Mind the Gap

September 7, 2017

Many problems in healthcare are complex and difficult to solve. In fact, it is far easier to ignore complex problems and instead just reduce things down to the bits that aren’t complex, ignoring everything else. Realist approaches do the opposite. Instead of ignoring these problems, they dive headfirst into the ‘black box’ of complexity. Making sense of them by daring to look into and unpacking the ‘black box’.

For example, one of my recent realist reviews looking at the antimicrobial prescribing practice of doctors in training was able to explain why many educational interventions that focused on providing mainly prescribing knowledge often had mixed fortunes. Our review unpacked the ‘black box’ of prescribing from the perspective of doctors in training and found that one of the most important influences on their prescribing behaviour was the medical hierarchy they worked in. To put it crudely, prescribing knowledge was important. But doctors in training felt they needed to fit into the medical hierarchy and this meant they usually followed what their bosses did or what they felt their bosses would want them to do.

For those interested in solving complex problems using a realist approach, there is increasing choice in the resources they can access and training on offer to get them started. My colleagues and I completed the RAMESES II project earlier this year and we’re delighted to have been able to add to the resources and training materials for those interested in realist research approaches (see www.ramesesproject.org).

What we have developed are open access quality and reporting standards for realist evaluations as well as resources and training materials. The latter cover a range of topics that many new to realist research approaches find the most challenging. For example, explaining what a mechanism is (and is not) and the different types of theory used realist research.

However, from my years of personal experience of working on realist review and evaluation projects, reading about something is very different to putting it into practice – something I’d call the ‘theory-practice gap’. For example, I’ve noticed that many of my less experienced colleagues seem to understand and can explain to others the important concepts in realist research, but when it comes to applying these concepts in the project, they seem to struggle. An example, par excellence, is the concept of mechanisms. Many can tell you what it is, quote chapter and verse on its definition, but then when analysing data often confuse mechanisms with intervention strategies. Most sadly, I run across this ‘theory-practice gap’ when peer-reviewing manuscripts of realist reviews or evaluations all too often.

This ‘theory-practice gap’ is nothing new and fortunately, those wiser than me have come up with solutions. The obvious one is practice, but my feeling is that it is much more useful if the practice is combined with help and advice from a more experienced hand. This will seem familiar to many of you as it is the approach used in most MSc and Doctoral programmes. Students have more experienced supervisors who can guide them along their learning journey.

It is this approach that we use on the Realist Review and Realist Evaluation module of the MSc in Evidence-Based Health Care Systematic Reviews. In fact this approach is used throughout the MScs we offer. Learners on the MSc get not only to learn about the theory, but also to choose the topic matter of their module assignment. This approach gives them the opportunity to apply theory into practice, on a topic of their choice under the watchful eyes of supervisors with experience of realist research approaches. So hopefully, if you do decide to join us on one of our MScs you will understand why assignments are not a chore, but each a valuable learning experience.

In summary, having access to high-quality resources and training materials is a good start for those who want to learn more about how to undertake their own realist research projects. However, for some less experienced realist researcher, a ‘theory-practice gap’ exists and this can lead to challenges as they undertake their project. My feeling is that there is no substitute for getting help and guidance from more experienced colleagues when working on a project. That way you can make sure you ‘mind the gap’ as you board the realist train.

Geoff Wong, Realist Review and Realist Evaluation Module Lead and Clinical Research Fellow, Nuffield Department of Primary Care Health Sciences


The RAMESES II Project team: Professor Trish Greenhalgh, Professor Ray Pawson, Dr. Geoff Wong, Dr. Gill Westhorp, Dr. Joanne Greenhalgh, Dr. Ana Manzano and Dr. Justin Jagosh.

I would like to thank Kamal Mathani for his helpful suggestions to improve an earlier draft of this blog.

The RAMESES II project was funded by the National Institute of Health Research Health Services and Delivery Research Programme (project number 14/19/19).

Professor Trish Greenhalgh’s salary is part-funded by the Oxford Biomedical Research Centre, NIHR grant number BRC-1215-20008.

The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the HS&DR programme, NIHR, NHS or the Department of Health.

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