Real Talk: A Realist Dialogic Approach in a Realist Evaluation

Abstract

Realist evaluation is a method increasingly adopted to provide an understanding of how and why a program works, for whom, and under what circumstances. Initial program theories (IPT) are the crucial starting point of any realist evaluation, however descriptions about how they are developed in practice remain under-reported in the published literature. This article argues for the value of genuine research-group conversations using David Bohm’s concept of dialogue in realist research. We label it the realist dialogic approach. We draw out the relational qualities as well as the contextual circumstances of dialogue through our development of IPT and interview guides for a research study on the implementation and scaling of a large-system value-based program to transform complex health services. We selected the relevant middle-range theories, conducted a literature review, and drew on informal discussions with key stakeholders, to develop IPT through research-group conversations. The benefits of this approach were: 1) development of rigorous, novel, deep and well-tailored IPT, 2) detailed understanding of the complex intervention under investigation and development of rapport and networks with participants, 3) empirically grounded Context-Mechanism-Outcome (CMO) configurations, predicated on suitable abstract and contextually-contingent middle-range theories, and 4) productive research team interactions which supported the entire research process. The challenges of this approach include: 1) establishing and retaining a sense of humility across the research team, 2) contextual circumstances can hinder dialogic relationship, and 3) time and resource heavy. This paper uses middle-range theory and ethnographic insights to advance the existing practice of realist evaluations and offer transferable lessons to other scholars considering similar approaches. Moreover, we content that the use of middle-range theory to extend the methodological literature is a novel contribution to realist work.

Four System Enablers of Large‐System Transformation in Health Care: A Mixed Methods Realist Evaluation

“…Once coded, researchers engaged in group consensus, building meetings to finalize each program theory. 30…”

“…We adopted a realist dialogic approach to develop our initial program theories, reported in detail elsewhere and summarized here 30 . The process followed four phases: to (1) understand relevant theories, (2) review academic and gray literature, (3) conduct informal discussions with key stakeholders, and (4) undertake research‐group conversations.…”

“…The development of the initial program theories started with the research team identifying and exploring relevant theories found through team knowledge or cited in realist or other studies. For instance, the leadership program theory drew on social capital theory, 32,33 social influence theory, 34 and Friedson's 35 theory of professions (see Francis‐Auton et al 30 for a worked example).…”

“…We adopted a realist dialogic approach to develop our initial program theories, reported in detail elsewhere and summarized here. 30 The process followed four phases: to (1) understand relevant theories, (2) review academic and gray literature, (3) conduct informal discussions with key stakeholders, and (4) undertake research-group conversations. First, several sources of academic and gray literature were reviewed to identify hypotheses that could inform the development of an initial program theory for how and why the program was expected to work.…”

“…We named this process a "dialogic realist approach." 30 Stage 2: Testing, Refining and Validating the Initial Program Theories. We next tested and refined our initial program theories formally by conducting interviews with key stakeholders.…”