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Table 4 Realist evaluation: conclusions on the impact of the context and the mechanisms on achieving outcomes

From: Improving palliative care in selected settings in England using quality indicators: a realist evaluation

Setting Context Mechanism Outcome
General practice Systemic organisational change in general practice (implementation of the Health & Social Care Act 2012) GPs avoid additional tasks that increase work burden or are perceived outwith remit No engagement with the project despite potential for general practice as a discipline and patient gain
Care homes Top-down decision to involve care homes, during period of care home chain re-organisation Care home managers avoid additional imposed tasks No lasting engagement
Hospital wards Top-down decision to involve hospital ward, and period of major staff turnover Ward staff minimise involvement, momentum lost when key staff leave Selection of indicators for change in order to minimise workload and maximise gain
Specialist palliative care schemes in hospices & communities Competing demands in hospices & community teams, with funding challenges, periods of staff absence; but strong audit & research culture Value of indicators appreciated, as supplement to existing audit & research culture Changes made, effects seen, though extended implementation timescale required