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A realistic evaluation : the case of protocol-based care

By Jo Rycroft-Malone, Maria Fontenla, Debra Bick and Kate Seers


Background\ud 'Protocol based care' was envisioned by policy makers as a mechanism for delivering on the service improvement agenda in England. Realistic evaluation is an increasingly popular approach, but few published examples exist, particularly in implementation research. To fill this gap, within this paper we describe the application of a realistic evaluation approach to the study of protocol-based care, whilst sharing findings of relevance about standardising care through the use of protocols, guidelines, and pathways.\ud \ud Methods\ud Situated between positivism and relativism, realistic evaluation is concerned with the identification of underlying causal mechanisms, how they work, and under what conditions. Fundamentally it focuses attention on finding out what works, for whom, how, and in what circumstances.\ud \ud Results\ud In this research, we were interested in understanding the relationships between the type and nature of particular approaches to protocol-based care (mechanisms), within different clinical settings (context), and what impacts this resulted in (outcomes). An evidence review using the principles of realist synthesis resulted in a number of propositions, i.e., context, mechanism, and outcome threads (CMOs). These propositions were then 'tested' through multiple case studies, using multiple methods including non-participant observation, interviews, and document analysis through an iterative analysis process. The initial propositions (conjectured CMOs) only partially corresponded to the findings that emerged during analysis. From the iterative analysis process of scrutinising mechanisms, context, and outcomes we were able to draw out some theoretically generalisable features about what works, for whom, how, and what circumstances in relation to the use of standardised care approaches (refined CMOs).\ud \ud Conclusions\ud As one of the first studies to apply realistic evaluation in implementation research, it was a good fit, particularly given the growing emphasis on understanding how context influences evidence-based practice. The strengths and limitations of the approach are considered, including how to operationalise it and some of the challenges. This approach provided a useful interpretive framework with which to make sense of the multiple factors that were simultaneously at play and being observed through various data sources, and for developing explanatory theory about using standardised care approaches in practice.\ud \u

Topics: R1
Publisher: BioMed Central Ltd.
Year: 2010
OAI identifier: oai:wrap.warwick.ac.uk:3293

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  1. (2008). A Context of Uncertainty: How context shapes nurses' research utilization behaviours. Qualitative Health Research doi
  2. (2000). A: Legitimating of Nurses' Knowledge Though Policies and Protocols in Clinical Practice. doi
  3. (2006). A: What is protocol-based care? A concept analysis. doi
  4. (2002). Agency & National Institute for Clinical Excellence: Protocol-based care underpinning improvement - what is protocol-based care?
  5. (1993). Applications of case study research Thousand Oaks,
  6. Bucknall T: Models and Frameworks for Implementing Evidence-Based Practice: Linking Evidence to Action doi
  7. (2000). Care pathways: an evaluation of their effectiveness. doi
  8. (1994). Case study research. Designs and methods 2nd edition. Thousand Oaks CA: Sage;
  9. (2010). Cite this article as: Rycroft-Malone et al., A realistic evaluation: the case of protocol-based care Implementation Science doi
  10. (2007). Cormie P: Developing a managed clinical network in palliative care: a realistic evaluation. doi
  11. (2006). Critical Realism as emancipatory action: the case for realistic evaluation in practice development. Nursing Philosophy doi
  12. (2003). Critical realism: A way forward for evaluation research in nursing? doi
  13. (2009). Effectiveness of strategies to encourage general practitioners to accept an offer of free access to online evidence-based information: a randomised controlled trial. Implementation Science doi
  14. (2002). Estabrooks C: Ingredients for Change: Revisiting a conceptual model. Quality & Safety in Health Care doi
  15. (2009). Estabrooks CA: Study protocol for the translating research in elder care (TREC): building context through case studies in long-term care project (project 2). Implementation Science doi
  16. (2009). European Commission Working Time Directive: [http://ec.europa.eu/ social/main.jsp?catId=706&langId=en&intPageId=205]. (accessed 9
  17. (2006). Evidence-Based Policy: a Realist Perspective London: Sage; doi
  18. (2008). Evidence-informed practice: From individual to context. doi
  19. Fizgerald L: Knowledge to Action Oxford: doi
  20. (1999). Health: Making a Difference: strengthening the nursing, midwifery and health visiting contribution to health and healthcare doi
  21. (1997). Health: The New NHS. Modern. Dependable doi
  22. (2009). How do you modernize a health service? A realist evaluation of whole scale transformation in London. Milbank Quarterly doi
  23. (2003). I: Evaluating change in health care practice: lessons from three studies. doi
  24. (2006). ICEBeRG Group: Designing theoretically-informed implementation interventions. Implementation Science
  25. (2009). Institutionalizing evidence-based practice: an organizational case study using a model of strategic change. Implementation Science doi
  26. (2004). Kyriakidou O: Diffusion of Innovations in Service Organisations: Systematic Review and Recommendations. The Milbank Quarterly doi
  27. (2002). Locock L: No magic targets! Changing clinical practice to become more evidence based. Health Care Management Review doi
  28. (2009). P: A randomized controlled trial evaluating the impact of knowledge translation and exchange strategies. Implementation Science doi
  29. (2004). Protocol-based care: The research agenda. Nursing Standard doi
  30. (2008). Re-mapping client journeys and professional identities: A review of the literature on clinical pathways. doi
  31. (2005). Realist review - a new method of systematic review designed for complex interventions. doi
  32. (2004). Realist synthesis: an introduction. doi
  33. (2008). Seers K: Protocol-Based Care Evaluation Project. Final Report for the National Institute for Health Research Service Delivery and Organisation Programme doi
  34. (2008). Seers K: Protocol-based care: Impact on roles and service delivery. doi
  35. (1997). Social Science: Beyond Constructivism and Realism doi
  36. (2000). The NHS Plan: A Plan for Investment. A Plan for Reform doi
  37. (2007). Theory and Knowledge Translation: Setting some coordinates. Nursing Research doi
  38. (1997). Tilley N: Realistic evaluation London: Sage; doi
  39. (2004). Titchen A: An exploration of the factors that influence the implementation of evidence into practice. doi
  40. (2002). Titchen A: Getting Evidence into Practice: The meaning of 'context'. doi
  41. (2004). Using qualitative methods for causal explanation. Field Methods doi
  42. (2005). Using realistic evaluation to evaluate a practice level intervention to improve primary healthcare for patients with long term mental illness. Evaluation doi

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