Realist Interviews Research Articles

Realist evaluations in low- and middle-income countries: reflections and recommendations from the experiences of a foreign researcher

Realist evaluation, a methodology for exploring generative causation within complex health interventions to understand ‘how, why and for whom’ programmes work, is experiencing a surge of interest. Trends indicate that...

How the Realism of Robot Is Needed for Individuals With Autism Spectrum Disorders in an Interview Setting.

The preliminary efficacy of interview training using an android robot whose appearance and movements resemble those of an actual human for treating social and communication difficulties in individuals with autism spectrum disorders (ASD) has been demonstrated. Patient preferences regarding the appearance of robots are crucial for incentivizing them to undergo robot-assisted therapy. However, very little is known about how the realistic nature of an android robot is related to incentivizing individuals with ASD in an interview setting. In this study, individuals with ASD underwent an interview with a human interviewer and an android robot. Twenty-three individuals with ASD (age, 17–25 years) participated in this study. After the interview, the participants were evaluated in terms of their motivation to practice an interview with an android robot and their impression of the nature of the android robot in terms of humanness. As expected, subjects exhibited higher motivation to undergo interview training with an android robot than with a human interviewer. Higher motivation to undergo an interview with the android robot was negatively correlated with the participants’ impressions of the extent to which the android robot exhibited humanness. This study brings us one step closer to understanding how such an android robot should be designed and implemented to provide sufficiently realistic interview training that can be of therapeutic value.

Factors supporting and constraining the implementation of robot-assisted surgery: a realist interview study

ObjectiveTo capture stakeholders’ theories concerning how and in what contexts robot-assisted surgery becomes integrated into routine practice.DesignA literature review provided tentative theories that were revised through a realist interview study....

Understanding the impact of a collective leadership intervention on team working and safety culture in healthcare teams: a realist evaluation protocol

There is accumulating evidence for the value of collective and shared approaches to leadership across sectors and settings. However, relatively little research has explored collective leadership in healthcare and thus, there is little understanding of what works for healthcare teams, why, how and to what extent. This study describes the approach that will be adopted to the realist evaluation of a collective leadership intervention with four heterogenous healthcare teams in four different settings. A realist evaluation will be conducted. Realist evaluation is a theory-based approach to evaluation. It enables the use of mixed-methods to explore the research question of interest. Development of an initial programme theory (IPT) constitutes the first phase of the approach. This IPT will be informed by interviews with members of teams identified as working collectively, an examination of extant literature using realist synthesis, and will be refined through consultation with an expert panel. A multiple case study design will be adopted to explore the impact of the intervention, including quantitative scales on teamworking, leadership and safety culture, realist interviews with key informants and observations of teams during intervention sessions. Analysis of data will be guided by the IPT to refine the theory and context-mechanism-outcome configurations. Findings from the cases will be compared to identify patterns or demi-regularities and to explore if the intervention operates differently in different contexts. This analysis and synthesis of findings across the teams will inform the development of a middle range theory that will not only add to our understanding of how collective leadership influences teamwork and patient safety, but also provide guidance for future collective leadership interventions. Favourable ethical opinion has been received from the University College Dublin Ethics Committee. Results will be disseminated via publication in peer-review journals, national and international conferences and to stakeholders/interest groups.

Unravelling how and why the Antiretroviral Adherence Club Intervention works (or not) in a public health facility: A realist explanatory theory-building case study.

BackgroundAlthough empirical evidence suggests that the adherence club model is more effective in retaining people living with HIV in antiretroviral treatment care and sustaining medication adherence compared to standard clinic care, it is poorly understood exactly how and why this works. In this paper, we examined and made explicit how, why and for whom the adherence club model works at a public health facility in South Africa.MethodsWe applied an explanatory theory-building case study approach to examine the validity of an initial programme theory developed a priori. We collected data using a retrospective cohort quantitative design to describe the suppressive adherence and retention in care behaviours of patients on ART using Kaplan-Meier methods. In conjunction, we employed an explanatory qualitative study design using non-participant observations and realist interviews to gain insights into the important mechanisms activated by the adherence club intervention and the relevant contextual conditions that trigger the different mechanisms to cause the observed behaviours. We applied the retroduction logic to configure the intervention-context-actor-mechanism-outcome map to formulate generative theories.ResultsA modified programme theory involving targeted care for clinically stable adult patients (18 years+) receiving antiretroviral therapy was obtained. Targeted care involved receiving quick, uninterrupted supply of antiretroviral medication (with reduced clinic visit frequencies), health talks and counselling, immediate access to a clinician when required and guided by club rules and regulations within the context of adequate resources, and convenient (size and position) space and proper preparation by the club team. When grouped for targeted care, patients feel nudged, their self-efficacy is improved and they become motivated to adhere to their medication and remain in continuous care.ConclusionThis finding has implications for understanding how, why and under what health system conditions the adherence club intervention works to improve its rollout in other contexts.

Health and Social Care influences on Long Hospital Length of Stay (LOS): A Critical Realist Study in a large metropolitan hospital

Introduction: Theory-driven design of integrated care interventions requires that research first be undertaken of the pre-existing system performance and factors that might be amendable to improvement. One indicator of health and social care system performance is hospital length of stay (LOS). LOS is one of the single most important indicators of hospital performance and health care delivery. LOS is an important measure of resource utilization with strong associations between LOS and hospital costs. The cost of long LOS has a significant impact on individual hospital budgets as well as being an overall burden on health systems. Consequently studies of LOS are essential for management and financing of hospitals and health systems. Patient pre-existing comorbidities, socioeconomic situation and base-line care-demands all have significant impacts on length of stay. Thus LOS not only evaluates bed management and the efficiency of hospital internal systems, but also the performance of pre-admission and post-discharge community-based health and social care systems. The study of long hospital LOS should therefore also examine the impact, and potential for modification, of complex health and social care, service, policy and system factors. The aim of this study is to determine the underlying internal and external health and social care factors that impact on the phenomenon of long length of stay in a major metropolitan hospital. Theory/Methods: Critical realism will provide the methodological underpinning for this mixed method study. Critical realism seeks to understand the underlying mechanisms and structures that are generating the observed phenomenon. The study will use a concurrent triangulated design that will contribute to explanatory theory building and subsequent design of interventions. The quantitative study will use longitudinal administrative data from the study hospital and supporting health district electronic medical records. Study variables will include: LOS, diagnosis and procedures, patient demographics, and various referral and discharge parameters. Statistical analysis will use exploratory data analysis, regression and time-trend methods. The qualitative study will use critical realist interview methods, purposeful selection of key staff and patients, and realist grounded theory approaches to analysis and development of realist theoretical propositions. Results: Quantitative data collection has commenced. Quantitative analysis will be used to concurrently to inform the qualitative interview questions. Interviews are expected to commence in early February 2018. Preliminary findings will be presented. We will identify underlying structures and mechanisms contributing to long LOS and develop realist MCO theoretical propositions in the form mechanism (M), context (C), Outcome (O). Discussions: We will demonstrate the use of critical realist research methods to study health and social care factors impacting on hospital LOS. The findings will be used to develop realist theoretical propositions that can be used to design service, policy and system-wide interventions. Conclusions: We anticipate that we will demonstrate that system-wide health and social care factors impact on the phenomenon of long hospital LOS. We will be able to propose interventions that will include the development of integrated care approaches in both the health and social care sectors.

Political leadership as statecraft? Aligning theory with praxis in conversation with British party leaders

How should prime ministerial and party leadership be understood and assessed? One leading approach posits that we should assess them in terms of whether they achieve statecraft, that is, winning and maintain office in government. This article supplements and then assesses that theory by drawing from Pawson and Tilley’s concept of the realistic interview, in which practitioners are deployed as co-researchers to assess and revise theory. Unprecedented interviews with British party leaders were therefore undertaken. The article provides new empirical support for the framework because many of the key generative mechanisms identified within the neo-statecraft model were present in an analysis of the interviews. The interviews also allowed the limitations of the model to be demarcated. Statecraft focuses purely on cunning leadership where the aim is to maximise power and influence. This approach differs from leadership by conscience where the aim is to achieve normative goals.

Privately practicing nurse practitioner services in Australia and patient access to care: Results from realist interviews.

To facilitate the expansion of nurse practitioners working in community and primary health settings, legislative changes were enacted in 2010. These led to privately practicing nurse practitioners (PPNPs) being enabled to provide care subsidized through the Australian Government Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme. Little is known about the impact of this legislation on patient access to care in Australia. To explore how, why and in which contexts PPNP services in Australia impact on patient access to care. Semistructured interviews using realist evaluation were undertaken with 20 participants, selected through stratified sampling using geographic criteria (State/territory in which practicing) and dividing the sample representatively between those who worked solely in private practice and those who worked in both private and public practice. Thematic analysis of qualitative data was undertaken. Findings suggest that PPNPs have increased access to care for patients, predominantly in community and primary health settings. In increasing access to care, PPNPs have the potential to reduce hospital and general practitioner attendance, thereby potentially reducing the ever-increasing demand for health care.

Building sport for development practitioners’ capacity for undertaking monitoring and evaluation – reflections on a training programme building capacity in realist evaluation

ABSTRACTAt present, the quality and practice of Monitoring and Evaluation (M&E) in Sport for Development (SfD) projects is under close scrutiny, mainly concerning the capacity that sport has to create social change. Critics have argued that a deeper understanding of ‘what works for whom and why’ is required when evaluating SfD projects. This article explores practitioner involvement in M&E, drawing upon a ‘realist participatory M&E training framework’ developed to train student sport development practitioners to make sense of how and why their SfD projects worked. The training framework was evaluated utilising a realist approach to understand what approaches to evaluation worked for those involved in the training framework. Specifically, 15 practitioners participated in the training framework encompassing 5 community focused SfD innovation projects delivered within the Coaching Innovation Programme at a south coast university in the United Kingdom. The realist evaluation incorporated Q-method factor analysis with realist interviews and reflective blogs. Findings on the value of realist evaluation for practitioners emerged. Practical and transformational evaluation characteristics unfolded and four groups of practitioners emerged, depicting how the training framework worked. These groups were ‘new and emerging evaluators’, ‘polished problem solvers’, ‘passive passengers’, and ‘proficient yet sceptical practitioners’. These were underpinned by holistic narratives in line with Q-method demonstrating shared viewpoints about the training framework. In conclusion, participatory approaches of M&E can work with practitioners and should be embedded to enable application of realist evaluation.

Developing a framework for a novel multi-disciplinary, multi-agency intervention(s), to improve medication management in community-dwelling older people on complex medication regimens (MEMORABLE)\u2013\u2013a realist synthesis

BackgroundMedication-related adverse events have been estimated to be responsible for 5700 deaths and cost the UK £750 million annually. This burden falls disproportionately on older people. Outcomes from interventions to optimise medication management are caused by multiple context-sensitive mechanisms. The MEdication Management in Older people: REalist Approaches BAsed on Literature and Evaluation (MEMORABLE) project uses realist synthesis to understand how, why, for whom and in what context interventions, to improve medication management in older people on complex medication regimes residing in the community, work.MethodThis realist synthesis uses secondary data and primary data from interviews to develop the programme theory. A realist logic of analysis will synthesise data both within and across the two data sources to inform the design of a complex intervention(s) to help improve medication management in older people.Literature reviewThe review (using realist synthesis) contains five stages to develop an initial programme theory to understand why processes are more or less successful and under which situations: focussing of the research question; developing the initial programme theory; developing the search strategy; selection and appraisal based on relevance and rigour; and data analysis/synthesis to develop and refine the programme theory and context, intervention and mechanism configurations.Realist interviewsRealist interviews will explore and refine our understanding of the programme theory developed from the realist synthesis. Up to 30 older people and their informal carers (15 older people with multi-morbidity, 10 informal carers and 5 older people with dementia), and 20 care staff will be interviewed.Developing framework for the intervention(s)Data from the realist synthesis and interviews will be used to refine the programme theory for the intervention(s) to identify: the mechanisms that need to be ‘triggered’, and the contexts related to these mechanisms. Intervention strategies that change the contexts so the mechanisms are triggered to produce desired outcomes will be developed. Feedback on these strategies will be obtained.DiscussionThis realist synthesis aims to develop a framework (underpinned by our programme theory) for a novel multi-disciplinary, multi-agency intervention(s), to improve medication management in community-dwelling older people on complex medication regimens.Systematic review registrationPROSPERO CRD42016043506

The craft of interviewing in realist evaluation

Pawson and Tilley suggest a unique strategy for conducting qualitative interviews within realist evaluation studies. Theories are placed before the interviewee for them to comment on with a view to providing refinement. The subject matter of the interview is the researcher’s theory and interviewees confirm, falsify, and refine this theory. This relationship – described as a teacher–learner cycle – is integral to realist evaluations. This article provides an overview of how interview techniques have been applied in realist evaluations in the last decade as well as suggesting two guiding principles. The first one relates to the design of realist studies and the second one explains how to ask questions like a realist, and proposes three different phases in realist interviews: theory gleaning, theory refining and theory consolidation. The article aims to contribute to a growing understanding of the practical and epistemological challenges presented by primary data collection in realist evaluation.

The Realist Survey: How Respondents’ Voices Can Be Used to Test and Revise Correlational Models

This article introduces the realist survey, an extension of the realistic interview. In a realistic interview, the researcher adapts his or her own theory in response to comments by interviewees, explaining the extent to which the theory applies or does not apply to themselves. The realist survey expands the reach of the realistic interview by including application to generally accepted theories, and it enhances the generalizability of its outcomes through the use of quantitative survey data. As a result, this extended realist interview/survey is a tool that can be used by researchers in widely varying contexts. A realist survey on the effects of the often replicated technology acceptance model shows that the original model is not the best realist fit.

Strategies to engage general practitioners in integrated care for frail older persons : a realist approach

Case management is one of the interventions believed to foster integrated clinical care for people with complex care needs, as is often the case of frail, community-dwelling older persons. Evidence shows that one of the cornerstones of case management is strong inter-professional collaboration between the case manager and the beneficiary’s own general practitioner (GP). Despite the positive outcomes found in many studies in terms of higher quality of care delivery and users’ satisfaction, a constant finding is that the beneficiary’s GPs’ engagement in the case management process is generally poor. The aim of this study is to investigate how, why and for which general practitioners strategies to engage them are successful – or not. Methods: The study is an ongoing action–research framed by a realist approach and using mixedmethods. Firstly, a realist synthesis was performed, in which explanatory candidate theories about successful case management were yielded. Secondly, results of an ongoing evaluation study including similar interventions in Belgium will be used to refine these theories. Thirdly, the refining and testing process will be continued by the means of a multiple-embedded case study of three case management projects. Data to be collected will focus on how the intervention is thought to produce results by stakeholders delivering, receiving, participating in case management at different levels of the local system, including the general practitioners (by the means of questionnaires, documentary analysis, interviews and focus groups). The analysis will be framed by the realist equation context-mechanism-outcomes (CMO) configurations explaining why general practitioners engage in this type of collaborative practice, under which conditions and to what extent. Fourthly, the results will be submitted twice a year to case managers and GPs during realist interviews, in order to validate and refine the CMO configurations and middle-range theories found in the previous steps. International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-116971 – http://www.ijic.org/ 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 2 Results: (Intermediate and expected) The realist synthesis and the first elements of the ongoing study found that the overarching theory of change likely to explain the effectiveness of case management for this population was composed of a set of six sequential steps. Each of the steps could not be achieved if the previous one had not been adequately addressed. In each step interprofessional collaboration, especially with the GP, was found of critical importance. In the next steps of the study, we have planned to test and develop this theory further by focusing on the strategies to engage successfully GPs in case management interactions. These successful interactions are expected to foster positive outcomes in frail older persons in terms of quality of care improvement and even in terms of “hard outcomes”, such as delaying institutionalisation and functional status. Moreover, it is expected that this action learning could also have an impact on the local system of primary care, in changing the perceptions of the role of other professionals in a given context. Discussion: The realist approach, dealing with whole-system thinking, seems a methodology particularly relevant to study complex social situations such as GPs’ involvement in case management of frail elderly. Engaging in a process of action-research with the stakeholders by submitting them the CMO configurations, we should be able to (1) identify and test a middle-range theory; (2) improve inter-professional collaboration by the means of encouraging GPs’ reflection about their own collaborative practices; (3) identify possible leverage points to address the constraints identified, while encouraging enabling factors. Conclusion: While it is unusual for researchers and clinicians to work together in such a way, we hope that this approach will contribute to the inter-professional dialogue through the lens of successful mechanisms operating in case management interventions. Moreover, even if policy makers are often more interested in the overall effect and efficiency of case management and the economy of what returns were achieved from the resources devoted to it, we also hope to be able to engage them at a later stage in the discussion about the clarification of the mechanisms and contexts likely to improve inter-professional collaboration, and by this means lead to better quality of care for the beneficiaries of the interventions.

How level of realism influences anxiety in virtual reality environments for a job interview

This study describes how the level of graphical realism required in a virtual social simulation setting can be therapeutically useful in reducing job interview anxiety through exposure. We developed a virtual job interview simulation at a university career service to help student populations faced with the prospect of their first job interview. The virtual job interview simulation can deliver a realistic mock job interview within a high-quality immersive system that is similar to professional virtual reality (VR) systems. We conducted two experimental studies with a common theme: the role of graphical reality of the virtual interviewer and the immersive visual display in the virtual job interview simulation. The results are presented in this study based on a psycho-physiological approach, revealing variation in the distribution of participants′ anxiety state across various VR conditions. The overall conclusion of this study is that the sense of anxiety is less correlated to the graphical realism in VR environment even though the more graphically detailed the virtual human was, the more it provoked a sense of presence. In addition, at least some degree of physical immersion is needed to maintain anxiety levels over the course of VR exposure.

Collaborative action research to develop the use of solution‐focused approaches

This collaborative action research project involves two educational psychologists (EPs) working with teachers from four primary schools to develop the use of solution‐focused approaches. The project illustrates a way in which EPs might make a distinctive contribution to improving outcomes for children and young people. Realist interviews were used to identify mechanisms responsible for encouraging change in practice and many of these can be linked to action research or solution‐focused approaches. The project will be funded for two years and this report is based on the first year. Progress has been encouraging and findings suggest that solution‐focused action research is a successful model for introducing a new initiative.

Real Versus Imagined Gender Harassment

Sexual harassment studies that use hypothetical situations and retrospective surveys may overestimate the degree to which victims actually confront their harassers. The result is that immediate emotional reactions are little understood and victims are often taken to task for nonconfrontational behavior. To address this neglect, we describe our experimental investigation of immediate reactions to sexually harassing questions encountered during a realistic job interview. Behavioral and emotional responses are compared to those in an imagined harassing interview. Results indicate that interviewees who are actually harassed react very differently than those who only imagine their responses. For example, imagined victims anticipate feeling angry but actual targets report being afraid. Anticipated behavior also did not mesh with actual behavior. Implications of these discrepancies for perceptions of “correct” ways to respond to harassment are examined.