Realist synthesis: illustrating the method for implementation research

Abstract

BackgroundRealist synthesis is an increasingly popular approach to the review and synthesis of evidence, which focuses on understanding the mechanisms by which an intervention works (or not). There are few published examples of realist synthesis. This paper therefore fills a gap by describing, in detail, the process used for a realist review and synthesis to answer the question ‘what interventions and strategies are effective in enabling evidence-informed healthcare?’ The strengths and challenges of conducting realist review are also considered.MethodsThe realist approach involves identifying underlying causal mechanisms and exploring how they work under what conditions. The stages of this review included: defining the scope of the review (concept mining and framework formulation); searching for and scrutinising the evidence; extracting and synthesising the evidence; and developing the narrative, including hypotheses.ResultsBased on key terms and concepts related to various interventions to promote evidence-informed healthcare, we developed an outcome-focused theoretical framework. Questions were tailored for each of four theory/intervention areas within the theoretical framework and were used to guide development of a review and data extraction process. The search for literature within our first theory area, change agency, was executed and the screening procedure resulted in inclusion of 52 papers. Using the questions relevant to this theory area, data were extracted by one reviewer and validated by a second reviewer. Synthesis involved organisation of extracted data into evidence tables, theming and formulation of chains of inference, linking between the chains of inference, and hypothesis formulation. The narrative was developed around the hypotheses generated within the change agency theory area.ConclusionsRealist synthesis lends itself to the review of complex interventions because it accounts for context as well as outcomes in the process of systematically and transparently synthesising relevant literature. While realist synthesis demands flexible thinking and the ability to deal with complexity, the rewards include the potential for more pragmatic conclusions than alternative approaches to systematic reviewing. A separate publication will report the findings of the review.

Implementing enhanced recovery pathways: a literature review with realist synthesis

“…However, this is true of any realist synthesis, and only further demonstrates the complexity of this research [40,13].…”

“…different hospitals, different wards within the same hospital, or even the same ward but at contextually distinct times (e.g. different rotation of staff, different times in the year, or several years apart) [13]. Even if a narrower review were conducted exploring the implementation of an ERP within a single surgical speciality, the local context of different hospitals (including organisational, ward level and individual level factors) affects the mechanism of implementation, and thereby the outcomes of the ERP.…”

“…Because of this, it was agreed that a traditional systematic review approach would be unsuitable. Instead, a realist synthesis approach was adopted [13,15].…”

Collective action for knowledge mobilisation: a realist evaluation of the Collaborations for Leadership in Applied Health Research and Care

“…Using the data extraction form ensured that the focus remained on eliciting any information to illuminate the review question 66 and identify evidence which linked collaboration with implementation and knowledge mobilisation. The development of the form was guided by existing templates for realist reviews, 67,68 and based on questions developed by the research team. 39 …”

Cochrane Qualitative and Implementation Methods Group guidance series—paper 2: methods for question formulation, searching, and protocol development for qualitative evidence synthesis

“…Approaches to involving stakeholders in the review process may be broadly characterised as before-after involvement, iterative involvement and synchronous involvement [21][22][23] as described in Box 2.…”