What is realist methodology?
Rather than simply determining whether interventions work, realist methodology seeks to uncover the underlying mechanisms that drive their effectiveness or ineffectiveness. This approach is particularly relevant in evaluating complex systems such as fitness to practise processes, where the interactions between various factors can be intricate and multifaceted.
Dr Millie Kehoe, a Lecturer in Medical Education who was a member of the research team, explained: “Realist methodology is a theory-based approach where you’re building this theory to apply.
“Realist is really high impact. It’s good for policymakers and policy change because you can see where things are going wrong or where they’re working really well.”
“Realist is really high impact. It’s good for policymakers and policy change because you can see where things are going wrong or where they’re working really well.”
At the heart of the realist methodology lies a commitment to understanding the ‘how’ and ‘why’ behind interventions. It begins by acknowledging the interplay of context, mechanisms, and outcomes, tracing the causal pathways that give rise to observable effects.
Realist methodology offers a theoretical framework that can be applied to diverse contexts, making it an invaluable tool for policymakers striving for evidence-based decision-making.
The study with the GDC used various methods, including in-depth realist interviews with more than 70 people involved in fitness to practise processes, including dental professionals, informants, registrants, witnesses, trade union representatives, mental health experts, and legal staff.
The research team conducted a documentary analysis of policy and website documentation, and personal communications. It also involved a literature review of key papers on fitness to practise, mental health, suicide/risk, and associated health professions and their regulation.
Read the Improving fitness to practise processes in the absence of regulatory reform a blog post from the General Dental Council which references our research
The study also observed two hearings including an interim order hearing and a full proceeding, as well as learning events with GDC staff members including those working in policy, fitness to practise, communications, education quality assurance, and the research team.
The last step included putting together and examining all these parts to present a developed programme theory. This theory, along with logic models and the insights it provides, will help those drawing on the findings to understand which aspects are important and should have more attention paid to them when planning future activities related to fitness to practise.
Dr Kehoe said, “The good thing about realist is it involves discussions with the stakeholders all the way through. So, as we were going through the process, we continually fed findings back to the GDC. That meant they could give their perspective and begin to apply the learning throughout the study, rather than waiting until the end.”
Research findings
Dr Kehoe said, “Reassuringly, participants felt that the fitness to practise outcomes were fair. However, they had less favourable views about their overall experience of the process. Receiving reassurance and having a clearer understanding of the progress of their case were areas for improvement.”
The key research findings included:
- Impact on mental health: Mental health emerged as a significant concern. Participants reported experiencing stress, anxiety, and other negative emotions as a result of the fitness to practise process.
- Communication and information challenges: Participants expressed confusion and anxiety due to unclear or inadequate information about the progress of their case and the overall fitness to practise process. The timing and tone of notifications, as well as the process of engagement, were pinpointed as pivotal aspects affecting participants’ emotional wellbeing.
- Lack of support: Dental professionals expressed a need for more support throughout the process, with the lack of support contributing to a negative impact on their wellbeing.
- Timing and length: Prolonged case resolution times were identified as a concern, exacerbating the stress experienced by participants. Delays in resolving cases contributed to heightened anxiety and uncertainty, and also identified a need for quicker resolution of what were perceived to be less serious complaints.
- Impact on dental profession and practice: The study emphasised that an unsupportive fitness to practise approach could negatively affect the confidence of dental professionals, potentially leading to their undertaking fewer procedures or even leaving the profession.
By sharing findings and collaborating with the GDC as the research unfolded, the study provided valuable evidence directly applicable to improvements to communication and engagement processes, and to support an increased focus on mental health and wellbeing.
Dr Kehoe said, “Our engagement with the GDC allowed for ongoing discussions based on the findings, and the GDC’s proactive response highlighted the potential of realist methodology to drive timely, meaningful change.