Developing a managed clinical network in palliative care: a realistic evaluation

Background The attainment of evidence-based practice is at the fore of the international practice development agenda. It is therefore imperative that robust evaluation methodologies are available to scrutinise new approaches to service development. Objectives This paper reflects on the merits and challenges of realistic evaluation design in the establishment of a new managed clinical network (MCN) approach to implementing a guideline concerned with the care of individuals with cancer-related pain. Design and methods There were three evaluation points scrutinising three versions of the MCN approach to care. At each stage, steps were taken to identify the context, mechanisms and outcomes associated with the version of the model under scrutiny. Findings from patient-centred case studies fed into realistic evaluation interviews with the management group. Setting A rural primary care setting in Scotland. Participants Three older men, their families, and the doctors and nurses providing direct care participated, along with 13 members of the network management group. Results The investigation highlighted the level of practitioner effort required to introduce the MCN approach to care. Progress was much slower than anticipated, at times frustrated by inexperience in change management and unfamiliarity with leading practice development projects and supporting practitioner learning. Issues to do with the age appropriateness of the evidence base in relation to the care of frail older people were also apparent. The professional group that experienced most role change were district nurses and community pharmacists. Conclusion The collaborative approach nurtured by the realistic evaluation framework was found particularly helpful and there was consensus that the evaluation had become integral to the intervention itself. There were a number of methodological challenges and a need to limit the depth of ‘realistic unravelling’. However, as a formative approach, in the messy world of interdisciplinary practice development, realistic evaluation proved a worthy design.