Realist reviews have a fundamental structure, including the phases: defining the scope;
searching for the literature; data extraction and appraisal; data analysis (see Figure 3.1) (Rycroft-Malone et al., 2012).
3.4.1 Defining the scope
Defining the scope of a realist review is a vital phase as it establishes the framework and structure for appraising the evidence (Pawson et al., 2005). The reviewer adopts a primary research rather than a synthesis role as they gather information from multiple sources with the aim of creating programme theories, rather than simply synthesising data from
secondary sources. This results in identification of key terms, concepts and mid-range theories (see glossary) that begin to provide an explanation of the area (Pawson et al., 2005). Mid-range theories relate to a social system but are not specific to the programme under evaluation; they are generic theories of human reasoning or activity that have relevance to the programme and facilitate explanation of the programme (Merton, 2013).
Rycroft Malone et al. (2012) stated that there should be a high-level of stakeholder
involvement throughout a realist review to ensure ‘official conjecture’ and ‘expert framing’
Figure 3.1 - Overview of the realist review
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of the problem (Pawson et al., 2004, p.16). Therefore, the realist review framework should be developed in collaboration with key stakeholders. The expert team and the methods used to involve them are discussed on p.59.
Two FCPs, a research associate (involved in FCP research) and a Patient Partner were consulted. A broad search of sources was carried out (see Table 3.1 - Search strategy utilised) and the supervisory team, Patient Partner, and two practising FCPs all facilitated the process of defining the scope in order to establish a theory framework. A more rigorous and formal phase of systematic literature searching and extraction followed.
Information about the literature source was extracted into an Excel spreadsheet, including;
the title; author(s); date; context, such as profession; key findings/conclusions. Themes were then identified from reviewing the spreadsheet information, they formed the basis of theories that may explain how the AP role works. An extensive list of potential theories was produced. Similar theories were categorised into overarching theory areas; resulting in four theory areas with sub-theories (see Appendix 1).
3.4.1.1 Methods for consultation of key stakeholders and an expert supervision team
The process of involving the FCP team members and Patient Partner were almost identical, however, the Patient Partner was provided with information in more accessible terms.
Prior to the meetings, the stakeholders were emailed an outline of the project (see Appendix 2 and Appendix ). The stakeholders were provided with a flowchart of the initial theory areas, formed through evidence and expert opinion from the supervisory team (see Appendix 3).
Population Intervention Setting Outcome
Patient OR
"practice nurse" OR "ESP" OR
"First contact practitioner" OR
Table 3.1 - Search strategy utilised
69 The review began with initial broad ideas on how the AP role works; these formed what were known as the theory areas that acted as a framework for the development of
hypotheses (Rycroft-Malone et al., 2012). The hypotheses developed the initial theory area framework. Each theory area was discussed with the FCP stakeholders and Patient Partner to individually validate, amend, and potentailly create new theory areas and preliminary hypotheses as appropriate. The meetings concluded with the stakeholders agreeing to contemplate theory areas and hypotheses and contact the researcher if they had any changes to theory; they did not contact the researcher any further.
3.4.1.2 Theory development
Following on from the FCP team meeting, there was development of the theory framework (see Appendix 4 and Appendix 5). The updated flowhcart was sent to the FCP team
members and the supervisory team to corroborate understanding. No changes were made to the flowchart following the meeting with the Patient Partner.
The initial theories were then discussed in a team meeting that included all members of the supervisory team and the Patient Partner. Initial theories were discussed in-depth to ensure mutual agreement of the theories under investigation. This resulted in the
development of a final theory framework that was circulated to the supervisory team, the Patient Partner and FCP team members for content validation (see glossary).
3.4.1.3 Initial theory areas
A total of seven initial theory areas were agreed which formed the theory area framework, these were:
• Theory area 1 - Patient’s prior experience of condition management
• Theory area 2 - Patient’s expectations of condition management
• Theory area 3 - Communication
• Theory area 4 - Continuity of the individual practitioner
• Theory area 5 - Practitioner’s scope of practice
• Theory area 6 - Accessibility
• Theory area 7 - Promoting the role to patients
The titles of these theory areas differed initially, as they were subject to change as understanding of the theory areas progressed. Figure 3.2 provides an overview of the process which is then detailed.
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Figure 3.2 - Development of theory framework
71 Only initial ‘digging through’ the literature informed the first theory area framework
(Rycroft-Malone et al., 2012, p.3). The databases searched included: The Allied and
Complementary Medicine Database; CINHAL Plus; Medline; Pedro; The CSP’s Evidence and Knowledge Discovery.
The supervision team highlighted that competencies and interpersonal skills are different and consequently, two distinct theory areas were created. Discussion with the supervision team and Patient Partner highlighted that ‘Acceptable aspects of the model’ covers multiple theory concepts; ‘Access ‘and ‘Continuity’ were different aspects. This meeting also highlighted that ‘Expectations’ was unclear as to whether this was expectations of the individual practitioner, or expectations of the service. Furthermore, the team perceived that the individual practitioner would fall within ‘Competency’ and ‘Personal
characteristics’. The theory area was therefore changed to ‘Service expectations’.
Email correspondences with the supervision team highlighted that, without stating whose experience or whose expectations, the theories are open to interpretation. The theory areas were adapted to state that they related to patients.
A new theory area – ‘Role Promotion’ – developed from presenting theory ideas to the FCP team members.
A meeting with the supervision team and Patient Partner highlighted that ‘Patient expectations of the service’ was similar to ‘Accessibility’, and would not include evidence on how patients expected their MSKDs to be managed. ‘Patient expectations of the service’
was therefore replaced by ‘Patient’s expectations of their condition management’.
New theory area – ‘Professional hierarchy’ – developed at the data extraction phase. This was not purposefully searched for, rather, the theory area was highlighted through reading the literature related to the other seven theory areas.
The supervision team highlighted that ‘Ways of working’ related to communication only.
The theory area title was therefore altered to ‘Communication’. Role Promotion was felt to be misleading by the supervision team, it was suggested that it may have referred to the professional bandings of the AP roles. Theory area 7 was renamed ‘Promoting the AP role to patients’. This was the final theory area framework.
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