A realistic evaluation: the case of protocol-based care
Open accessAbstract
BACKGROUND: '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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.
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RE is concerned with finding out about what mechanisms work, in what conditions, why, to produce which outcomes and for whom.
“Rather than identifying simple cause-and-effect relationships, RE is concerned with finding out about what mechanisms work, in what conditions, why, to produce which outcomes and for whom.124”
From ReseArch with Patient and Public invOlvement: a RealisT evaluation – the RAPPORT study (2015) · cites this paper as [124]
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- Authors
- Rycroft-Malone, J., Fontenla, M., Bick, D., & Seers, K.
- Affiliations
- University of Warwick (GB)
- King's College London (GB)
- Venue
- Implementation Science
- Published
- 2010-05-26
- Volume
- 5
- Issue
- 1
- Pages
- 38-38
- ISSN
- 1748-5908 (ISSN-L)
- PMC
- PMC2889857
- OpenAlex
- W2032357725
- Cited by
- 173
- References
- 40
- Citations by year
- 2026: 1 · 2025: 2 · 2024: 8 · 2023: 6 · 2022: 9 · 2021: 18 · 2020: 11 · 2019: 15 · 2018: 17 · 2017: 13 · 2016: 10 · 2015: 18 · 2014: 17 · 2013: 8 · 2012: 10
- FWCI
- 15.95
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Implementation Science (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Warwick Research Archive Portal (University of Warwick) (acceptedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- Lancaster EPrints (Lancaster University) (submittedVersion)
- Research Portal (King's College London) (submittedVersion)
- Funders
- National Institute for Health and Care Research
- Service Delivery and Organisation Programme
- Topics
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Social Sciences › Decision Sciences › Management Science and Operations Research › Evaluation and Performance Assessment
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Clinical practice guidelines implementation
- Keywords
- protocol-based care, realist evaluation, realist synthesis, standardization of care, clinical guidelines, care pathways, implementation research, context-mechanism-outcome, evidence-based practice, health service improvement, causal mechanisms
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Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
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