In the context of modern nursing practice that is embedded within complex social situations, critical discussions about the contribution of major philosophers are relevant and important. Whilst nurse theorists have advanced and shaped nursing as a discipline, other major philosophers can offer much to advance nursing enquiry. In this paper, we focus on philosopher Roy Bhaskar who, amongst others, developed critical realism, a philosophy for social science which connects with how many of us think about the world. Bhaskar's work focuses our attention on the interplay between structure and agency and on the search for the causative or generative mechanisms that explain the social world. Bhaskar was interested in human emancipation, and we suggest his work is of great importance to advance understanding of complex social situations. Critical realism has already been endorsed by a range of disciplines, especially in research which focuses on real problems and acknowledges the complexities of the social world. In recent evidence from healthcare literature, there has been a surge in research using realist methodology (realist evaluation and realist synthesis), which is underpinned by the philosophy of critical realism and which offers a different perspective to understanding nursing and healthcare problems through the realist lens. However, we suggest that sufficient attention is not always paid to the philosophical roots of this methodology. In this paper, we provide insight into Bhaskar's work and demonstrate how research positioned within critical realism and realist methodology can advance nursing and healthcare-related knowledge. Through shining a light on Bhaskar, we illustrate how critical realism philosophy is a natural fit with human and health science enquiry, including nursing.

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Bringing critical realism to nursing practice: Roy Bhaskar's contribution.

Exploring and optimising maternal and infant nutrition in North West Pakistan.

Bagnall, A and South, J and Trigwell, J and Kinsella, K and White, J and Harden, A (2015) National Institute for Health and Care Excellence Review 4: Community engagement – approaches to improve health: map of the literature on current and emerging community engagement policy and practice in the UK. Project Report. Centre for Health Promotion Research, Leeds Beckett University / Institute for Health and Human Development, University of East London, Leeds.

National Institute for Health and Care Excellence Review 4: Community engagement – approaches to improve health: map of the literature on current and emerging community engagementpolicy and practice in the UK

Maternal and infant malnutrition is prevalent in rural regions of NW Pakistan. This article reports on the use of a combination of a realist Context–Mechanism–Outcome framework and participatory appraisal methods to facilitate the development of a locally sensitive and responsive nutritional intervention programme. Data were gathered through a series of focus group (FG) discussions with local lady health workers, as well as pregnant and breastfeeding women attending an Emergency Field Hospital in North West Pakistan between May 2008 and March 2009. A nutrition intervention programme was implemented that involved cookery demonstration kitchens and free food supplements, coupled with nutrition and healthcare information and advice for pregnant and breastfeeding women. Subsequent FG discussions revealed that the programme had a positive impact on knowledge gained by women in the community and generated an openness to receiving and spreading knowledge. The framework, which rested on the use of a double feedback loop, involving local women, lady health workers, local researchers and UK-based researchers, has enabled not only the establishment of the programme, but has also given the local team the tools to apply for, and gain, further funding for the development of nutrition support services. The development of such methodological tools, which empower local researchers and service providers (wherever located) to operationalize local knowledge and assess interventions, is particularly relevant in international financially-constrained contexts.

Development and implementation of a nutrition intervention programme in North West Pakistan: a realist framework.

Background
Not being breastfed is internationally considered to have a lifelong impact on morbidity and mortality. In the UK and other developed nations, adolescent mothers are among those least likely to breastfeed and require additional support to do so due to their unique developmental position. Evidence indicates that many young mothers who intend to breastfeed never initiate breastfeeding or stop soon after giving birth, and there may be factors in the UK health system or wider society preventing the success of breastfeeding support interventions. These considerations led to a two-phase investigation which aimed to study the context of breastfeeding support and evaluate a targeted breastfeeding support intervention for young women.

Methods
A realist evaluation framework was used. 83 UK health professionals responded to an e-questionnaire. Focus groups and interviews were conducted with 15 young mothers (aged 16-20) in Oxford, England. A breastfeeding support package was then developed and implemented on a UK postnatal ward for six months. A concurrent mixed methods evaluation was carried out. Each component of the investigation was analysed thematically using inductive content analysis. Ethical approval was received.

Findings
Young women appear motivated to breastfeed to show that they are good mothers. However, breastfeeding can alienate them from their families at a time when they need to be accepted in their new mothering role. Young mothers can feel disempowered after birth and like 'fish out of water' on the postnatal ward. A need was identified for proactive breastfeeding support from health professionals focusing on relational care, particularly as some maternity professionals displayed negative attitudes to teenage mothers and breastfeeding. Despite staff training developing a more positive and enabling attitude towards young women, much of the proposed support package proved impossible to implement in a busy, task-orientated medical environment where time, convenience, control, and individual staff beliefs were used as yardsticks to determine the acceptability of different aspects of care.

Conclusion
This study highlights the importance of proactive, relational breastfeeding support for young mothers. Such support requires a facilitative environment in order to be implemented successfully. It is suggested that such an environment could be created on the postnatal ward if midwives and MSWs created workplace communities and claimed ownership of their time and space. Action Learning may facilitate this process.

Supporting teenage mothers to initiate breastfeeding and developing a support intervention to increase breastfeeding rates in a vulnerable group - the importance of place

This paper aims to inform the development and evaluation of small-scale community-based initiatives by describing an evaluation of one such health promotion programme. Realistic evaluation is an under-explored resource for practice development, particularly within the context of informing evidence-based practice. A combination of the context-mechanism-outcome framework and principles of health impact assessment were used in the evaluation of the programme. Telephone interviews and half-day sessions were utilised in order to conduct reviews of the programme's work with both providers and users. This approach engaged the practitioners in the process of evaluation in a way that was novel to them, and introduced the possibility of a stepped approach to outcomes achievement and measurement. The evaluation gave the practitioners the means to understand and effectively formulate which outcomes were most appropriate to their particular intervention, and to design the means to assess these in future.

The potential contribution of realistic evaluation to small-scale community interventions.

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The potential contribution of realistic evaluation to small-scale community interventions.