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Realist synthesis: illustrating the method for implementation research

Jo Rycroft-Malone1*, Brendan McCormack2, Alison M Hutchinson34, Kara DeCorby5, Tracey K Bucknall34, Bridie Kent67, Alyce Schultz8, Erna Snelgrove-Clarke9, Cheryl B Stetler10, Marita Titler11, Lars Wallin12 and Val Wilson13

Author Affiliations

1 School of Healthcare Sciences, Bangor University, Fron Heulog, Ffriddoedd Road, Bangor, UK

2 Institute of Nursing Research/School of Nursing, University of Ulster, Shore Road, Newtownabbey, Co. Antrim, Northern Ireland

3 School of Nursing and Midwifery, Deakin University, Burwood Highway, Melbourne, Australia

4 Cabrini-Deakin Centre for Nursing Research, Cabrini Health, Wattletree Road, Melbourne, Australia

5 School of Nursing, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada

6 School of Nursing and Midwifery, Deakin University, Melbourne, Australia

7 Eastern Health Nursing Research Unit, 5 Arnold Street, Box Hill, Melbourne, Australia

8 EBP Concepts, Alyce A. Schultz & Associates, LLC, 5747 W Drake Court, Chandler, AZ, 85226, USA

9 School of Nursing, Dalhousie University, 5869 University Avenue, Halifax, Canada

10 Independent Consultant, 321 Middle Street Amherst, Massachusetts, & Health Services Department, Boston University School of Public Health Boston, Massachusetts, USA

11 School of Nursing, University of Michigan, 400 North Ingalls Building, Ann Arbor, Michigan, MI, 48109-5482, USA

12 Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Stockholm, Sweden

13 Faculty of Nursing, Midwifery and Health, University of Technology Sydney, Building 10, 235-253 Jones Street, Ultimo, Australia

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Implementation Science 2012, 7:33  doi:10.1186/1748-5908-7-33

Published: 19 April 2012



Realist synthesis is an increasingly popular approach to the review and synthesis of evidence, which focuses on understanding the mechanisms by which an intervention works (or not). There are few published examples of realist synthesis. This paper therefore fills a gap by describing, in detail, the process used for a realist review and synthesis to answer the question ‘what interventions and strategies are effective in enabling evidence-informed healthcare?’ The strengths and challenges of conducting realist review are also considered.


The realist approach involves identifying underlying causal mechanisms and exploring how they work under what conditions. The stages of this review included: defining the scope of the review (concept mining and framework formulation); searching for and scrutinising the evidence; extracting and synthesising the evidence; and developing the narrative, including hypotheses.


Based on key terms and concepts related to various interventions to promote evidence-informed healthcare, we developed an outcome-focused theoretical framework. Questions were tailored for each of four theory/intervention areas within the theoretical framework and were used to guide development of a review and data extraction process. The search for literature within our first theory area, change agency, was executed and the screening procedure resulted in inclusion of 52 papers. Using the questions relevant to this theory area, data were extracted by one reviewer and validated by a second reviewer. Synthesis involved organisation of extracted data into evidence tables, theming and formulation of chains of inference, linking between the chains of inference, and hypothesis formulation. The narrative was developed around the hypotheses generated within the change agency theory area.


Realist synthesis lends itself to the review of complex interventions because it accounts for context as well as outcomes in the process of systematically and transparently synthesising relevant literature. While realist synthesis demands flexible thinking and the ability to deal with complexity, the rewards include the potential for more pragmatic conclusions than alternative approaches to systematic reviewing. A separate publication will report the findings of the review.