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Realist review–Is a theory-driven approach to synthesising quantitative, qualitative or mixed methods research, from a perspective based in Realism. One of the key tenets of realist methodology is that programmes work differently in different contexts–hence an audit that achieves ‘success’ in one setting may ‘fail’ (or only partially succeed) in another setting, because the mechanisms needed for success are triggered to different degrees in different contexts [25, 28]. A realist review does not provide a definite answer as to whether ‘something works or not’; rather it answers questions of the general format ‘what works for whom under what circumstances, how and why?’ to enable informed choices about further use and/or research. The results of a realist explanation are context-mechanism-outcome configurations (CMOcs) constituting a refined programme theory. The refined theory can then be tested in a subsequent realist evaluation covering the same kind of project or programme. |
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Context–Context refers to the ‘setting’ in which interventions take place. As conditions change over time while the audit is executed, the context may change as well and reflects aspects of that change in conditions. As such, contextual elements influence the relationship between audits and their outcomes and, vice versa, the process of the audit and its outcome will influence the context (for example, the outcomes of an audits may generate a culture change) [24, 25]. |
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Mechanism–Mechanisms are a combination of resources offered by the intervention (Mresource e.g. information, skills or support) and the participants’ response to these resources (Mreasoning). Intervention resources are introduced in a context that might affect participants behaviour based upon their beliefs, attitudes or logic (reasoning), which will, in turn, affect the outcome [24, 25, 27]. |
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Outcome–Outcomes can be either intended (did the project succeed against the criteria it set itself at the outset), or unintended, and can be proximal or final. Proximal outcomes can be changes in skills, commitment or intentions of healthcare professionals, whereas final outcomes relate to improvements in quality of care. |
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Context-mechanism-outcome configuration (CMOc)–In realist reviews, observed associations are expressed as context-mechanisms-outcome (CMO) configurations, to explain how particular contexts trigger mechanisms to generate certain outcomes [24]. CMO configurations can be applied to design future audits across different contexts. |
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Programme theory–Programme theories are theory informed associations organised as ‘abstracted descriptions’ about the ideas and assumptions underlying how, why and in what circumstances complex social interventions work [19]. Typically, realist reviews start with initial programme theories (in our review formulated as ‘If-then statements’) and end with a more refined programme theory, expressed as CMOcs. |
