Symposium 16: Realist synthesis – methodology and application

Symposium lead and chair: Bridie Kent, Associate Professor/ Director of Clinical Nursing Research, Nursing, The University of Auckland, Auckland, New Zealand b.kent@auckland.ac.nz

Symposium chair: Dr Bridie Kent, Associate Professor/ Director of Clinical Nursing Research, University of Auckland, New Zealand

Symposia focus

The four presentations within this symposium explore different aspects of Realist Synthesis, which is a methodology that has been developed by Pawson and colleagues (1997, 2002, 2005) to reflect the emerging ‘realist’ approach to evaluative research.

The symposium content arises from the experiences of an international team of researchers, from six countries across three continents, who are involved with knowledge utilisation for nursing practice. It will be chaired by one of the team, Associate Professor Bridie Kent.

The four papers in this symposium will explore:

  • an overview of the methodology
  • the application of Realist Synthesis to evidence implementation strategies
  • searching and retrieval of evidence by an international team
  • other process issues to assist others utilising this methodology.

Source of funding: N/A

Level of funding: N/A

Abstract one: What is realist synthesis?

Dr Gill Harvey Senior Lecturer in Health care and Public Sector Management, Manchester Business School, University of Manchester & Professor Brendan McCormack, Professor of Nursing Research, School of Nursing, University of Ulster.

Realist synthesis is a method for studying complex interventions using diverse bodies of data and is underpinned by realist/theory-led evaluation methodologies; realism positions itself between the positivist and constructivist approaches. It provides a complementary, approach to traditional effectiveness reviews and is particularly suited to reviews of more complex social interventions. This methodology encourages wider inclusion criteria, enabling data from qualitative studies, case studies and other research designs including RCTs to be included in the analysis. The focus of a realist synthesis is a review of complex social interventions e.g. policy, management, service delivery. The review takes place at the level of theories that underpin complex interventions with an explanatory focus; seeking answers to the question ‘What works, for whom, in what circumstances, in what respects and why?’

The characteristics of complex social interventions are:

  • consists of theories
  • involves actions of people
  • consists of a chain of steps or processes that interact
  • constituent steps and processes that are rarely linear
  • embedded in social systems
  • prone to modification
  • open systems that change through learning (Pawson et al, 2005).

This approach has flexibility coupled with rigour. It also has the capacity for providing detailed and practical recommendations. This first paper in the symposium will explore in more detail this new approach, how it has been used to date to synthesise research, its strengths and its limitations.

References

  • Pawson R. 2002. Evidence-based policy: the promise of realist synthesis. Evaluation, 8 (3): 340-358
  • Pawson R, Greenhalgh T, Harvey G, Walshe K. 2005. Realist review – a new method of systematic review designed for complex policy interventions. Journal of Health Services Research and Policy, Supplement 1: 21-34
  • Pawson R, Tilley N. 1997. Realistic Evaluation. Sage Publications: London

Abstract two: Using realist synthesis in practice

Dr Bridie Kent, Associate Professor/Director of Clinical Nursing Research, School of Nursing, University of Auckland & Dr Jo Rycroft-Malone, Reader, School of Healthcare Sciences, Bangor University

This paper builds on the first by exploring the application of realist synthesis to review the evidence associated with implementation strategies for Knowledge Utilisation (KU). This project has arisen from the work undertaken by twelve leading scholars and practitioners in the field of knowledge utilisation in health care. It is an international collaboration involving universities in NZ, Australia, USA, Canada, Sweden and the UK.

The aim of the project was, and still is, to synthesis the research related to strategies and interventions used in the field of evidence based healthcare using realistic synthesis, rather than a traditional systematic review methodology.

There is existing systematic review evidence (Foxcroft & Cole 2003, Grimshaw et al 2004, Thompson et al 2007) that provides some indications for successful implementation strategies such as facilitative approaches, feedback, and education. However, there are some limitations that include equivocal findings that do not necessarily relate to the professional practice of all practitioners; the use of behaviour change as an outcome measure; and a lack of acknowledgement about complexity and context. Therefore the team decided to use a different lens to increase understanding about what is working and what is not working in different contexts (& levels) and with different stakeholders. The review was intended to address meaningful questions and be theoretically driven. The question driving the review was ‘What are the interventions and strategies that are effective in enabling evidence informed health care?’ Details of how realist synthesis methodology was applied to address this question will be discussed, together with some preliminary findings.

References

  • Foxcroft DR, Cole N. Organisational infrastructures to promote evidence based nursing practice
  • Cochrane Database Systematic Reviews. 2003;(4):CD002212
  • Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay CR, Vale L, Whitty P, Eccles MP, Matowe L, Shirran L, Wensing M, Dijkstra R, Donaldson C. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technolology Assessment. 2004 Feb;8(6):iii-iv, 1-72
  • Thompson DS, Estabrooks CA, Scott-Findlay S, Moore K, Wallin L. 2007. Interventions aimed at increasing research use in nursing: a systematic review. Implementation Science, 11;2:15

Abstract three: Searching and retrieval of evidence by an international team

Dr Bridie Kent, Associate Professor/Director of Clinical Nursing Research, School of Nursing, University of Auckland

This paper focuses on the collection of the evidence in realist synthesis, particularly that which has been undertaken by the international team to answer the question: ‘What are the interventions and strategies that are effective in enabling evidence informed health care?’ Realist synthesis adopts a generative approach to causation to uncover the underlying reasons, or theories offered by interventions that generate practice or behaviour change (Pawson 2002). Therefore the scope of the evidence search is, by necessity, wider than with traditional effectiveness reviews. The international nature of the team posed significant challenges for the successful completion of the search and retrieval process. Searching was undertaken in stages to that allowed the team to firstly get a ‘feel’ for the literature and from there, identify key programme theories (and refine inclusion criteria). These were then discussed in the team to facilitate limited testing followed by further refinement. The literature was searched across policy domains using a broad, not discipline-specific approach, corresponding to healthcare in general. Approximately 39 lines of search text were used with Boolean operators exploring six online databases (1997-2007): (Medline, CINAHL, Embase, PsycInfo, Sociological Abstracts, Web of Science) as well consulting with Health Sciences Librarians (Dalhousie University, McMaster University). The search strategies were run March 5, 2007 in OVID. A final search for additional studies will be undertaken when the review is nearing completion. The search results were subsequently shared among the international team in order to facilitate retrieval, followed by data extraction and review. In a large geographically dispersed team, this presented some interesting challenges which will be discussed along with the strategies used to ensure that this part of the realist synthesis review was successful.

References

  • Pawson R. 2002. Evidence-based policy: the promise of realist synthesis. Evaluation 8 (3): 340-358

Abstract four: Other process issues to assist others undertaking this systematic review approach

Professor Brendan McCormack, Professor of Nursing Research, School of Nursing, University of Ulster & Dr Jo Rycroft-Malone, Reader, School of Health care Sciences, Bangor University

The application of realist synthesis to address a complex social intervention in healthcare posed a number of challenges to the team of international researchers that needed to be overcome. These will be discussed in this last part of the symposium to assist others who might be contemplating using this methodology. Despite its emerging status, realist synthesis has been used to explore complex issues in health care ranging from the examination of how delays in breast cancer diagnosis and treatment currently are conceptualised (Angus et al 2006), to evidence associated with practice development (McCormack et al 2007) and healthcare education (Attree 2006). Some of the issues raised in this final part of the symposium reflect the challenges of team-working at a distance while others will be more general in nature. They include methodology questions such as asking the right question to get the literature, search terms, the volume of literature found, decisions around the refinement process, the specifics of inclusion or exclusion criteria for realist synthesis and the process of analysis given that few of the team could work together in person due to distance. The successes will be discussed, along with the strategies used to overcome these challenges.

References

  • Angus J, Miller KL, Pulfer T, McKeever P. 2006. Studying delays in breast cancer diagnosis and treatment: critical realism as a new foundation for inquiry. Oncology Nursing Forum, 33(4):E62-70
  • Attree M. 2006. Evaluating healthcare education: Issues and methods. Nurse Education Today, 26(8): 640-646
  • Research and review McCormack B, Wright J, Dewar B, Harvey G, Ballantine K. 2007. A realist synthesis of evidence relating to practice development: methodology and methods. Practice development in Health Care, 6(1):5-24.