Table 4.

Realist evaluation: conclusions on the impact of the context and the mechanisms on achieving outcomes

Setting	Context	Mechanism	Outcome
General practice	Systemic organisational change in general practice (implementation of the Health & Social Care Act 2012)	GPs avoid additional tasks that increase work burden or are perceived outwith remit	No engagement with the project despite potential for general practice as a discipline and patient gain
Care homes	Top-down decision to involve care homes, during period of care home chain re-organisation	Care home managers avoid additional imposed tasks	No lasting engagement
Hospital wards	Top-down decision to involve hospital ward, and period of major staff turnover	Ward staff minimise involvement, momentum lost when key staff leave	Selection of indicators for change in order to minimise workload and maximise gain
Specialist palliative care schemes in hospices & communities	Competing demands in hospices & community teams, with funding challenges, periods of staff absence; but strong audit & research culture	Value of indicators appreciated, as supplement to existing audit & research culture	Changes made, effects seen, though extended implementation timescale required