial terms. It may be helpful to: distinguish between proximal outcomes (e.g., confidence to provide peer support, stigma reduction), intermediate outcomes (e.g., help-seeking behaviour, psychological safety), distal organisational outcomes (e.g., absenteeism, retention). This layered outcome logic could strengthen the program theory and prevent conflating mechanisms with endpoints. The use of a PICO structure to guide searching is understandable for transparency, but it sits somewhat uneasily with realist logic. PICO tends to imply intervention–outcome testing (and pragmatically used for systematic reviews), whereas realist synthesis is theory-led and mechanism-focused. Consider clarifying inclusion decisions more theory-driven. Without this clarification, the criteria (e.g., limiting to staff who participated MHFA, or requiring certain outcomes) may inadvertently exclude conceptually rich studies that inform mechanisms but do not report predefined metrics. Restricting settings to ‘acute hospitals participating in MHFA training for two years or more’ may unintentionally narrow the explanatory potential of the review. Realist reviews often benefit from conceptual heterogeneity, including studies from adjacent contexts that illuminate mechanisms. The authors might reflect on whether: shorter implementations, other healthcare or organisational settings, or broader workplace MHFA applications could provide transferable insights into mechanisms. A slightly more permissive approach could enrich theory development. The description of synthesis is appropriate but could be made more explicit. For example: How will CMO configurations be documented (software, templates, coding framework)? Will coding be double-checked or discussed collaboratively? How will disagreements about inferred mechanisms be resolved? Providing these operational details would enhance methodological transparency. The protocol mentions “realist hunches,” CPTs, and IPTs, which is consistent with realist language. However, the process could be described more concretely. A brief illustrative example of a potential CMO hypothesis (even hypothetical) would help readers unfamiliar with realist work to understand how theories will be articulated and refined. Minor suggestions: Ensure consistent terminology (MHFA programme vs training vs intervention). Check citation formatting and typographical accuracy. Avoid over-assertive claims about “evidence-based” status unless clearly specified. Consider a short reflexivity statement describing the team’s positioning, particularly given local implementation links. Overall, this is a thoughtful and promising study that is likely to make a meaningful contribution to both implementation science and mental health research. with modest refinements the protocol will provide a robust foundation for a high-quality realist review. Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise mental health research I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (1) Author Response 03 Apr 2026 Sean Paul Teeling, UCD School of Nursing and Midwifery and Health Systems, University College Dublin, Ireland, Dublin, Ireland Dear Dr Desmet Sincere thanks for the constructive suggestions provided. These comments were extremely helpful in strengthening the clarity and methodological transparency of the study. In response, several revisions have been made throughout the manuscript. Additional detail has been added to clarify the composition and roles of both the Local Reference Group and the Expert Panel. These sections now outline the inclusion of MHFA programme participants, accredited MHFA instructors involved in programme delivery, and staff responsible for organisational wellbeing initiatives within hospital settings, alongside academic researchers with recognised expertise in realist methodology and organisational wellbeing (Lines 81–84; 93–98). The introduction has also been revised to provide a clearer definition of staff wellbeing within hospital contexts, specifying that it refers to psychological wellbeing and related workplace experiences such as burnout-related strain, psychological safety, mental distress and perceived organisational support. Workplace culture is clarified as a contextual influence that may shape how programme mechanisms operate, rather than as a standalone outcome (Lines 11–16). In response to your observation that outcomes were framed too narrowly in managerial or metric-driven terms, the outcomes section has been revised to distinguish between proximal, intermediate and distal outcomes. This layered structure supports realist programme theory development by recognising that interventions may produce different types of outcomes across stages of implementation and organisational influence (Lines 125; 127–132). Your observation regarding the rigidity of the original PICO structure was also particularly helpful. The manuscript now clarifies that PICO is used only to structure the initial search strategy and that the review will follow an iterative, theory-led searching process consistent with realist methodology, allowing further purposive searches to explore emerging contextual and mechanistic explanations as programme theories develop (Lines 133–138). In addition, the restriction to acute hospital settings has been relaxed to allow inclusion of studies from adjacent healthcare contexts where they provide transferable explanatory insight relevant to hospital staff wellbeing (Line 125). To further support methodological clarity, a brief illustrative Context–Mechanism–Outcome example has been added to the introduction to demonstrate how provisional programme theories may be articulated and refined during the review process (Lines 43–47). Finally, a reflexivity statement has been included in the methods section outlining the research team’s background in healthcare improvement and organisational wellbeing research and describing the reflexive processes that will be used to support interpretive rigour, including team discussion, expert panel adjudication and stakeholder engagement during programme theory refinement (Lines 203–214). All revisions have been highlighted in yellow in the revised manuscript and the relevant line numbers have been provided above to assist the reviewer in locating the changes. We are grateful for your constructive feedback, which has helped strengthen the explanatory focus and methodological coherence of the protocol and ensures that the review is positioned to generate programme theories that can inform how and under what conditions MHFA may contribute to staff wellbeing across healthcare settings. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Desmet K. Peer Review Report For: A Realist Review Protocol on the Contribution of a Mental Health First Aider Programme to Staff Health and Wellbeing within an Irish Hospital Network [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2026, 9 :7 ( https://doi.org/10.21956/hrbopenres.15761.r53127) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. 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