title: Realistic nurse-led policy implementation, optimization and evaluation: novel methodological exemplar.
abstract: OBJECTIVE
  To report the first large-scale realistic nurse-led implementation, optimization and evaluation of a complex children's continuing-care policy.
  
  
  BACKGROUND
  Health policies are increasingly complex, involve multiple Government departments and frequently fail to translate into better patient outcomes. Realist methods have not yet been adapted for policy implementation.
  
  
  METHODS
  Research methodology - Evaluation using theory-based realist methods for policy implementation.
  
  
  METHODS
  An expert group developed the policy and supporting tools. Implementation and evaluation design integrated diffusion of innovation theory with multiple case study and adapted realist principles. Practitioners in 12 English sites worked with Consultant Nurse implementers to manipulate the programme theory and logic of new decision-support tools and care pathway to optimize local implementation. Methods included key-stakeholder interviews, developing practical diffusion of innovation processes using key-opinion leaders and active facilitation strategies and a mini-community of practice. New and existing processes and outcomes were compared for 137 children during 2007-2008.
  
  
  RESULTS
  Realist principles were successfully adapted to a shorter policy implementation and evaluation time frame. Important new implementation success factors included facilitated implementation that enabled 'real-time' manipulation of programme logic and local context to best-fit evolving theories of what worked; using local experiential opinion to change supporting tools to more realistically align with local context and what worked; and having sufficient existing local infrastructure to support implementation. Ten mechanisms explained implementation success and differences in outcomes between new and existing processes.
  
  
  CONCLUSIONS
  Realistic policy implementation methods have advantages over top-down approaches, especially where clinical expertise is low and unlikely to diffuse innovations 'naturally' without facilitated implementation and local optimization.
authors.affiliation: Centre for Health-Related Research, School of Healthcare Sciences, Bangor University, UK.
authors.forename: Jane
authors.initials: J
authors.lastname: Noyes
authors.affiliation: Royal United Hospital Bath NHS Trust, UK.
authors.forename: Mary
authors.initials: M
authors.lastname: Lewis
authors.affiliation: School of Healthcare Sciences and Centre for Health-Related Research, Bangor University, UK.
authors.forename: Virginia
authors.initials: V
authors.lastname: Bennett
authors.affiliation: Children with Complex Care Needs, South Warwickshire Foundation NHS Trust and Coventry and Warwickshire Partnership Trust, UK.
authors.forename: David
authors.initials: D
authors.lastname: Widdas
authors.affiliation: Helen and Douglas House, Oxford, UK.
authors.forename: Karen
authors.initials: K
authors.lastname: Brombley
mesh_terms: D002648:Child; D002669:Child Welfare; D003253:Consultants; D003266:Continuity of Patient Care / Q000458:organization & administration*; D004059:Diffusion of Innovation; D004739:England; D006291:Health Policy; D006801:Humans; D007857:Leadership; D024802:Nurse's Role; D009732:Nursing Care / Q000458:organization & administration*; D010043:Outcome and Process Assessment, Health Care; D010371:Pediatric Nursing / Q000458:organization & administration; D013222:State Medicine / Q000458:organization & administration
keywords: children; complex needs; continuing-care; health systems; implementation; nurse; policy; realist; theory-based evaluation