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Realists have a unique way of understanding the constituents of theory. Theories are framed in terms of propositions about how mechanisms are fired in contexts to produce outcomes.

"Programmes are broken down to identify what it is about the measure which might produce change, which individuals, subgroups, and locations might benefit most readily from the programme, and which social and cultural resources are necessary to sustain the changes" (Pawson &Tilley 1997, p.85).

Realists hold that programmes are theory incarnate and realist evaluation involves the processes of developing, refining, and testing such programme theory. It stresses three key linked concepts for explaining and understanding how programmes work, mechanisms, contexts, and outcome patterns, which are used to formulate context-mechanism-outcome (CMO) pattern configurations or CMO theories. This thesis argues that this approach may help articulate the underlying theory at play in an interprofessional SRC with the potential to provide insight into this area of practice, which to date has received little attention.

3.1.5.1. Mechanisms

“This realist concept tries to break the lazy linguistic habit of basing evaluation on the question of whether ‘programmes work’. In fact, it is not programmes that work but the resources they offer to enable their subjects to make them work. This process of how subjects interpret and act upon the intervention stratagem is known as the programme ‘mechanism’ and it is the pivot around which realist research revolves” (Pawson and Tilley 2004, p.6).

Mechanisms describe what it is about the programme that makes things happen. An IPE programme may work in very different ways by triggering different mechanisms, for example, a case based IPE activity where students from different professions come together to develop a plan of care for an individual may aid in the development of collaborative behaviours (outcome) by exposing students to the range of client needs (resources), leading them to reason that these needs cannot be met by a single profession (reasoning). Gaining knowledge of the unique contributions that other professions can bring to that individuals care (resource), might make a student realise that they need to ask others to contribute to care (reasoning), and may change their behaviour in seeking out and collaborating with other professions (outcome).

Mechanisms explain both a programme’s successes and failures, for example, if the group structure and introductions are not carefully designed (context), exposure may act as an opportunity to reinforce professional stereotypes held by students (reasoning) and lead them to not engage with other professions or to have negative interactions with them (outcome). If students are not at similar points in their professional development and cannot equally articulate their own profession's role (context) it may confuse students as to the roles and responsibilities of other professions (reasoning) and lead to them not to seek the input of other professions (outcome). So mechanisms are the process through which programme resources and participant reasoning interact to produce change (outcomes). Mechanisms, therefore, relate to the reasoning or choices of programme participants (Dalkin et al 2015; Dalkin et al 2016). Mechanisms are understood as being a combination of the resources offered by an intervention (mechanism resource) and the reasoning this produces (mechanism reasoning) within in a particular context (Dalkin et al. 2015). This alters the behaviour of participants leading to measurable or observable outcomes (Dalkin et al. 2016, p.691).

3.1.5.2. Contexts

Many mechanisms may be at play in a programme, being activated, or not depending on the context. Realist approaches suggest this interplay of mechanisms and contexts is the process by which programmes generate varied patterns of outcomes, for different

participants, or when attempts are made to replicate a successful programme at a different setting, at the same setting at a different time, or with different groups of participants. It is assumed that mechanisms are only triggered if the conditions, or context is right. The contextual component allows for the investigation of ‘for whom’ a programme might work and ‘in what circumstances”, examining contexts that are supportive to or may hinder a programme in achieving the desired outcomes. Pawson and Tilley (1997) suggest that an understanding of context includes the characteristics of the individual players, their interrelationships, the institutional location and the surrounding infrastructure.

3.1.5.3. Outcomes

Empirical realists propose that if we are to identify causal connections in complex social programmes we must attempt to understand outcome patterns as opposed to searching for single outcomes (Pawson and Tilley 1997; Dalkin et al 2015; Dalkin et al 2016). One must be prepared to consider the variety of outcomes achieved by a programme including those that were expected and those that were not. Pawson (2006) argues that it is the total pattern of outcomes that are valuable to understanding what works, for whom, under what circumstances? A varied pattern of outcomes is thought to develop through the interaction of mechanisms and contextual elements. This study aims to identify programme theory by uncovering the pattern of outcomes for an IP SRC and identifying associated contexts and mechanisms that shape these outcomes for the various clinic participants.

3.1.5.4. Theory building in realist evaluation – CMO theories

The UK Medical Research Council (2000) recommends that in the development and evaluation of complex interventions, an essential first step is the development of a

theoretical understanding of the likely processes of change. This involves the use of existing explicit theory, which may have been considered by those who commissioned the

programme, or the programme designers, but may have been lost in translation or modified as the programme was put into practice. Therefore such theory is supplemented by primary research usually through interviews with those involved in the development and delivery of the programme and those individuals who are targeted by a programme, incorporating their implicit theory and practice theory. Pawson and Tilley (1997) describe this process as engaging in theory formation, through the development of CMO theories. As mechanisms are held to be real, repeated programme evaluation in differing contexts, may result in the development of middle-range theories concerning what works, for whom, in what

As previously stated, a realist perspective suggests that the same programme can produce different outcomes by triggering different mechanisms in different participants and that the triggering of such causal mechanisms is contextually dependent (Pawson and Tilley 1997). In its most simplistic form this relationship is represented as:

Outcome = Mechanisms + Contexts.

Westhorp (2008) suggests that a particular contribution of the work of Pawson and Tilley (1997) is this generative explanation of the relationship of mechanisms to the reasoning of programme participants and thus outcomes. Programmes provide resources to participants that impact upon their reasoning and the choices they make. By articulating the

interrelationships between resources and reasoning hypotheses can be generated about how programmes work (Pawson and Tilley 1997). This is how programme theory is developed. Such programme theory is articulated as context-mechanism-outcome configurations or CMOC theories. A programme theory specifies the underlying

assumptions about how an intervention is supposed to work. Dalkin et al. (2015) separated the two components of mechanisms, into mechanism resources and mechanism reasoning, and present CMO theories as:

Mechanism Resource + Context à Mechanism Reasoning = Outcome This formula has been used in developing and presenting the CMO theories within this study.