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The performance of healthcare organisations with their considerably complex structures is often on the agenda due to limited resources. Service quality, commonly assessed using the SERVQUAL scale, represents a key performance dimension in healthcare delivery. This paper aims to investigate the extent of meeting the expectations in health service provision in Turkiye and countries in Asia. We searched electronic databases, namely Web of Science, Google Scholar, PubMed, and Turkish Council of Higher Education National Thesis Centre, to find relevant and accessible English and Turkish studies published until 1 January 2023. Eligible studies were empirical research conducted in healthcare settings using the SERVQUAL scale and reporting expectation-perception gaps. Mean differences with 95% confidence intervals were calculated. Heterogeneity was assessed using the I2 and τ2 statistics, and publication bias was evaluated using funnel plots and Egger's test. A total of 47 studies (N = 13,581) were included. The highest quality gap occurred in the responsiveness (0.59) and reliability (0.54) dimensions. Patients had high levels of expectations from healthcare organisations in all five subdomains examined for both Turkiye and other Asian countries. Highly significant quality gaps in the examined domains emphasise the need for improvements in appropriate and quality service delivery and the implementation of compassionate patient-centred approaches. We have concluded that healthcare managers and decision-makers should regularly monitor the quality level of provided healthcare services, find the gaps that need to be improved, and better understand how client expectations in healthcare might be shaped in different settings and countries. Limitations include the restriction to English and Turkish languages, the cross-sectional design of studies, and variability in hospital settings. No protocol was registered.

The new generation of network information technology has become a significant tool to promote public health. The application of information and communication technology (ICT) in the traditional medical industry has changed the medical service model, improved the public medical service system, and provided diversified medical services to the public. This paper discusses the impact of ICT on residents' health, and analyzes the possible heterogeneity impact in different groups and its impact mechanism using the China Family Panel Studies (CFPS) data and a fixed-effects model. The ordinary least squares estimation method was adopted to quantitatively identify the impact mechanism of ICT applications on residents' health. Multisource big data were collected, including the CFPS questionnaire (gender, age, marriage status, work status, income level, smoking, sports, and insurance participation), regional economic development, as well as service industry development. The quantitative phase involved conducting in-depth investigation across 25&#xa0;Chinese provinces. Then, a quantitative analyse-based study empirically tested the effects of internet applications on residents' health by matching macro data and micro survey data. After controlling for these identified factors, the data were tested using ordinary least squares and fixed effect models, with the assistance of STATA version 14 to measure and validate the proposed model. The regression results support the conclusion that ICT can significantly improve residents' health (p&#xa0;<&#xa0;0.001). After a series of robustness tests through replacing explanatory variables and choosing appropriate exogenous policy shocks, the results still hold. We analyse the possible heterogeneous effects and conclude that the health-promoting effect of ICT is stronger among middle-aged individuals, high-income groups, women, urban residents, unmarried individual, those who engage in sports and non-smokers. Our study confirms a significant association between ICT applications and residents' health and reveals substantial heterogeneity in this effect. It also provides insights into how to apply internet information to better realise disease surveillance and prevention goals.

Health promotion policy is an effective way to improve population health and reduce the burden of chronic disease, yet how implementation of health promotion at policy levels occurs within healthcare remains unclear. Healthcare organizations, on the one hand, aim to improve population health and 'upstream' health determinants through the Quintuple Aim, but, on the other, are complex and dynamic organizations, with a particular emphasis on downstream clinical care services. Many types of practitioners interpret health promotion policies within the healthcare setting and must implement them in their everyday work: policy implementation as an everyday occurrence. Healthy eating policies focused on creating supportive food environments (e.g.,&#xa0;cafeterias, cafes) are being adopted by healthcare organizations as a way to improve diets and reduce the burden of chronic disease. An examination of healthy eating policy implementation is essential to better understand how health promotion is integrated into healthcare organizations. This qualitative phenomenological study uses organizational social theory on street-level bureaucrats to interpret the implementation of a healthy eating policy within healthcare food retail services and the relationships between street-level bureaucrats. We conducted 12 in-depth policy key informant interviews and analysed findings using directed content analysis. The findings showed a shift in priorities from leadership to allocate resources for health promotion tasks to make food more accessible and available to staff. Participants considered context as they implemented the policy using local knowledge arising from informal and formal networks and identified other opportunities to influence healthy eating. Studying the actions of healthcare practitioners in everyday policymaking provides essential context and insight into how policy implementation unfolds. Although standards for health promotion are lacking, practitioners can engage in quality improvement initiatives to challenge the status quo and improve food environments.

Pakistan has hosted Afghan refugees for more than four&#xa0;decades, in one of the world's most protracted displacements of people. Afghan refugees receive health services through United Nations High Commissioner for Refugees (UNHCR) and non-governmental organisation (NGO) supported programmes alongside public sector facilities at every tier. They remain excluded from key national health protection programmes such as the Sehat Sahulat Programme. Understanding the system-level enablers and barriers is essential for advancing equitable and sustainable healthcare for refugees and host populations. An exploratory qualitative case study was conducted using 30 key informant interviews and three participatory Group Model Building (GMB) workshops across Khyber Pakhtunkhwa, Sindh, and Islamabad Capital Territory. Data were thematically analysed using a Health System Resilience and Refugee Response Framework. Findings reveal a mixed picture of resilience and fragility. Refugees with Proof of Registration and Afghan Citizen Cards reported using primary care on a par with residents, while high reported immunisation coverage was widely perceived to have reduced polio risk among Afghan refugee children since around 2014, in line with national data showing a sharp decline in wild poliovirus cases over this period. While essential health services are being provided to refugees in the camps, they continue to face critical shortages, including frequent stock-outs of medicines, limited diagnostic capacity, too few trained female healthcare providers, and fragmented referral pathways. Financing remains heavily donor-dependent, with refugees excluded from the Sehat Sahulat Programme, the National Health Insurance programme. Governance challenges, including overlapping mandates, poor coordination, and a lack of refugee-specific data, undermine efficiency and planning. Despite these challenges, community health workers and shared health initiatives fostered social cohesion and equitable treatment in public sector health facilities. Our study demonstrates that inclusive health services can be delivered in Pakistan at scale but cannot be sustained and scaled without broader health system strengthening reforms. The inclusive and resilient refugee health services require embedding refugee health into national strategies, ensuring predictable financing, stronger coordination mechanisms, and integrating refugee data into health management information systems. These findings offer lessons for other host countries managing protracted refugee crises that create substantial challenges for national health-system financing, workforce, and service delivery.

Evidence shows limited use of routine data to support health actions in lower and middle-income countries (LMICs). To address that, there are several ongoing efforts to strengthen routine health information systems which are largely crippled by the fragmented nature of the health system. This scoping review aims to identify the key enablers of routine health data use and examine gaps in the institutionalization of data use practices across different levels of the health system in LMICs. We scoped up four literature sources, that is, PubMed, IEEE Xplore, the Public Library of Science (PLOS), and Google Scholar for the article published between January 2019 and December 2023. Three reviewers independently screened article titles, abstracts, and full text against inclusion and exclusion criteria, following the Arksey and O'Malley and PRISMA framework to guide the review process. We classified our findings into three health system levels: that is facility, district, and national/sector-wide. Out of 380 screened articles, 41 were selected for inclusion, where most of the articles (48.8%), were on the health facility level. The study found that factors influencing the use of routine data vary across health system levels, with human resource capacity and friendly data collection tools being more important at the facility level. In contrast, the availability, and capacity to use analytical tools and governance structures were more reported at the district and national levels. Further, capacity building in health information systems, IT infrastructure, and regular supervision were crucial across all health system levels. We argue for focused interventions to be designed to institutionalise routine data use practices for better healthcare outcomes across health system levels.

The Eastern Mediterranean Region (EMR) of the World Health Organisation (WHO) consists of 22 countries and territories which are exposed to high levels of natural and man-made emergencies, and which have significant gaps in coverage of essential health services. Narrow fiscal space, economic distress, periodic shocks of conflicts, pandemics and natural disasters, and sharp declines in development assistance, are factors contributing to gaps in access to essential health services. The region receives development assistance from a range of development partnerships, which, although contributing to improved programme coverage and disease prevention, has been limited in developing and sustaining longer term health system capabilities. The increasing threats of conflict, pandemics and climate-related natural disasters, as well as the recent sharp downturns in development assistance, builds the case for more effective, efficient and equitable development assistance programming. Development assistance principles of alignment of health partnerships with sector priorities and building of country systems provide opportunities to sustainably address chronic health coverage and equity challenges, improve the capability of health systems to withstand periodic shocks, and sustain health programme improvements over longer time frames. In this paper, we describe how these principles are being applied in the region through country health compacts for universal health coverage, country and regional coordination models, and implementation of monitoring and evaluation of development effectiveness. Given the rapidly changing development landscape, application of development effectiveness principles provides opportunities to strengthen health systems, safeguard health security, and progress towards universal health coverage.

Humanitarian settings face a growing healthcare workforce crisis marked by staff shortages, unsafe working conditions, and limited professional development. Despite being critical intermediaries in outbreak responses, demands on health workers come at a substantial cost to their health and wellbeing. Research on health workers responding to the Rohingya refugee crisis in Cox's Bazar, Bangladesh, is limited. Focussing on health systems "software" (relationships between people and structures), this study explores health workers' interactions with different levels of governance structures, including humanitarian response governance, the health sector coordination leadership team, and their affiliated NGO management structures when responding to disease outbreaks in the camps, particularly during COVID-19. Qualitative research consisted of 33 interviews and 4 data validation workshops with frontline health workers, and 13 key informant interviews with humanitarian stakeholders. Health workers' dependence on government camp authorities for their safety and public health enforcement produced complex relationships and sometimes compromised medical practices and professional support. Through the support of the health sector leadership team, infection prevention and control training was perceived as a key strength; however, health workers reported limited inclusion in decision-making and being professionally unprepared during outbreaks. These experiences compounded risks to their mental and physical health, and they reported receiving minimal organisational support. These relational and structural tensions undermined worker resilience and patient-provider trust. The findings underscore the need for outbreak preparedness and strategic reforms in humanitarian decision-making that prioritise health workers' safety, promote inclusiveness in decision-making, and embed sustained professional support in humanitarian health systems for future outbreaks.

Decentralisation is the transfer of authority from central to local governments, involving shared responsibilities in planning, management, and decision-making. In public health, decentralisation might help improve service delivery by allowing local authorities to tailor interventions to the specific needs of diverse, geographically dispersed communities. However, no systematic review has been done on the state of knowledge regarding the capacity of local governments to influence the emergence and operation of national public health programmes in Marxist-Leninist single-party states. Following the PRISMA protocol, 859 articles from the PubMed, EMBASE and Web of Science databases were examined. To be selected, studies had to be conducted in a Marxist-Leninist single-party country with a centralised economy and focused on the question of the condition of power sharing between government levels in the design and implementation of specific public health programmes. Only articles in English published between 2013 and 2023 were considered, resulting in 18 studies. Their quality was assessed using the MMAT 2018 and SANRA tools. Limited resources and the Party's fundamental ideology may constrain the extent of power sharing influencing local government empowerment. However, factors such as the Party's local unit engagement, collaboration with external organisations, and use of digital communication platforms enhance the capacity of local government to participate in public health programmes design and execution. Despite a politically centralising structure, one-party countries can, under certain circumstances, share responsibilities across government levels in order to increase the adequacy of programmes to meet the health needs of the population.

The COVID-19 pandemic has not only revealed pre-existing vulnerabilities in global health systems and imposed heavy costs on countries worldwide, but also exacerbated existing disparities. These institutional and financing limitations were part of the development strategy, which did not adequately accommodate the health risks accompanying the outbreak of the virus. This disruption has ongoing implications for access to healthcare and treatment, particularly in economically disadvantaged and marginalised communities. This study documents the spatial spillover and threshold effects of health development assistance per capita (HDApc) and health expenditure (HEAEXP) on health-related outcomes (HROs) in Sub-Saharan Africa (SSA), which is a potential vector of the dissimilation of viruses. The study utilises panel data from 38 SSA countries spanning the period from 2000 to 2021. Employing the fixed effect (FE), fixed effect spatial Durbin Model (FE-SDM) and the threshold methods, and adding immunisation rate, GDP per capita growth and democracy as additional variables, this study finds that (1) HDApc and HEAEXP significantly improve the health status of the population, (2) HDApc and HEAEXP have a favourable spatial effect as both significantly reduce the under-five mortality rate, infant mortality rate, age-standardized deaths from infectious diseases, and the death rate in neighbouring countries, (3) HDApc has a double threshold effect on HROs and that its effect on the HROs is higher at higher threshold level of 12%.

This study aimed to develop and psychometrically validate the Medical Brain Drain Attitudes Scale (MBDAS) to measure attitudes towards the conditions underlying medical brain drain. The final scale was also used to describe the attitudinal pattern observed in the study sample. During the scale development process, we generated the item pool and examined face and content validity. We then conducted exploratory factor analysis using data from 246 clinical and intern medical students. Next, we performed confirmatory factor analysis and tested the convergent, discriminant, and criterion validity with a further sample of 560 participants. We assessed reliability using Cronbach's alpha, item analysis, upper-lower 27% group comparisons, and test-retest analysis with 87 participants. Once the final scale was established, we calculated mean values for its dimensions in the study sample. The final scale comprised a total of 18 items within six dimensions: Earnings and Living Standards (ELS), Professional Safety and Fairness (PSF), Professional Prestige (PP), Workload and Duty (WD), Career and Development (CD), and SocioPolitical Climate (SPC). Factor analyses supported this structure and confirmatory analysis indicated acceptable model fit. Analyses of validity and reliability confirmed the psychometric adequacy of the MBDAS. In the study sample, mean values across the scale dimensions were high or very high. The MBDAS enables attitudes towards emigration to be examined multidimensionally on the basis of the conditions associated with physician emigration. The scale serves as a quantitative assessment tool that extends beyond the commonly used binary push-pull framework. In this study's sample, the highest mean values were observed in relation to economic conditions, violence in healthcare settings, the functioning of the health system, and workload conditions.

The lack of healthcare trust is strongly associated with low rates of access and utilization of care, adherence to medical advice, and adverse health outcomes, especially among vulnerable populations. We used a descriptive qualitative design and employed thematic analysis to examine the contributing factors to the lack of trust in healthcare among African immigrants in Florida, US. We conducted in-depth interviews with 19 participants selected through purposive and snowball sampling. The interviews were audio-recorded, transcribed verbatim, and thematically analysed using Nvivo14 software. The findings revealed two overarching themes: (a) personal and (b) institutional factors of lack of healthcare trust. Personal factors included language and communication challenges, lack of knowledge, past negative healthcare experiences, fear of losing legal status, and the use of traditional medicine and prayer as a substitute for modern medicine. Institutional factors included providers' lack of knowledge, wrong assumptions and ignorance, lack of diversity in healthcare, repeated tests and burdensome documentation, malpractice, lack of financial transparency and unfair cost, over-medicalisation, racial divide and discrimination, and unfavourable policy conditions. The findings suggest a holistic approach that involves improving healthcare navigation skills among African immigrants; adopting a patient-centred approach; enhancing health literacy; strengthening cultural competency training and education on tropical medicine for healthcare providers; promoting diversity within the healthcare workforce; and engaging in anti-racism practices that ensure provider accountability. It is also critical to promote policies that ensure financial transparency and coordinated care, reduce unnecessary testing and documentation, and promote safe and equitable access to healthcare for African immigrants.

Time savings in prehospital emergency medical services are vital for human life. Ensuring that these services can meet potential demands is essential for successful delivery. This study aimed to forecast the demand for ambulance services within prehospital emergency medical services and to plan the capacity of ambulance stations. In this descriptive, cross-sectional, and analytical study, the population consists of 943,412 cases directed by 139&#xa0;ambulance stations in the capital of T&#xfc;rkiye. The forecasting was carried out at the district level with a particular focus on seven districts. Various forecasting methods such as Holt-Winters, ARIMA, MLP, NNAR, and LSTM were employed. The optimal number of ambulances required at various stations to meet response time targets was identified using Monte Carlo simulations to account for uncertainties in call volumes and response times. A total of 943,412 calls were directed to ambulances. The annual distributions showed slight increases each year. Forecasting performance of various methods was evaluated based on RMSE, MAE, and MAPE metrics, with the ARIMA and NNAR models generally showing the best performance. The study also identified the optimal number of ambulances required at various stations to meet response time targets. The study underscores the importance of accurate demand forecasting and capacity planning for ambulance services in ensuring timely and effective prehospital emergency medical services. By addressing critical response time targets and optimising ambulance capacity, the findings contribute to improving the quality and accessibility of emergency health services, ultimately enhancing human life and health outcomes.

In Latin America, indigenous populations' access to sexual and reproductive health services is burdened by ideological neocolonial practices. Qualitative information was collected in three Latin American countries regarding barriers to sexual and reproductive healthcare access for indigenous populations. Three types of informants were interviewed: pregnant women, health care providers, and key actors. In the three countries studied, we found some similarities in the social and cultural context of indigenous communities that represent the greatest barriers to guarantee their access to sexual and reproductive healthcare. The similarities revolve around three main themes: roots of inequalities, access to health services, and interculturality. The determinants of indigenous women's access to public sexual and reproductive healthcare services in the three countries are articulated in a complex set of factors. Traditional beliefs about pregnancy, delivery care practices, and newborn care differ significantly from the biomedical perspective of healthcare workers. The latter can be understood as a historical mechanism of colonization and allows understanding the conflictive relationship of indigenous groups towards institutional care practices. The knowledge and beliefs of indigenous cultures bolster their own ways of understanding and caring for sexual and reproductive health and need to be respected to provide them with appropriate healthcare suited to their needs.

The global refugee population has nearly doubled in the last decade, and many of these populations face chronic displacement, often in neighbouring countries with limited resources. Emergency, short-term responses are being transitioned to longer term approaches, including a focus on inclusion through coverage in national health systems. However, analysis of empirical and comparative evidence on how to enact these approaches has been limited. In this article, we analyse the inclusion of refugees in six low and middle-income country (LMIC) health systems (Kenya, Kurdistan Region of Iraq (KRI), Mauritania, Pakistan, Peru and Zambia). Using a shared framework and tools, we collected data over 2023 to 2025, using document reviews, key informant interviews, focus group discussions and participatory workshops. Analysis was carried out separately for each setting, validated locally, and later compared for synthesis. We focus on key health system domains-governance, health financing, service delivery (including the health workforce) and health information systems-outlining the attributes of refugee inclusion and system integration in each, identifying patterns across the case studies and barriers and enablers. We identify leverage points for improving integration but highlight that inclusion of refugees into national health systems is complex and does not guarantee improved outcomes, especially when refugees previously benefited from a higher level of resources and are being included in strained host health systems. However, committed government leadership, coordinated international support, and multi-year investments in strengthening key components of the local health system, including enabling refugee health staff to engage effectively in it, can make the transition to an integrated system a beneficial one for both refugee and host communities.

This study investigates the role of complementary clusters of human resource management (HRM) practices in explaining the persistent productivity variations across English NHS hospitals. While prior research has highlighted the importance of individual HRM practices, their impact is often indeterminate. A critical gap remains in the systematic analysis of complementarity, non-linearity, and the interdependencies between these practices. To address this gap, we draw on complementarity theory to propose and test a novel framework. This framework posits that hospital performance is shaped by three distinct effects: indeterminacy, where isolated practices have an inconsistent impact; non-linearity, where practices are effective only above a certain intensity threshold; and complementarity, where synergies between practices amplify their collective impact. We use this framework to explain the significant productivity dispersion observed across hospitals. Using panel data from English NHS hospitals, we employ machine learning techniques to identify distinct HRM clusters and test their significance using correlated random effects models. Our findings confirm that individual HRM practices often have no significant effect until their intensity surpasses a critical threshold. Crucially, we identify several distinct complementary clusters involving incentives, workplace flexibility, training, team quality, and job design. High-performing hospitals are distinguished by their adoption of these synergistic bundles-such as combining job design, team quality, and incentives-whereas persistent low performance is linked to the adoption of incomplete clusters. For instance, workplace flexibility or training only boosts productivity when supported by an effective incentive system, underscoring the powerful non-linear and interdependent effects at play. This study advances the HRM and healthcare management literature by systematically demonstrating the non-linear and complementary nature of HRM practices and by introducing data-driven methods for their analysis. The key implication for policymakers and hospital administrators is the need to prioritise bundles of complementary practices and holistic organisational change over isolated, piecemeal initiatives.

Reflection and learning about the use of virtual care in healthcare delivery has become a central goal for health systems internationally. Insights drawn in the aftermath of the COVID-19 pandemic have led to vast changes to embed virtual care in health care delivery. This study explored the methodologies used to manage change that encompasses virtual care and factors contributing to success. A systematic review and narrative synthesis was undertaken. Eligible articles were those reporting structured change management processes in the context of virtual care published between 1st January 2019-31st December 2023, identified by searching four electronic databases (Scopus, MedLine, PsycInfo and Business Source Premier). Data were extracted and synthesised from the eligible studies. Seventeen studies met inclusion criteria describing changes occurring within hospital settings or in community health centres. Kotter's 8-Step Model was the most frequently applied change framework, often combined with other approaches. Commonly enablers included high quality communication among all parties involved and strong leadership. Common barriers included overemphasis on technology at the expense of people and processes, linear application of models, and lack of mechanisms to monitor change progress. Structured change methodologies were often integrated in a strategic change framework with process improvement methods utilised to support the change process. Managing change relating to the technology with attention to the clinical and people aspects of change was considered a key gap and challenge in the context of virtual care change. Change leadership and the integration of technical and clinical teams were identified as key enablers.

As eldercare service platforms (ECSPs) are becoming increasingly popular due to the rapidly ageing population, using only a single pricing strategy has resulted in a mismatch between bilateral users (providers and consumers) in these platforms. To address these challenges, multiple innovative pricing strategies, considering the characteristics of the consumers, service providers, governments, and the private sector should be formulated by governments. Therefore, based on social welfare maximisation, this study develops a concession pricing model for ECSPs that combines different government subsidy methods, platforms' service quality, network externalities, and price elasticity. The results suggest that ECSPs should set a higher price for the group with more significant network externalities and a lower price for the group with more negligible network externalities. The optimal concession price decreases with service quality, while the size of bilateral users increases with service quality. It is further found out that governments should prioritise subsidising eldercare services with a low price elasticity of demand to improve subsidy efficiency, and that their subsidies can expand the size of bilateral users, decrease the concession prices, and improve social welfare. This study contributes to the body of knowledge of public services by proposing a concession pricing model for ECSPs, adding further evidence to the discussion about social and health services in platform. In practice, the findings would be of utmost interest to governments and the private sector that need to make more informed pricing decisions to improve the efficiency of eldercare services provision and maximise platform profit.

Current management of hemostatic consumables is challenged by inefficient inventory control, substantial wastage, and recurrent operational adverse events. The SPD model offers an integrated supply chain approach with strong potential to optimize medical logistics. This study aims to evaluate the impact of the SPD model on cost control and management efficiency in hemostatic consumables. This retrospective study was conducted at a tertiary (Grade A) cancer hospital. Hemostatic consumables managed under the traditional model (January-December 2023) were compared with those under the SPD model (January-December 2024). The SPD model integrated an information technology platform, IoT-enabled smart cabinets, barcode scanning, and a pay-on-consumption settlement mechanism. T-tests and chi-square tests were used to compare the two groups in cost control metrics, management efficiency scores, staff satisfaction, and the incidence of operational adverse events. In terms of cost control, the SPD model demonstrated statistically significant reductions in monthly average hemostatic material expenditure, requisition frequency, expiration loss rate, and reported loss rate (all p&#xa0;<&#xa0;0.05). Regarding management efficiency, the SPD model showed significantly higher scores in timely delivery, work efficiency, standardization, supply traceability, waste recovery, delivery satisfaction, and demand forecasting, while achieving significantly lower scores in item issues and operating costs (all p&#xa0;<&#xa0;0.05). Staff satisfaction surveys revealed significant improvements in operational convenience, clinical reliability, system usability, and overall satisfaction under the SPD model (all p&#xa0;<&#xa0;0.05). Furthermore, the incidence of all documented operational adverse events was significantly reduced under the SPD model (all p&#xa0;<&#xa0;0.05). The SPD model facilitates precise, low-loss, and highly efficient control of hemostatic consumables, representing an effective optimization strategy with considerable clinical benefits and significant potential for widespread adoption. Despite limitations including single-center design and a one-year observation period, future multi-center and longitudinal studies are warranted to validate these findings and assess long-term sustainability.

Canada is committed to supporting internationally educated nurse (IEN) integration into the healthcare system, as a strategy to address post-pandemic nursing shortages. The province of Nova Scotia has emerged as a Canadian exemplar with the development of NICHE (Nova Scotia's International Community of Healthcare Workers Engagement) programme, which anchors intersectoral collaboration between the government, the nursing regulator and healthcare systems in service of streamlining IEN integration. We conducted a province-wide realist evaluation of the integration of IENs into the Nova Scotia healthcare system and community. We collected data from interviews with 24 participants, comprised of IENs and stakeholders at meso- and micro-healthcare system levels. We used a theory-driven approach to data analysis which utilised elements of content analysis, reflective dialogue and the construction of CMOCs (context-mechanism-outcome configurations). We constructed three main CMOCs which highlight facilitators for IEN integration related to (1) the development of adaptive programme pathways for IENs, (2) the critical role of IEN allies and advocates within healthcare systems, and (3) the shift in focus from recruitment to retention. The study findings describe the contextual factors and key mechanisms that promote 'successful' IEN integration which may be useful for leaders and policymakers integrating IENs into their local health human workforce. The findings raise important questions about supporting IEN retention, consistent with the vision for a healthy and sustainable nursing workforce. The findings from this study underscore the need for further evaluation research in on the topic of IENs.