2. Critical Realism and Realist Synthesis Sam Porter School of Nursing and Midwifery March 2016

3. What is real? Domain of RealDomain of Actual Domain of Empirical Mechanisms ✓ Events ✓✓ Experiences ✓✓✓

4. What are causal mechanisms? Causal mechanisms are real Causal mechanisms are multiple Causal mechanisms generate tendencies Causal mechanisms can be natural, social or psychological

5. Health Problems and Healthcare Interventions Health problems are often are the result of a combination of natural, social and psychological causal mechanisms. Healthcare interventions involve the introduction of novel causal mechanisms designed to counter the actions of mechanisms causing health problems.

6. Healthcare Interventions Sometimes health problems can be resolved solely by countering the natural generative mechanisms responsible for them through the introduction of a clinical treatment. e.g. vaccine for infectious diseases. But this is rarely the case. Where human interpretation and behaviour are a significant factor, psychological and social mechanisms come into play. e.g. need for campaigns to encourage uptake of vaccines

7. Complex Healthcare Interventions Complex healthcare interventions consist of a number of components that may act both interdependently and independently (MRC 2002). In realist terms, they consist of a number of multiple generative mechanisms. Typically, they are introduced into open systems, so their social context needs to be considered.

8. Realist Synthesis (or realist reviews) Developed on the basis of realist assumptions discussed above. Not just aimed at whether or not an intervention tends to work, but on: How it works (what natural or social generative mechanisms does it contain that are designed to alter outcomes?) With whom it tends to work (How do the interpretations and choices of the individuals involved influence outcomes?) In what circumstances it tends to work (how does social and cultural context influence outcomes?)

9. Realist Synthesis: Uncovering the theoretical basis of interventions Interventions are grounded in ‘programme theories’ – hypotheses about what is causing the problem and what will be effective in countering those causes. Realist reviews seek to identify programme theories and track and evaluate the programme mechanisms introduced on their basis. The importance of ‘grey literature’ (policy documents, position papers etc.).

10. Realist Synthesis: Taking account of human agency The success or failure of interventions is dependent on the interpretations and actions of the people involved – both those who deliver and who are subject to the intervention. Realist reviews take account of the reasoning, interpretations and choices of the human agent involved. The importance of qualitative research.

11. Realist Synthesis: The complexity of intervention chains Typically, the chain moves from policy architects to healthcare managers to clinicians to clients. Realist reviews examine the integrity of the chains, seeking out factors along the line that inhibit or promote successful outcomes. They also examine the relative influence of the various actors involved on the outcomes observed.

12. Realist Synthesis: The importance of social context Because complex healthcare interventions are typically introduced into open social systems, the effects of those systems on the success or failure of interventions needs to be taken into account. In addition to examining the interpretations and choice of individuals, realist reviews consider evidence relating to: Interpersonal relations, including the relationships and lines of communication between the various stakeholders. Institutional setting, including institutional culture, resources available, leadership support. Wider social and cultural context.

13. Annotated Bibliography: Critical Realism Bhaskar R (2008) A Realist Theory of Science, 2 nd Edition. London: Verso. This is the source of the table at the start of the presentation. While one of the key texts in critical realist philosophy, it is extremely dense and not for the faint- hearted. Danermark, B., Ekström, M, Jakobsen, L and Karlsson, J. (2001) Explaining Society: critical realism in the social sciences. A more accessible tomb, but still a fairly long read.

14. Annotated Bibliography: Critical Realism McEvoy P, Richards D (2003) Critical realism: a way forward for evaluation research in nursing? Journal of Advanced Nursing; 43(4): 411-420. A short introduction to CR with a healthcare focus. Porter, S. (1998) ‘Critical realism’ in Social Theory and Nursing Practice. London: Palgrave Macmillan. As above (a bit old now but still has the basics).

15. Annotated Bibliography: Realist Synthesis Pawson, R., Greenhalgh, T., Harvey, G. and Walshe, K. (2004) Realist Synthesis: an introduction. Manchester: ESRC Research Methods Programme. The standard introduction by the developers of the technique. Downloadable from researchgate. Or if you want to read a whole book about it … Pawson, R. (2006) Evidence-Based Policy: a realist perspective. London: Sage. Rycroft-Malone, J. et al. Realist synthesis: illustrating the method for implementation research. Implementation Science 7(33): 1-10. Open access. Runs through an example. More useful for method than empirical information.