title: Developing a managed clinical network in palliative care: a realistic evaluation.
abstract: 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.
  
  
  OBJECTIVE
  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.
  
  
  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.
  
  
  METHODS
  A rural primary care setting in Scotland.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: School of Nursing, Midwifery and Community Health, Glasgow Caledonian University, Cowcaddens Road, Glasgow G4 OBA, UK. d.tolson@gcal.ac.uk
authors.forename: Debbie
authors.initials: D
authors.lastname: Tolson
authors.forename: Jean
authors.initials: J
authors.lastname: McIntosh
authors.forename: Linda
authors.initials: L
authors.lastname: Loftus
authors.forename: Paul
authors.initials: P
authors.lastname: Cormie
mesh_terms: D003299:Cooperative Behavior; D019091:Critical Pathways / Q000458:organization & administration*; D004059:Diffusion of Innovation; D019317:Evidence-Based Medicine; D006302:Health Services Research; D006801:Humans; D007400:Interprofessional Relations; D009369:Neoplasms / Q000150:complications; D015403:Nursing Evaluation Research; D009936:Organizational Innovation; D017063:Outcome Assessment, Health Care; D010146:Pain / Q000209:etiology / Q000517:prevention & control; D010166:Palliative Care / Q000458:organization & administration*; D010348:Patient Care Team / Q000458:organization & administration; D010594:Pharmacies / Q000458:organization & administration; D010865:Pilot Projects; D017410:Practice Guidelines as Topic; D011320:Primary Health Care / Q000458:organization & administration; D024382:Professional Role; D016730:Program Development / Q000379:methods* / Q000592:standards; D015397:Program Evaluation / Q000379:methods* / Q000592:standards; D011637:Public Health Nursing / Q000458:organization & administration; D012107:Research Design; D019035:Rural Health Services / Q000458:organization & administration; D012606:Scotland