Optimising the impact of health services research on the organisation and delivery of health services: a mixed-methods study

Knowledge transfer

When framed as a knowledge transfer problem, researchers are seen as having expert knowledge that needs to be transmitted to decision-makers in the health service in an accessible and timely fashion. 5 Knowledge is perceived as a relatively tangible, bounded and moveable ‘product’, whereas the decision-making process is likely to be seen as time-limited, linear and rational. Research evidence, regarded as the most valid and reproducible form of knowledge, is ‘pushed’ from the research community, through guidelines or evidence summaries, or ‘pulled’ by practitioners who are (or should be) well informed about the benefits of using research evidence.

The emergence of sophisticated informatics and communication technologies in recent years, and their use by the National Institute for Health and Care Excellence (NICE) and others, has helped to reinforce a view that the knowledge transfer model is the most appropriate way of closing the so-called ‘know–do gap’. 6 This may be a reasonable assumption in situations in which scientific knowledge is fairly unambiguous, easy to interpret and largely uncontested, such as is often the case (relatively speaking) for much of the clinical evidence underpinning the practice of evidence-based medicine. The transfer approach is more troublesome in the field of health services improvement or service redesign, where the issues that research attempts to address are more complex and the nature of the social science evidence is more contested. 7

Knowledge co-production

This recognition of the limitations of the knowledge transfer model has resulted in a reframing of the integration of research and practice, as requiring different approaches to the nature of evidence, its production and use, and the complexities of the challenges faced by care systems. 3,8

Rather than being separate processes, the production and utilisation of research evidence are seen to merge as complex, iterative and situated social processes. 9–12 That is, knowledge is created, understood, adapted, used and reiterated in the context in which it is needed, and through partnership between different actors.

Furthermore, decision-making by practitioners is regarded more as a situated, social and evolving process than as a one-off, rationally determined event. 6,11 Rather than research evidence needing to be fed into this in a linear and methodical way from outside, the emphasis becomes one of the integration of empirical evidence with other forms of knowledge in situ, including practical knowledge about how to improve and redesign services, and user knowledge about the experience of care services.

This integration is seen as a situated social process based on productive ongoing relationships, effective systems and conducive organisational cultures and contexts. 13–16 Increasingly, the literature in this area embraces a ‘complex adaptive systems’ way of understanding the world, as a means of understanding how actors have to overcome social and epistemic boundaries to helpfully facilitate knowledge processes. 17–19

Such a reframing suggests that the relationship between research producers and research users should focus on the ‘co-production’ of knowledge, rather than merely its transfer. 2,3,20–23 Co-production models of knowledge mobilisation are based on the assumption that knowledge created by researchers often needs to be adapted in some way if it is to be useful. Indeed, for knowledge to have influence, all participants need to be involved in its creation and use. 24 Researchers, using the scientific method as their predominant way of knowing, are not seen to have a monopoly on expert knowledge. Instead, they need to be willing to negotiate actively their forms of knowledge with others (‘a meeting of experts’, e.g. experts in research evidence and experts in improving health services), to recognise and act on power differentials in who dictates how knowledge is defined, and to adopt a more pluralistic orientation to knowledge to achieve change. 25,26

Broadly defined as joint working between people who or groups that have traditionally been separated into categories of user and producer, the term ‘co-production’ came to prominence in the 1970s27 and has gained much currency in public service discourse since. 28,29 When applied in health services research, it is increasingly used as a term to describe the co-production of research-informed knowledge through the engagement of policy-makers and practitioners with researchers. 30–33

However, the increasing popularity of the principle of co-production in public services comes on the basis of promising, but far from complete, evidence. 29,34–36 The literature highlights a range of dilemmas and challenges that need to be explored more fully; for example, is it desirable or feasible to bring researchers and practitioners more closely together, or might the logistical challenges and potentially greater costs than traditional approaches outweigh the benefits?32,37,38 What are the challenges of reconciling divergent or even incommensurate epistemologies?39 Should greater attention be paid to the political and social dimensions of co-production (e.g. the different interests, power and expectations of the parties)?30,31,39,40 Might co-production lead to a narrowing of focus towards problem-solving dimensions of research use,41 instead of encouraging important broader perspectives?23 Should the boundaries between researchers and practitioners be firmly drawn, or are there advantages in flexibility and in the blurring of boundaries?9,21 In what ways can researchers and service users get involved in the co-production of service redesign or improvement?42–44 And can health-care research that is co-produced in one location be translated effectively to other settings?32

The challenges posed by these questions have been exposed by the growing range of new initiatives that seek greater interactivity over research (and, by extension, knowledge co-production in some form) that have emerged in the NHS over the past two decades,17,45–47 as well as in the in the health systems of Canada,48,49 Australia50 and the USA. 51,52

Embedding researchers to encourage co-production

Many different terms and models have been used to describe approaches to research use that seek greater engagement and sustained interactivity, including knowledge brokers,53–60 NHS management fellows,12 Health Foundation improvement science fellows, National Institute for Health Research (NIHR) knowledge mobilisation research fellows, and researchers-in-residence. 61–65 What many of these models have in common is a desire to ‘embed’ researchers in service settings, for significant periods of time, to secure the sorts of sustained interaction thought necessary to promote knowledge co-production. Yet much of the literature is unclear about the relationship between knowledge co-production as a generic concept, ‘brokerage’ (the process by which knowledge is shared across boundaries) and ‘embeddedness’ (whereby researchers are, to a variable extent, located within practitioner teams).

Moreover, other aspects of the schemes that have emerged are highly variable and usually not well described. For example, schemes may vary markedly on the individuals involved (e.g. researchers, health professionals, managers, service users), the degree of close interaction or embeddedness of individuals (e.g. physical locations, contractual arrangements), the nature and degree of co-production sought (calling into question complex issues of epistemology and power) and the types of activities that take place (e.g. the balance between the brokering in of external knowledge and the co-creation of new knowledge in situ). These different models are emerging largely independent of each other, with little evidence of shared learning and only a very few examples of formal evaluation. What has been published mostly comprises descriptions of isolated initiatives, but little in the way of deep analysis and interpretation, and even less in terms of practical guidance.

Both the literature and current practice, therefore, highlight a rich research agenda around embedding researchers as a means to knowledge co-production and, hence, better research use. This includes a clear need to develop a better theoretical and empirical basis for such schemes in the NHS, and the need for evidence-informed practical guidance to support implementation of embedded co-production in practice. 32,38 This project addresses these gaps.

Approach to engaging and influencing

The fundamental premise of this research is that knowledge needs to be produced in and through relationships with those who are going to use it (the rationale that underpins both embedded research and knowledge co-production). This, therefore, was also the approach that we took to knowledge creation in this research project. Hence, engaging and influencing key stakeholders were core elements of the proposal.

The principles underpinning our approach were aligned to the theory and practice of co-production models of knowledge mobilisation and to the principles of participatory research. 17,46,66 To that end, the influencing plan was co-produced by practitioners, service users and academics, and used approaches that focus on social interaction, as well as more traditional academic approaches to dissemination.

Audiences and actions

We identified three target audiences that we considered most likely to benefit from the new insights and the associated tools and resources. The primary audience was NHS and local government leaders, both managers and clinicians, whose provider and commissioning decisions could potentially be improved by making better use of health services research evidence.

The secondary target audience comprised the applied research and associated implementation communities, such as members of NIHR Applied Research Collaborations (ARCs) [formerly known as Collaborations for Leadership in Applied Health Research and Care (CLAHRCs)] and Academic Health Science Networks (AHSNs). The twofold aim here was both to encourage actors in these initiatives to explore the benefits and risks of engaging in embedded models of knowledge co-production and embedded research, and to contribute theoretical and empirical knowledge to the field.

The third target audience comprised front-line staff and service users; their interaction with embedded researchers are at the heart of the model. Helping those who want to access and use applied health research to see more clearly how the structural arrangements for the creation of that research affect its use is key.

The Embedded project team had extensive personal and professional networks in the field of NHS service management and knowledge mobilisation, in the UK and internationally. We used the team’s wider local and national networks in local health economies, ARCs/CLAHRCs, AHSNs and higher-education institutions to ensure that the outputs of the project had maximum impact.

A range of actions were devised to engage and influence these audiences.

Assembling the published literature

To gather a wide array of perspectives, we collected literature that featured theoretical or conceptual discussion of knowledge co-production, including reports of co-productive research activities incorporating reflective and theoretical insights into knowledge co-production, and editorial/review articles in which the main focus was knowledge co-production.

We conducted systematic searches of the Web of Science™ Core Collection™ (Clarivate Analytics, Philadelphia, PA, USA) in March 2018. The search terms and strategy are set out in Table 1. Because we wanted to bring together insights from a wide range of health, science and social science fields, we did not limit this search by discipline or by year, although the earliest article that satisfied our inclusion criteria was from 2003.

Screening the search results, we removed sources in which knowledge co-production between academic researchers and non-academics was not the principal or main topic. We therefore excluded writings on value and service delivery co-production, public service co-production and other kinds of collaborative co-production not involving researchers working with non-academics, or an explicit concern to make knowledge.

Other relevant articles identified through the reading and networks of the project team were subject to the same process of formal inclusion/exclusion. The numbers of articles screened, removed and included are shown in Figure 1.

FIGURE 1.

Flow chart of literature-gathering and screening.

The articles included for analysis are listed in full in Report Supplementary Material 1. As well as articles from health and directly health-related disciplines (n = 24), we reviewed articles from management studies (n = 15), environmental science (n = 15), sociology and social policy (n = 9), sustainability studies (n = 8), ecology (n = 5), human geography (n = 3), communication studies (n = 2), and one each from humanitarian and disaster studies, engineering, psychology and genomics. Source articles dated from 2003 to 2018.

Analysing the data

The framework analysis technique is well established for analysing large bodies of literature subsequent to searching, screening and preliminary reading. 86–88 This approach was appropriate because of its flexibility (allowing us to interrogate sources from diverse disciplines); its capacity for ongoing modification and revision in response to data reading, re-reading and re-interpretation; and its orientation towards descriptive understanding rather than prediction or normative goals. 89 Framework analysis facilitates an iterative, team-based approach to analysis, giving increased confidence that the categories and themes discerned have stability and interpretive utility.

An initial interpretive reading conducted by one member of the team (BR) aimed to discern and label groups of concepts occurring within and across the source articles. For instance, writers might report concerns around institutional politics, or the difficult emotions of perturbed professional identities, without necessarily using the words politics, identity or emotions.

The review team (BR, VW, HD and TT), which had access to the full set of sources as well as the evolving analytic categories, then discussed this working set of conceptual labels, or domains, for their face validity, coherence, completeness and overlaps, and made modifications as agreed. A closer re-reading of source articles was then conducted to see if the conceptual categories emerging provided a sufficient framework for interpreting the data. This second reading allowed us to identify additional content that would not fit easily into the domains, and to refine or develop further domains and, more significantly, subthemes within domains.

In discussions across the whole project team, it became evident that differing perspectives on knowledge co-production created tensions within each domain. We recorded and labelled these tensions and grouped them together into connected accounts of meaning.

What emerged was a set of five conceptual domains overlaid with a continuum of perspectives from the conventional to the radical. A conventional view of knowledge-making would see the boundaries between different knowledges and different roles largely maintained, with the goal of worthwhile but incremental change. A more radical approach would see boundaries more thoroughly dissolved, in pursuit of a more substantial overhaul of priorities and possibilities.

Given our goal of creating a language of shared meaning that would make knowledge co-production easier to discuss, we sought categories that were defined and coherent enough to allow for shared understanding, broad enough to encompass the messiness of divergent practices, and flexible enough to allow ongoing debate and refinement. The structured reading we lay out is not the only one available, but it has survived repeated interrogation across the wider project team of knowledgeable, diversely experienced collaborators, and through presentations at various professional events.

Five domains of meaning

Meanings and perspectives in knowledge co-production can be located, understood and compared within five related domains of meaning: politics, knowledge, identity, space–time and aesthetics:

1. The politics domain brings to the surface those negotiated and meaning-laden processes (among large and small groups, and individuals) that in conventional knowledge production are obscured or unspoken.

2. The knowledge domain concerns implications around the tangible product that co-producing parties reach for – what is this knowledge, and what is it for?

3. The identity domain allows a close examination of people who co-produce knowledge – what makes them who they are, individually and collectively?

4. The space–time domain concerns the physical processes and happenings of knowledge co-production. More than just a practical question of ‘where and when’, it involves different configurations and enactments of collaboration.

5. The aesthetic domain makes visible aspects of knowledge co-production experience and expression that may seem intangible and subjective, but that are highly significant – human likes and dislikes, and emotions that escape easy expression but are fundamental to collaboration.

These five domains mark out a conceptual space in which to consider the complex interplay of diverse ideas and understandings involved in knowledge co-production.

Spectrums within domains

In each domain we found that, underlying any superficially isolated points of opposition and difference, there were subtle variations of thinking that merge and separate, creating a spectrum of interpretations and actions. These range from non-collaborative or reservedly collaborative approaches that leave existing boundaries relatively unchallenged (we term these ‘conventional’ research or ‘provisional’ co-production), to approaches that challenge or unravel such boundaries in pursuit of more disruptive and substantial change (what we term ‘committed’ or ‘radical’ knowledge co-production). This spectrum is set out in Figure 2.

FIGURE 2.

Styles of knowledge co-production.

The extremes of this spectrum (conventional and radical) serve as idealised anchor points for clear thinking, but also reflect knowledge-making processes actually (in some cases) performed. Rather than a barrier or problematic void between them, there is a rich space of variation among subtly different approaches. Real-life knowledge co-production mostly happens in this intermediate space. To guard against binary thinking, we included a middle category of moderate co-production, which models a roughly equal balance and interplay between ideals.

These labels proved useful to unpack, interrogate and lay out subtle contrasts within domains, but should not be thought of as overly rigid or proscriptive. Labelled marker points do not indicate static types of knowledge co-production, but dynamic approximations, signposts that we have settled on after repeated interrogations of the literature and discussions among the team.

Subthemes within domains

In further exploring and categorising the themes in the literature, we identified two subthemes within each domain:

1. politics includes ideological and transactional politics

2. knowledge includes the substantive product and output of collaboration, and is also something that exists and has nature in itself

3. identities includes both the roles fulfilled by individuals and the way in which those individuals are less or more socially intertwined

4. space–time incorporates time and space as distinct physical dimensions that can be configured in a variety of ways, according to how they are realised and occupied in collaborations

5. aesthetics includes the preferences and affinities of people and groups involved in knowledge co-production, and the valuation and influence of emotions in collaborative proceedings.

In the subsequent section, we summarise each domain and subtheme, giving examples from the literature. These discussions are encapsulated graphically in Figure 3, and also in Table 2).

Domain 1: politics

The politics domain incorporates ideologies of research, ranging from the apolitical (conventional co-production: politics seen as separate from knowledge-making) to the emancipatory (radical co-production: knowledge-making as a tool for social justice and structural change). Intermediate points are the utilitarian (provisional co-production: knowledge for instrumental application), the engaged (moderate co-production: research and practice/policy substantially shape each other) and the transformative (committed co-production: sustained micro- and meso-level change is part of the programme).

This domain also incorporates the instrumental politics of transactions, the often mundane institutional politics of co-producing knowledge. Attitudes across that subthematic spectrum range from politics as pollution (conventional), through politics as necessary (provisional) or valuable (moderate), to politics as essence (committed), and politics as all-encompassing (radical).

Domain 2: knowledge

The knowledge domain incorporates perspectives on the outputs of knowledge co-production, and implied positions on the nature of knowledge. Beyond being a pure commodity made for truth’s sake (conventional co-production), knowledge can have utility, transfer and ‘impact’ potential (provisional co-production). Or knowledge can be something through which people become inclusively engaged in social life (moderate co-production), or through which they gain new productive capacities (committed co-production). Knowledge may even enable actors to become empowered (radical co-production). Accordingly, knowledge has different kinds of existence: as an object in itself; as something exchanged or negotiated among those who hold it; as something held communally by ever-changing collections of people; or finally, as a constitutive property of a wider collective group, in a deeper, ongoing and embodied sense.

Domain 3: identity

Politics experienced at the individual level can be conceptualised through identity, both in terms of the roles that participants occupy, and by acknowledging individual feelings, affinities and sensibilities.

We found that roles in co-production might be separate and securely fixed (conventional style), or they might fit together as complementary and negotiable where they meet (provisional style, in which case conflict is more likely found to be counterproductive). Sometimes there is an expectation that roles naturally overlap (moderate style), interfere and contradict (committed style), or disintegrate and multiply (radical style), in which cases conflict may be naturalised and valued as significant.

The individuals involved might be thought by nature to be autonomous, or connected to each other in singular, transactional ways; they might be more interwoven and interdependent; or, in the extreme cases, less clearly separable from each other in terms of the multiple knowledge roles they embody.

In this domain, it is useful to hold in mind some typical characters in narratives of knowledge co-production. The basic players are academic researchers (whose accounts are usually of central interest for academic writers and audiences, even under committed and radical modes of co-production) and non-academic stakeholders, such as (health) professionals, policy-makers and service users (whose accounts rarely surface in enduring forms). Recurring figures include non-academics who gain skills and empowerment from involvement in research,116 researchers who skilfully ‘surf the boundary between ways of knowing’96 and ‘critical friends’. 117,118 ‘Critical friends’ implies researchers who are aligned with non-academic institutions, but remain able to be critical, or non-academics who develop an expert voice and agency in knowledge production by virtue of their insider status. 119

Domain 4: space–time

Time and space are highly visible points of interest in knowledge co-production literature. Conventionally, time is imagined in a linear way, with knowledge first produced, then moved into policy or practice settings; provisional arrangements may be made around a variable but linear process of production and dissemination. Moving along this spectrum, time can enfold different collaborative stages that repeat and overlap or become more consciously iterative. In the radical ideal, ongoing production and ongoing application are in a mutually constitutive continuous cycle of renewal.

Space may be strictly divided between separate research and practice locations, or attention may be given to in-between, liminal meeting points where institutions begin to overlap. A blurring of boundaries and conscious challenging of spatial designations characterise more committed and radical forms of co-production.

Domain 5: aesthetics

Knowledge co-production involves an aesthetics of attitudes, dispositions and emotional attunement that resonates across domains. Preferences for simplicity, rigidity and predictability in more conventional forms merge into a tolerance and interest in social complexity in intermediate forms of knowledge co-production. Beyond this, there is a positive solicitation of emergent outcomes, and an attraction to collective knowledge states that cannot be foreseen (implied in more radical approaches).

Alongside this, we find different valuations and language around emotions. Emotions can be marginalised, or a manageable complication to knowledge mobilisation and application; can be a complementary and useful form of rationality; or can be of foundational value in themselves as part of knowledge-making processes. At the radical extreme, the emotion/rationality distinction disappears, as communal production becomes shared, embodied and affect infused.

Assembling the published literature

For our review of the embedded research literature, we used a modified CLUSTER (Citations, Lead authors, Unpublished materials, Google Scholar, Theories, Early examples and Related projects) method. 157 This approach to systematic reviews of complex interventions was developed as a way of providing both contextual thickness (an adequate description of the intervention and its context) and conceptual richness (the theoretical and conceptual development that explains how an intervention is supposed to work). The developers of the method argue that this level of detail is unlikely to be present in a single publication, but may be present in a ‘cluster’ of related publications and materials. We reasoned that this method would help us better understand the intent, structures and processes underpinning embedded research initiatives. The aspects of the method that we used are outlined in Figure 4, adapted from Booth et al. 157

FIGURE 4.

Aspects of the CLUSTER method used in our study. This figure was created using the logic and approach as laid out in Booth et al. 157 Pearl citation, a key paper on an identifiable initiative that acts as a retrieval point for related outputs that may help to explicate theory or understand context; cluster search, a systematic attempt using a variety of search techniques to identify papers or other research outputs that relate to a pearl citation.

We began by assembling a database of 45 potential ‘pearl’ citations (papers focusing on an identifiable embedded research initiative; see Figure 4) from different disciplines including education, health and urban development. These citations were sourced from a review conducted by members of the wider team in 2015,158 from database searches between that review and January 2018, and through personal contact with key informants.

We discarded those citations that did not focus on a specific embedded research initiative, and then grouped together those that focused on the same initiative and/or involved the same authors. This resulted in 26 distinct ‘clusters’ of papers. We then used forwards and backwards citation-tracing and author searches to identify related materials to add depth to each cluster. This resulted in a total of 47 papers across the 26 clusters.

Scoping extant schemes in health and health care

For our scoping exercise (workstream 2), we focused on embedded research initiatives in operation in health settings across the UK. These settings included public, private and voluntary sector organisations with a role to play in commissioning and/or delivering health services. We used our network of contacts; requests via mailing lists such as the NHS Contact, Help, Advice and Information Network (CHAIN); and posts on Twitter to identify potential embedded research initiatives. We kept the definition broad at this stage to capture initiatives described as embedded and researchers who defined themselves as embedded.

We identified a total of 90 potential embedded research initiatives. We then used three criteria to determine which were of most interest and relevance to this study. These focused on identity (were the researchers in the initiative trained and/or experienced in research and were they seen as a researcher by those in the health setting?), knowledge production (was the initiative designed to produce knowledge that would have direct relevance and application to the organisation?) and immersion (were the researchers physically located in the health setting for a significant portion of their working week?). These enabled us to narrow our focus to 45 initiatives, a summary of which can be seen in Tables 3 and 4.

For each initiative, we gathered publicly available information if possible (e.g. from websites). Each initiative was asked to share internal documents including role descriptions, strategy documents and reports. In this way, we constructed a database of documentation on each of these schemes (a total of 236 source items). To deepen our understanding of the varying types of initiatives, we also conducted telephone interviews with individuals from 12 initiatives, selected on the basis of diversity, taking into account their setting, longevity, structural features and overall purpose. When possible, we interviewed both an embedded researcher and the manager or instigator of the initiative, conducting 17 interviews in total. Interviews focused on adding depth to our understanding of the intent, structure and processes associated with embedded research initiatives, with the interview guide being developed from the evolving literature analysis.

Analysing the assembled materials

We used an inductive and iterative analysis process to bring together the embedded research literature and scoping materials. We began with a detailed reading of the clusters identified during the literature review, concentrating on extracting definitions, concepts and working theories associated with each cluster. Through ongoing discussion between team members, we developed provisional and emergent themes. Next, we applied these themes to materials gathered during the scoping exercise, using them to produce detailed analytical descriptions of each initiative. During this process, we sometimes identified additional themes or merged or disaggregated others (going back to the literature clusters as necessary), until the analytic descriptions gradually stabilised. Finally, we coded the interview data using the same themes, while being alert to the identification of further themes or destabilisation of existing ones. Throughout the analysis process, we compared and discussed the coded materials and descriptions, with repeated and intensive discussion across a core group (VW, TT, BR and HD) and broader sense-testing across the whole project team. Over time, we settled on a set of 10 themes, and a finer-grained set of subthemes, that seemed to represent the key features of embedded research initiatives.

Testing the emergent findings with embedded research actors

The third and final part of this study involved testing and validating the themes and putting them into an overarching framework. We held a day-long co-production workshop with embedded researchers and their managers (n = 18) that made use of a range of creative activities and was facilitated by an experienced team of researchers in design and health (see Acknowledgements). Activities included commenting and adding thoughts to postcards representing each of the themes, discussing the relative priority of each theme, and building physical metaphor models of the themes and their interconnections. Workshop participants confirmed and validated the importance and relevance of all 10 themes and suggested ways of linking the themes in a single metaphor for an embedded research initiative. This was used subsequently to derive practical guidance and web-based tools and resources for those designing or analysing embedded initiatives (see Chapters 6 and 7).

The intent of embedded research initiatives

Across the data, we were able to identify two themes relating to the underlying intent of embedded research initiatives: the intended outcomes and the nature of the power dynamics. The first of these is often to the fore in discussions about embedded research, whereas the latter often remains obscured. These are now explored in turn.

The structure of embedded research initiatives

As outlined in Tables 3 and 4, the on-the-ground initiatives that we identified were located in different institutional settings and structured in diverse ways; such structural diversity was also seen in the literature. We were able to draw out four themes that represented the various structural features of embedded research initiatives: scale, involvement, proximity and belonging.

The processes of embedded research initiatives

Just as the embedded research initiatives we identified were structured in different ways, they also made use of a wide range of processes. We were able to categorise these into four themes that represented the ways in which initiatives played out day to day: functional activities, researcher skill and expertise, relational roles and learning mechanisms.

Sampling and selection

Workstream 3 involved qualitative comparative case studies of four purposively selected examples of embedded research, although, as we show, one of these comprised additional subcases (multiple embedded researchers). Qualitative case study research affords depth, providing descriptive and explanatory understanding of any given case. Cases can be selected for a range of reasons: from the discovery or exploration of unique situations, the examination of comparative aspects or search for replicative logics, through to more conventional forms of representative sampling. 172–174

Sampling here aimed to identify and select examples of embedded initiatives that were likely to co-produce knowledge, while also taking into account key differences in their configuration that might explain how and why co-production varies (see Chapter 2). Selection was informed by the learning from workstreams 1 and 2, especially the national review of current initiatives, the emerging understanding of knowledge co-production (see Chapter 2) and the thematic summary of the design considerations and operational features of embedded research initiatives (see Chapter 3).

Through a robust and independent review process with additional moderation (detailed in Appendix 3), four cases were identified, reflecting differences in approach, outcomes, setting, scale, employment, maturity and location, as set out in Table 6. These sites were selected to explore anticipated variations in approach, outcomes, settings, scale, employment, maturity and location, with these considerations being informed by the design choices and operational features developed in workstream 2.

Preliminary discussions with key gatekeepers signposted us to important individuals and groups involved with each initiative. We also used a ‘partner identification tool’ (see Appendix 1, Figure 13) to identify additional stakeholders for each initiative. Ultimately, we sought to identify those practitioners, managers, commissioners and patients who, in different ways, supported, worked with and interacted with the embedded researcher. Appendix 2, Table 19, offers an overview of the participants from each site. After appropriate ethics and research governance permissions [see the project web page: www.journalslibrary.nihr.ac.uk/programmes/hsdr/165221/#/ (accessed 18 February 2021)], these people were contacted by e-mail and invited to participate in the study. The invitation to participate, including details of the project and use of data, and the consent form can be found on the project web page [www.journalslibrary.nihr.ac.uk/programmes/hsdr/165221/#/ (accessed 18 February 2021)].

Data collection

We used a range of qualitative research methods to collect and analyse data, including semistructured interviews, focused observation and reflective diaries. In practical terms, these were organised with each participating case through a series of site visits over a 12-month period with the intention of studying changes over time. For the more geographically remote sites, on-site data-gathering took place over two discrete periods, each of 2–3 days’ duration, supplemented by multiple and various physically distanced interactions (telephone and e-mail). One site was more local to the research team, making multiple day-long visits possible. In total, each site received around 7–10 days of observation.

The initial site visit involved introducing the research to key study partners, carrying out the initial interviews with the embedded researcher and key partners, observing aspects of day-to-day practice and observing one or more planned meetings. On subsequent visits, we conducted follow-up interviews with the embedded researcher and additional partners (identified through the use of the partner identification tool; see Partner identification tool), and we carried out additional observations and shadowing of embedded research activities.

Between visits, additional short telephone interviews were carried out with each embedded researcher to discuss ongoing and planned embedded research activities. The research methods are detailed in the following paragraphs and elaborated on in Appendix 3, with major data extracts in Report Supplementary Material 3.

We recorded 46 formal interviews with 31 participants across the four case study sites. Interviews were usually one to one; some were completed face to face, others over the telephone (see Appendix 3, Table 19). Participants included embedded researchers and members of their wider network, identified through use of the partner identification tool and a broader ‘snowballing’ approach. We also completed extensive informal interviews as part of the periods of observation. The observations took place at three case study sites (Evansville had already concluded), and included observing a variety of specific events and more generalised shadowing of the embedded researchers in their roles (specific details of which can be found in Report Supplementary Material 4). Further details on each of these modes of data gathering now follow.

Data analysis

We designed a co-production workshop with the aim of testing preliminary ideas and themes to develop a shared understanding of the in-depth case study findings. The workshop was attended by embedded researchers from three of the four cases and members of their wider teams; other colleagues from the embedded network (and some who attended the first workshop) also attended. Workshop 2 was facilitated by Kaleidoscope Health and Care colleagues (see Acknowledgements). The event was thought-provoking and engaging, and we gathered extensive feedback. These outputs were particularly helpful for the workstream-3 analysis and also fed into the work of workstream 4.

The initial (descriptive) account for each case is presented in the following section. Further details of the analytic strategy, together with significant data extracts, can be found in Report Supplementary Material 3. Through descriptive overviews of each embedded initiative, we sought to show how and why embedded researchers developed their roles, what activities they undertook to co-produce and translate knowledge, what types of relationships they developed and the boundaries they negotiated, and what types of impact they made on translating knowledge into everyday practice. For each case, we looked at the:

• backstory to the initiative, including when it was established and the organisational context, such as employment positions

• rationale and specifications for establishing the initiative – its strategic reason

• features of the embedded researcher, such as their professional background and experience

• key relationships the embedded researcher developed or used in their work, including those in university and NHS contexts

• PPI built in to the initiative

• embedded activities that reflected the particular rationale and specification

• achievements and challenges that characterised the initiative.

In the next section, we outline the findings case by case under each of these headings, before exploring in more detail the diversity and range of experience for each of the descriptive categories.

Bridgetown

Bridgetown is a hospital-based initiative in Scotland that was formed through collaboration between an NHS trust and its local university. At the time of the study, the embedded researcher (Anna) had a joint appointment with both organisations and, in broad terms, was engaged in providing academic and professional input to a portfolio of service-facing research and improvement activities. She had a particular interest in implementation science and knowledge mobilisation theory. As Anna’s role was in its infancy, her time was spent mapping out the research culture and building relationships. Her early findings suggested a commonplace fear among front-line staff relating to academia and research; however, she was already beginning to receive positive feedback regarding her role, from the NHS trust in particular.

Coxheath

Coxheath is an acute hospital-based embedded initiative located in the South East, formed through a collaboration between an NHS trust and a local university. The initiative was well established (in excess of 8 years) and focused primarily on the role and activities of one embedded researcher, Jane, who had a joint appointment with both the trust and the university. Her role encompassed various work related to practice development, implementation and evaluation. Jane had established a broad network with multiple stakeholders, inside clinical practice, in academia and elsewhere: her collaborative relationships were at both a national and an international level. The impact of Jane’s work – and as such, the initiative – was far-reaching; however, Jane felt that her role had not yet been used as effectively at a strategic level as it might have been.

Porter

Porter represented a relatively distinctive case study. Rather than involving a single researcher, it comprised five embedded researchers working across four initiatives or areas of activity in an NHS trust specialising in community and mental health services. Together, these initiatives represented an embedded research portfolio that was nominally led by Carol, who, as the trust’s head of research and development (R&D), was responsible for some aspects of the embedded research initiative and acted as the trust’s primary link with the local universities and research ecosystem.

The five embedded researchers worked on different initiatives across the trust’s clinical divisions, typically with direct line management within the relevant division. Some of these roles could perhaps be interpreted more as traditional clinical research or quality improvement posts, rather than as embedded researchers seeking to co-produce knowledge. However, the participants and the oversight lead (Carol) did construe them as embedded researchers. The researchers faced individual challenges in their roles, but there was a shared sense of achievement relating to the sustainability of the initiative.

Evansville

This initiative was located in a large acute hospital trust and was funded for 3 years from April 2014; it has now ended and, for the purposes of this study, represented a mature and concluded initiative. Over its course, the initiative was characterised by a number of different configurations as the embedded team worked on different applied research projects, each requiring a slightly different working model. As the funding was not extended for this initiative, sustainability and legacy were relevant concerns. Despite the lack of ongoing funding, there was still a sense of enduring impacts relating to the research capacity-building undertaken, with ongoing developmental research projects and relationships.

Backstory

Here we focus on understanding the history of the initiatives, taking into account the broader context from which they developed, such as funding arrangements, primary location and current (active) status (Table 8). Clearly, the background of each initiative is closely linked to its intended purpose and specifications, as discussed subsequently, but the history is also relevant to its trajectory, priorities and activities, making its inclusion important.

An important background issue relates to the history of collaboration between different partners, especially university and NHS organisations or leaders. These vary from highly developed institutional partnerships, often in the form of clinical academic departments, to less developed collaborations often relying more on personal connections between key individuals in each organisation. Linked to this, it could be suggested that the wider environment of applied health research, in particular translational health research, also conditions the development of each initiative, for example when there are connections with other professional research and training pathways or NIHR infrastructure.

A further consideration is the extent to which the initiative was led or shaped by one partner organisation more than another, or if it represented a ‘marriage of equals’. Certainly, one initiative (Porter) had been championed by a research-active leader based in an NHS hospital trust who then nurtured connections with university partners to further develop the initiative and its specifications.

Each initiative’s contextual background was reflected in notable practical differences in configurations, such as contractual arrangements, funding, line management and accountability. Some embedded researchers were employed solely by the trust or university with honorary status in the second institution, and these arrangements seemed to matter for subsequent relationships.

Each initiative told a different story regarding its funding. For some, the original funding was ongoing; in others, the source of funding had changed over time; and in one (Evansville), it had ended. Porter offered insight into some of these challenges and the associated negotiation, sometimes ongoing, involved. Two of its researchers, Rachel and Victoria, saw significant changes in funding throughout the course of their roles, which unsurprisingly created anxiety and uncertainty for them. For many of the researchers, contractual arrangements and sources of funding were split across different organisations; line management and accountability were therefore sometimes shared and came with competing ideals in relation to the purpose of the initiative. Researchers often had to juggle expectations in response.

The study found that each initiative had been devised, designed and established at a particular time to address a set of specific and locally significant issues that had been identified by one or two strategic partners. In all cases, however, the focus and significance of issues evolved over time, influenced by changing organisational priorities and expectations and by the experiences and expertise of all parties. As such, the more developed or ‘mature’ initiatives – those with a longer history – often had a clearer, more evolved sense of purpose. Bridgetown was a prominent example of this, whereby the experiences of the initial embedded researcher, Jill, had provided lessons for the current, ongoing initiative and her successor, Anna. Anna’s role was specifically designed to reduce the risk of the challenges Jill had faced, relating to the overall objectives, degree of impact and practical issues such as workload.

In terms of promoting the development of embedded research, each case had one or two ‘champions’ who strongly advocated the need and potential of the embedded approach. For example, the chief nurse at Coxheath (at the time of role construction) engaged with constructing a dual role and collaborative working across the university and her local hospital. In Porter, all five embedded researchers described how one or two senior people had helped get their roles off the ground and sustained them, alongside the background support of Carol (head of R&D at the trust). Embedded initiatives appear to need an advocate or champion operating at a relatively high or strategic level, who can ‘see the big picture’ and influence organisational and interorganisational decision-making, leverage necessary resources and legitimise the risk of investment.

Rationale and design specifications

To understand the rationale and specifications of each initiative, we examined their aims and intended purposes as linked to their particular background (Table 9). This analysis was informed by the findings of workstream 1, specifically the differentiation of initiatives according to their approach towards co-production (i.e. from the more conventional to the more radical; see Chapter 2). We also observed how the intent and purpose of each initiative changed over time.

Across the four cases, there were significant and stark differences in how each embedded initiative was specified in terms of purpose. This revealed important differences in how ‘embedded research’ as a broader concept or construct was seen by the wider health-care and health research communities. Initiatives were intended to address markedly different issues, such as:

• capacity and capability development (organisational or professional) (e.g. Bridgetown, Coxheath)

• professional development for nursing and allied health professional (AHP) staff [e.g. Bridgetown, Porter (Victoria and Rachel)]

• research development (design, planning and management) (e.g. Coxheath, Evansville)

• research translation and use (dissemination and mobilisation) [e.g. Coxheath, Bridgetown, Porter (Victoria)]

• applied (co-produced) research projects (e.g. Coxheath)

• service improvement projects (e.g. Porter, Evansville)

• service evaluation [e.g. Porter (Katrina and Bev)].

In all cases, there was no single or sustained purpose; rather, each initiative addressed multiple purposes that matured and developed over time. The experiences and interests of the embedded researcher(s) could have an important bearing on how these aims and purposes evolved, especially as they could bring new ideas to the initiative or mediate between the strategic priorities of multiple organisations. We found, for example, that the Coxheath initiative was shaped by the embedded researcher’s passion and commitment to professional development and co-creation. There was, however, arguably less scope for the researcher to influence the initiative’s rationale and direction when working as part of a team or with less organisational or strategic involvement. For example, some researchers at Porter, particularly those with bounded roles in service improvement, appeared to have very little influence over the purpose or direction of their role.

Although the explicit rationale and design specification of each initiative differed (through job specifications, descriptions and other documentation), there were also evident similarities in, for example, the translation of evidence into practice; empowering of front-line staff; transformation of the research culture; and, ultimately, the aim of improvements to service delivery.

Importantly, there was no single or shared understanding of the purpose of embedded research initiatives, a finding that echoed the conclusions of workstreams 1 and 2 (see Chapters 2 and 3). In each of the case studies, the embedding was designed and evolved against the backdrop of a particular institutional context to address certain strategic or operational priorities for research, research use, staff development and service improvement. However, the precise configuration or specification of these purposes varied according to the influence of key partners in the background and design, and the experiences of key stakeholders in the operation and maturation of the initiative. Significantly, embedded research could mean different things to different groups, and one of the roles of the embedded researcher could be to mediate and reconcile these differences in their own work.

The embedded researcher

As the previous sections suggest, embedded research initiatives are, in many ways, defined or differentiated by the embedded researcher(s), who, in many ways, provide the tangible focus and actionable work of the initiative (Table 10). We investigated each researcher in terms of their professional background, career and history; motivations and aspirations for undertaking the role; perceived skills, strengths and qualities; and understanding of the purpose and significance of embedded research.

Embedded researchers in the four cases held a variety of formal titles. Anna from Bridgetown was an AHP research lead and university lecturer – clinical academic. Jane, at Coxheath, was a university professor of practice development, research and innovation and an NHS trust research centre co-director. At Porter, Rachel was an NHS trust senior research associate and university honorary fellow; Bev and Katrina were service evaluation and research associates at their NHS trust; Karla was an NHS trust service evaluation analyst; and Victoria was a university associate professor of communication in mental health, an NHS research consultant and an NHS and associate research lead. Finally, Bella from Evansville was an embedded researcher team member and anthropologist.

The embedded researchers thus varied in a number of key areas or dimensions that provided important points of comparison and shaped how their initiatives functioned. These included the following:

• clinical or non-clinical background, affording different levels of understanding of clinical practice, culture and care organisations or health (or other academic) research environments and priorities

• specialism, in terms of their area of professional (e.g. nursing, AHP) or research expertise (e.g. clinical, social science, translational)

• level and type of qualification, especially whether or not the embedded research was trained to doctoral level in an area relevant to applied health or translational research

• motivation, relating to their personal interests and commitment to embedded research and knowledge co-production, especially the perceived benefits to organisational and professional partners.

There appeared to be a marked difference between ‘traditional’ academic researchers in embedded roles and embedded researchers with a professional clinical background who had subsequently trained to doctoral level in an area of applied health research. The latter background gave the researcher a dual and combined understanding of two relatively distinct areas of practice, with relatively high levels of credibility in both domains (through professional and doctoral qualifications). Therefore, they seemed more qualified and legitimate to work across the boundaries of research and practice than those who might have primary qualifications in only one area.

Porter was a particularly interesting example in terms of diversity. Here, one initiative housed a mixture of professional backgrounds. For example, one researcher had a psychology background and a PhD in family therapy, and another had degree-level qualifications and experience in pharmaceutical research. These individuals’ backgrounds held a relevance both for their own embedded roles and for the initiative more broadly: the former influencing a broader, interdisciplinary network and contributing to organisational and strategic priorities, whereas the latter carried out work largely bounded within a specific clinical context.

Perhaps most interestingly, despite the significant diversity between researchers, we found similarities in the embedded researchers’ motivations in undertaking the role. There was a strong shared sense of the potential for research to provide tangible and applied ‘real-world’ change in the design and delivery of health services, and to improve patients’ experience of this care. This motivation was also relevant for those supporting the initiatives, particularly initiatives based in clinical practice.

Relationships

Key to the role of the embedded researcher is the ability to develop, use and broker relationships within and across the research and practice boundaries. We therefore investigated each embedded researcher’s patterns or networks of relationships, and how they understood these networks as informing and supporting their activities. To do this, we used the partner identification tool (see Partner identification tool and Appendix 1) in conjunction with qualitative interviews. The tool helped participants think about, identify, appraise (in terms of frequency or quality) and categorise (as NHS, university, other) their relationships.

The study found that interpersonal relationships, and the strength of these relationships, were fundamental to how the initiative was configured and functioned. Key contacts (Table 11) were seen as fundamental for each initiative’s success and sustainability, and also played an important role in securing and maintaining funding. As noted previously, such ‘champions’ offered sponsorship, endorsement and a degree of protection for the researchers and for their initiatives more broadly. These individual champions spanned clinical settings and university, although examples of the former were more widely noted. Champions tended to be those in senior management roles with associated status and power, with the ability to ‘open doors’, fight the researcher’s corner and ensure that they had ‘a seat at the table’.

The diversity and scope of the researchers’ networks and intrinsic relationships differed greatly. These networks can be seen most clearly in the completed partner identification tools for each embedded researcher depicted in Figures 5–11 [note that Bev and Katrina at Porter (see Figure 8) completed their partner identification tool together].

FIGURE 5.

Embedded researcher key partners: Bridgetown – Anna.

FIGURE 6.

Embedded researcher key partners: Coxheath – Jane. HEE, Health Education England; HR, human resources.

FIGURE 7.

Embedded researcher key partners: Porter – Rachel.

FIGURE 8.

Embedded researcher key partners: Porter – Bev and Katrina.

FIGURE 9.

Embedded researcher key partners: Porter – Karla. QI, quality improvement.

FIGURE 10.

Embedded researcher key partners: Porter – Victoria. CAMHS, child and adolescent mental health services; QI, quality improvement.

FIGURE 11.

Embedded researcher key partners: Evansville – Bella.

As the completed tools show, all embedded researchers had developed relationships across university and NHS organisational boundaries, but it was also clear that some relationships were weighted towards one more than the other, often depending on their background and contractual location or home. Given the focus and intent of all the embedded researcher initiatives (largely, research-informed service improvement), relationships within the NHS (especially NHS trusts) were seen as especially important. Moreover, some of the researchers at Porter (Bev and Katrina in particular) had very few academic relationships and infrequent contact with academia because of the ‘service evaluation’ nature of their work. As a result, university contacts were informal and based largely on involvement with previous treatment trials in their clinical setting. In comparison, but also at Porter, Victoria had strong, formal (contractual) relationships with both practice and academia. Again, the intent and purpose of her role was relevant: it was much more flexible, diverse and targeted at a broader organisational and strategic level.

In addition, some embedded researchers had large local, regional, national and international networks, involving a range of different stakeholders and collaborators. These could be drawn on to enrich the work of the embedded research (in terms of new or different ideas) and also to spread learning beyond the local initiative.

Overall, our research found (albeit to varying degrees and reflecting their particular backgrounds and contexts) that the embedded researchers acted as relational conduits or brokers within and between different communities to support the (co-)production, dissemination and utilisation of research to address particular strategic and operational purposes (see Embedded activities).

Most significantly, relationships with senior actors, within either or both the NHS and university sectors, were seen as particularly important for the success of each initiative. In broadly similar ways (but varying according to the level and experience of the embedded researchers), these relationships provided:

• clarity and assurance about the embedded role and initiative (intent and purpose)

• ongoing mentorship, support and guidance (for academic and/or clinical development)

• sponsorship or buy-in for embedded research initiatives with third-party groups or organisations, by ‘opening doors’ and ‘providing air cover’

• additional support and assurance around contractual and funding matters.

Researchers, then, were embedded, not just in service-related settings, but in dense and diverse networks across multiple institutions. Creating, maintaining and navigating these networks was clearly a major part of their day-to-day activities.

Patient and public involvement

The level of engagement with formal PPI groups in the embedded initiatives was variable, as were the structures and mechanisms that underpinned this involvement (Table 12).

This finding only illuminates further the level of diversity (in intent, structures and processes) across the case studies, especially in terms of stakeholder involvement. Often this relates to the nature of the embedded researcher and the distinction between an explicit embedded researcher team (e.g. Evansville) and a single embedded researcher working on various, individual projects (e.g. Coxheath). As an example of the latter, as noted in Table 12, PPI at Bridgetown was not relevant for Anna’s broad embedded role, but was relevant for external projects [e.g. through INVOLVE at the NIHR: see www.invo.org.uk (accessed 3 March 2021)] and also in terms of her capacity-building work, whereby Anna pointed clinical staff towards more effective PPI in their own work.

It is important to note that experiences of PPI were shared only sparingly during the interviews and observation periods, although specific questioning by e-mail did elicit useful additional data. An analysis of the relational dimension for the PPI activity set out in Table 12 is offered in Chapter 5.

Embedded activities

The embedded researchers took part in a variety of activities and tasks commensurate with the prescribed intent and specification of their initiatives; so some activities in those initiatives oriented towards capacity development differed from those more concerned with service improvement. We observed striking differences in relation to the diversity and variability of these activities between initiatives, as outlined in Table 13.

Detailed examples of the spectrum of activities in each of the case study sites are given in Report Supplementary Material 3, but, in brief, these comprised different mixes of the following:

• capacity development – supporting and reviewing funding applications (e.g. master’s degrees or PhDs); methods training; assisting with individual projects (research design and implementation); mentorship, support and encouragement; relationship-building; signposting

• improvement – service evaluation (information collation, report writing and dissemination), quality improvement (e.g. individual project support and supporting broad organisational agenda), supporting clinical colleagues with involvement in improvement work

• research development and use – writing for publication (academic and practice audiences); grant applications; presentations (e.g. at conferences, events); networking and building opportunities for collaboration; implementation and dissemination.

As with other aspects, the embedded activities often evolved over time. In some cases, this change of focus was less visible or perhaps even intended. For example, as the research team at Evansville became established and relationships with front-line staff grew, the researchers found that their involvement in capacity and capability activities also developed and became more prominent. This had implications for their workload (as their role and work related to ongoing health services projects). The success of this ‘extra’ work left a void in some areas when the initiative ended.

Activities associated with more ‘traditional’ and ‘original’ research were also diverse, again relating to the overarching purpose of the initiative, but also the individual role. For some, contact with research in this sense was in building site capacity for randomised controlled trials. For others, they took part in funding applications, publications and various dissemination activities, offering a further example of contrast between roles in different initiatives.

The level of activity relating to strategic involvement and influence was also an important observation when examining the embedded researcher’s role: their strategic ‘voice’ either directly or indirectly was variable. For some, attending senior management team meetings was an explicit part of their role, for others their ‘attendance’ was indirectly through line managers and key strategic-level contacts. Some researchers undertook no activities outside their clinical specialty or department. In the main, the potential to engage embedded researchers in strategic activities was not always thought to have been fully realised.

Achievements and challenges

Embedded researchers and identified stakeholders were asked to reflect on the achievements and challenges of the initiative. There were stark differences in responses both within and between case study sites, suggesting differences in the perceptions, expectations and assumptions of participants. In other words, it was not easy to list achievements that were universally recognised or agreed on; rather, each local stakeholder group saw particular benefits and achievements, but also challenges, with each initiative (Table 14).

Despite the diversity of intentions and processes among the different initiatives, we were able to collate insights into some possible criteria for assessing and measuring success. Key areas where the nature of success might be explored include:

• capacity development – positive staff feedback; clinicians engaging in further research training and seeking out support (e.g. workshops, enquiries, e-mails); clinicians applying for grants, further research education (e.g. master’s degrees, PhDs, scholarships); front-line staff presenting at conferences and other events

• improvement – tangible outputs such as report writing at departmental level (achieving deadlines), meeting the requirements of governance (relating to improvement involvement), interest and engagement with improvement initiatives from front-line staff, changes to practice based on findings

• research development and use – grant applications (number and quality), publications (number and quality), uptake of findings in practice (impact case studies), international collaborations (and uptake of findings outside own organisation, nationally and/or internationally).

Importantly, the degree and nature of achievement of each initiative reflected, in part, their maturity. For example, one embedded researcher had been in post for only 12 months, limiting the scope or reach of their achievements, but also making more noticeable the significance of their impact in such a short time, especially in terms of building new relationships and networks around the role. In comparison, another long-established multiresearcher initiative showed individual role achievements (largely service improvement) and a broader sense of longevity.

Given the challenges of measuring success or achievements, it seemed that, when initiatives were more narrowly defined in their specific activities or goals, stakeholders were more able to comment on their relative success in delivering within an agreed time frame. Similarly, and again noting ambiguity, roles that were less bounded (in terms of focus, activities and scope) were often victims of their own success, and personal capacity became problematic. This was less challenging in roles bound by the requirements and focus of a specific project, service or department. Conversely, those with more ambitious or ambiguous aims, such as capacity-building or cultural change, could be seen and assessed in less concrete ways, with the likelihood of disagreement among stakeholder groups as to the level of success attained.

Presentation of findings

In presenting the cross-case analysis, we use the 10 subthemes identified in Chapter 3 that encapsulate the domains of attention required in designing and describing embedded research initiatives.

These subthemes are arranged under the three headings of ‘intent’, ‘structures’ and ‘processes’, and these overarching categories provide the ordering for the findings presented here, with subthemes as follows:

• intent – intended outcomes, power dynamics

• structures – scale, involvement, proximity, belonging

• processes – functional activities, skills and expertise, relational roles, learning mechanisms.

The names and basic contours of the four cases were laid out in Chapter 4 (see Table 7). The individual embedded researchers are also described in Chapter 4, and cross-referencing to Table 10 and the full list of interviewees, including other stakeholders, in Appendix 2 will be necessary to make sense of the findings presented here. Fuller case accounts, with extensive data, are presented in Report Supplementary Material 3.

Intended outcomes

Analysing and comparing the case studies in terms of their intended outcomes demonstrated considerable variation between initiatives, and showed that the intended purpose and outcomes of a given initiative are likely to change over time. In all cases, there were important, but often subtle, changes in emphasis between producing knowledge, building capacity and enhancing reputation, which reflected broader transitions in the strategic priorities of NHS organisations and the evolving expertise of the embedded researchers.

Different partner organisations (NHS and university) and key actors (the embedded researcher, line managers, front-line staff) could hold divergent expectations about the purpose and intent of the initiatives. This was a potential source of tension as the researchers tried to meet the expected and preferred outcomes of various parties.

A strong example of this was when embedded researchers faced competing intentions from academic and clinical practice, in terms of which type of outputs were valued: research publications for university assessment or service-facing development outputs. In cases where the researcher had two sets of competing expectations and outputs, they sometimes found creative means to meet multiple requirements at the same event, for example raising the clinical trust profile while presenting to a wholly academic audience:

So, in terms of your week then, 2 days here, 3 days there, does it look like that in practice?

No [chuckling], no, because I would have only been doing that if I was rigid about it; because the reality is, that there’s always things going on in both organisations that you need to be at, and some of those events actually benefit both organisations and that’s great . . . it makes me happy because that way I can do a bit of both jobs in one afternoon . . . For example, I’m going up to [place] to present to [academic conference] in November. That really benefits the trust – I shall, you know, put the trust banner on my presentation, and it’s all kind of clinically relevant research, but I can also count that as academic work because it’s research, and research is part of my academic job as well . . . So, it has a double benefit.

It sounds like there’s still two sets of priorities then?

Oh yeah, very different sets of priorities as well.

For senior NHS managers, the over-riding intention, in many cases, was capacity-building, specifically capacity-building that influenced patient care directly and delivered ‘real cultural change’. The researchers themselves shared similar intentions and were motivated by the potential to grow a research culture, change perceptions of research and ultimately improve staff and patient experience.

In this sense, there was sometimes a sense of superiority associated with the intentions of the embedded researcher, who had different expectations of their work to that of more ‘traditional’ academics:

I don’t want to be a full-time ivory tower academic [who] does research that’s philosophical or abstract or metaphysical or any of those kind of things. I wanted to do research that had some applied meaning, that would mean something to children and families.

Victoria, embedded researcher, Porter

The evolving and sometimes competing intentions and motivations of initiatives could put pressure on the embedded researcher, with practical implications for workload and their personal capacity. Anna, the embedded researcher at Bridgetown, was aware of this from the outset, particularly in relation to the work associated with research capacity-building (a strong intention underpinning her NHS support network). She had learned from her predecessor, Jill, that, to influence large-scale change, her approach would need to adapt:

One of the things I learned from Jill’s experience of having done a similar role before, running grant-raising groups . . . [you develop] one or two people who go on to have great careers, but they have great careers from an academic standpoint so they, they move over, they cross that boundary . . . So it doesn’t break down the boundary, it just helps one or two people cross over, as opposed to changing the system and how it works and dismantling the boundary or creating different boundaries.

Anna, embedded researcher, Bridgetown

Addressing and balancing multiple intended outcomes was central to these embedded research initiatives. Moreover, what was intended was not always explicit, fixed or even realistic, and the embedded researchers needed to pay close attention to the evolving discourses among partners and to be prepared to flex as appropriate.

Power dynamics

We observed how embedded researchers occupied an arguably unique space between clinical practice and academia. This often meant that the researcher must work across, and sometimes against, existing ‘silos’.

One of many implications of this was the distribution, and sometimes redistribution, of power and control, both for themselves and others. In some examples, such as those noted in the previous section, this redistribution of power and control was intentional; one aim of capacity-building was seen to be for front-line staff to gain more power and control to bring about change in services. There was a general sense that this change in dynamic was needed, although its far-reaching implications were possibly not always fully understood by those endorsing it, and, despite this widespread drive to empower front-line staff, researchers felt that organisational structures were not always ready for this change.

Jane in Coxheath, an experienced embedded researcher, offered her insights into ‘speaking truth to power’ – in this instance, that meaningful culture change (and power shifts) were unobtainable, being restricted by leadership styles and values:

There’s no sign-up from the executive team, and the executive teams themselves don’t have the shared values . . . I try and help the organisation to recognise what they’ve got to do to support our front-line teams . . . If you look at [name] report, the [name] report culture is the most frequent work, but they’re talking about organisational culture, not microsystems and I don’t think our chief exec[utive] understands the difference or why one is more important than the other.

And the interplay between them?

Yeah, the interplay between . . . I don’t feel there’s anybody else supporting the microsystems side, so I have to exaggerate their importance to get people to listen.

You’re saying things that people necessarily don’t want to hear?

Yeah, you’re speaking the truth to power?

‘Speaking truth to power’, in some form, was an established part of the embedded researchers’ role, and the respondents all shared their varied experiences of being a ‘critical friend’. This required a strong interpersonal skill set, contextual understanding and sometimes diplomacy (see Skills and expertise). It also required the embedded researcher to maintain professional objectivity and avoid ‘capture’ by the settings in which they were embedded.

For example, projects undertaken by the Evansville team regularly involved feeding back findings to senior NHS stakeholders. The tensions involved here were intensified for the researchers when findings were perceived as unexpected and sometimes uncomfortable. In these instances, the researchers shared how crucial it was to have senior support from outside the clinical setting, namely a senior academic to whom they could ‘diffuse’ responsibility when situations became difficult to manage:

I think that’s one of the big things around being an embedded researcher . . . all those relationships, but you need to constantly remind yourself that, you know, you are there to do a particular job. You are not like any other staff member within that organisation, you’re there as a researcher, and there is that kind of academic layer to the work that you’re doing, where you need to maintain that critical point really.

Bella, embedded researcher, Evansville

Of course, power was not always addressed directly or raised overtly in the interviews and conversations during site observations. Nevertheless, issues of power – implicit, unspoken, frequently unacknowledged – ran through the data and are touched on in subsequent sections, especially those concerning proximity, belonging and relational roles. In that sense, power, like ideas of identity and boundaries (straddling, crossing, breaching or maintaining), suffused and cut across many of the meaning categories created in the review and scoping work of Chapter 3.

Scale

The scale of the initiatives ranged from a single embedded researcher to an embedded team of up to five. Some schemes were bounded and time limited; others were more open, emergent and evolving. There were differences in terms of configuration too; for example, the Coxheath initiative was primarily configured and constructed around Jane as an individual, whereas Evansville was configured around an evolving portfolio of projects. Porter was different again, with an overarching strategic priority and focus to the configuration aimed at building research capacity and capability. The descriptive accounts in Chapter 4 outlined some of these differences in more depth.

Despite these differences, there was a sense that, in their timescales and overall life cycles, initiatives had identifiable stages of development: initially an incubation period, followed by formalisation and then a developmental stage, and finally (for fixed-term projects) a conclusion.

In the incubation period, relating to a specific individual, group or intention/idea, the initiative would begin to grow and the foundations would be laid, including the building of important relationships, ‘buy-in’ and extensive discussions over many months or even years. In Bridgetown, for example, this growth started under an earlier role-holder, Jill, developing the intentions of the role and identifying the key academic and practice stakeholders.

The initiative would then be formalised to a certain degree with role specification(s) and appointment(s) to address a given issue or project. This would include many practical considerations and arrangements, surrounding contracts and lines of reporting. At Porter, this phase in Victoria’s role offered helpful insight into the complexities of funding and contractual arrangements, in line with various expectations and intentions of the role:

I was in post for a very long time before I started to work out exactly what I was supposed to be doing, which was . . . kind of typical of the way these structures work; and to some extent, I was involved in writing my own job description . . . I’m employed by one of the directorates, not by the trust per se . . . so, I’m not actually affiliated with the R&D department . . . That made it even more complicated. [It’s] one contract with the university, that the trust buys out for 2 days a week, so it was set up as a university post, with trust partnership. So, the trust pay the university my salary for 2 days a week.

Victoria, embedded researcher, Porter

A developmental period would then follow. During this, the embedded researcher would demonstrate their potential and the role would grow; often the details of the role (particularly in terms of the nature of the work) would change and evolve in line with various expectations and demands. In many instances, the role undertaken would be different from that proposed and the overall workload larger than anticipated. Karla’s main duties in Porter related to service evaluation, but, as her role grew, she also became heavily involved in the trust’s quality improvement strategy: extra work that was not part of her original role.

In some instances, the initiative would then come to an end, as in the case of Evansville, where funding stopped at the end of its fixed timescale. Even so, there could be a degree of influence ‘left behind’ by the completed projects, in terms of increased research awareness, cultural change and service improvement. Bella, formerly at Evansville, said she was still contacted by members of the NHS trust for advice and support.

Many initiatives however – like three of the four studied here – would be funded indefinitely, with the embedded researchers on permanent contracts. As a result, the timescale of individual projects and activities would become important, rather than the duration of the overall initiative. Maintaining researcher objectivity over such longer timescales might become a concern. Scale and longevity, then, would sometimes be planned from inception, and, at other times, would emerge contingent on local circumstances.

Involvement

The teams surrounding the initiatives tended to be relatively small, compromising largely line managers and senior academic support, before branching outward to team members. Each initiative and embedded researcher had a distinct configuration or network of relationships. The partner identification tool used in the interviews helped us to identify those involved with the initiative (rather than the projects/work undertaken by the researcher in this instance), and how intrinsic their involvement was. The schematics drawn from use of that tool are displayed in Figure 5.

Each researcher identified two or three key contacts, often those to whom they reported directly or indirectly and who they felt had fundamental involvement with their work. These individuals often held senior positions in either the academic institution or the NHS, and the embedded researcher often described being ‘accountable’ to these individuals. In line with this seniority, such key contacts usually provided the embedded researcher with a degree of protection and a voice at a senior or strategic level. They were often important in ensuring funding and also access to other areas of the organisation, setting the tone from a senior level. There was universal agreement that, without these individuals and their ‘buy-in’, the embedded roles would be unsustainable.

Moving out from the centre of the partner identification tool, the individuals and groups came from a variety of sectors. Unsurprisingly, other members of the NHS team, often clinical specialties and/or professional group members (managers and department leads), were seen as important. In addition, relationships with members of the trust R&D teams were quite often seen as necessary. Again, these individuals brought access to front-line staff and their knowledge or expertise around each specific clinical context.

Academic colleagues were also identified here, showing collaborative relationships. The degree of importance placed on these formal and informal academic connections differed depending on each role. In some cases, senior academics (at dean or professorial level) were responsible for line management, but many of the academic relationships were with peers and brought shared research interests, support and a critical friend for the embedded researcher. In most instances, these relationships had been built over many years and their involvement and inclusion were of mutual benefit. Karla (Porter) offered her experience of the involvement she shared with colleague Victoria (also embedded at Porter):

So another person that I . . . have quite a bit of contact with, but I don’t know, I don’t know how to put her in terms of influence, is [Victoria] . . . Talking to her, she spans across the trust and [place]. So yeah, I suppose she’s, she’s very much like a partner, partner in crime, I guess.

So, between us we run the quality improvement group for the directorate . . . She was brought in as the strategic lead to basically get research on people’s agendas. So she is, in terms of the pecking order, very high up within the organisation, and it was her job to integrate research into people’s day jobs . . .

I’d say [she provides] peer support to be honest, because we meet every couple of months, and we just chew the fat about life in the different organisations and things . . . Because [Victoria] is still quite active in actually doing research, doing evaluation. So, it’s kind of peer support, that she’s done a PhD, I’ve done a PhD, and there aren’t many of us, what are we doing with that now? So, with that one it is more peer support, I guess, and thinking about and talking about the development of the quality improvement agenda.

Karla, embedded researcher, Porter

Other sectors involved with the embedded initiatives included non-profit organisations and wider collaborators including national and international partners (e.g. NHS England and NHS Improvement). In these instances, the embedded initiative might provide consultancy or informal input to other organisations or agencies. Students were also frequently included in the identification tool, their involvement relating to shared interests, capacity- and capability-building, and mentorship.

It is also important to note the involvement of patients. Although patients were noted infrequently during the completion of the partner identification tools, the motivation to improve their experience and the care they received was reiterated often by the embedded researchers and those supporting the initiatives. In terms of formal PPI, the researchers shared diverse experiences, largely related to the nature of their role and the projects in which they were involved.

Generally speaking, PPI was undertaken for specific projects for which it was perceived as relevant, and was accessed through existing PPI groups; this included internal, trust-level service user networks, charity PPI groups (relating to specialism or illness) and national PPI representation through schemes such as NIHR INVOLVE. Other experiences relating to PPI were shared through research capacity-building work; in these examples, the embedded researchers were encouraging and supporting others to employ PPI effectively. Evansville was the only case study to set up a designated PPI panel in relation to the initiative and the role of the embedded researchers more broadly. Despite this variability and the sometimes less tangible examples of patient involvement in initiatives, their inclusion (directly and indirectly) was viewed as fundamental by the embedded researchers.

The networks of involvement then were very specific and bespoke to each initiative and often to each individual embedded researcher. Although some connections were tight (e.g. to line managers and scheme champions), others were loose and informal, forming and reforming as needs were identified and projects developed. In most cases, PPI was limited to projects rather than being linked to the overarching strategic goals of the embedded initiative. In few cases did it seem that the connections described had been fully constructed or specified at scheme inception; instead, they emerged contingently as the schemes evolved.

Proximity

Each initiative varied in terms of how its relationships and activities afforded contact and proximity with different groups. In more obvious ways, this related to where embedded researchers and research activities were physically located. Researchers at Porter were generally located within the NHS organisation, with allocated desk space, whereas researchers at Coxheath, Bridgetown and Evansville had multiple desks (as did Victoria, the only researcher at Porter with a dual contract). Irrespective of desk space, there was a sense that work location was changeable and flexible:

I have to live my life with a pair of trainers and a rucksack, because I’m never in one building long enough to just be able to settle, I have to, I run round [location] – you know, I walk up to [location A] . . . and [location B] site is right over the other side of the city and I walk there; and the university campus is all spread out over here, and in 1 day I can be in four or five different buildings.

Victoria, embedded researcher, Porter

Much of the movement between locations was done in a conscious attempt to be more visible. There was a shared sense among researchers that physical visibility, particularly within the NHS organisation, was crucial to the success of their work. Visibility was seen as intrinsic to informal relationship-building, and generated opportunities to reduce the gap between practice and academia. Karla, at Porter, said she spent most of her time at one main location, ‘the main base [because] I like to be in the thick of things’, and went on to link this to perceptions of ‘embeddedness’:

Through writing these narrative reports I’ve started to get a really, really good understanding of the service . . . I’m visible as well, people have got to know me so people will then contact me and say, ‘oh’, you know, ‘you can you help me with this’. And actually, if I was just a name, people wouldn’t necessarily feel confident to do that . . . I think part of the embeddedness as well is actually like physical proximity . . . their hub is sat sort of probably where that couple are over there [about 5 m away], they’re that close to where I am, so quite often I’ll sort of go over and introduce myself, talk to them, work with them, so it’s sort of getting to know them as well.

Karla, embedded researcher, Porter

Embedded researchers in these case studies generally prized close proximity to the organisations in which they were embedded, but often had to work with great flexibility and agility across multiple sites and settings. Being physically co-located and ‘being seen’ were literal manifestations of the metaphorical need to close gaps between research and practice and required considerable effort.

Belonging

All the initiatives brought to the fore the importance of social, cultural and knowledge boundaries, and the degrees to which actors shared particular ways of thinking, values and norms, and a sense of belonging by virtue of their professional socialisation or organisational affiliation.

Much of the hidden or unseen work of the embedded researcher involved working across and mediating the tensions between these boundaries. At the same time, however, this created certain role ambiguities for the researchers themselves. As discussed previously, the original intention of the role could evolve, resulting in researchers taking on different areas of work. In Porter, Karla’s contracted work related to narrative report writing for local service evaluation, but her role had since grown unexpectedly and she was now also heavily involved in setting up a local, trust-wide quality improvement initiative. This ambiguity of role was experienced across all of the case studies and, in some instances, had significant implications for the number of hours worked, with few boundaries in place to limit this:

Technically [I] devote 16 hours [per week] to [the trust], but the reality is I do a bit at home on top, because you can’t squeeze it into 16 hours, that’s a nonsense . . . The other 24 hours then are university hours, but again, it’s impossible to fit my university job into 24 hours . . . I do an awful lot of the evening work, an awful lot of weekend work, a lot of juggling between posts, and a lot, wherever possible, [of] double-weighting, to try and make up some of the shortfall, because I work about 80 hours a week.

The problem is that both organisations [need you] to do the job properly, and I can’t bear not to, [and I] haven’t got enough time to do either job properly unless I put in extra hours.

Karla, embedded researcher, Porter

All of the embedded researchers therefore struggled with role and identity ambiguity relating to their sense of professional self, that is whether they were clinicians or academics (or both), whether they were aligned with the needs of the university or NHS (or both), and how they cultivated relationships with front-line staff or those facing the real-world need for research and evidence.

Each embedded researcher found their own paths to navigate these tensions of belonging, and appeared to find creative ways of resolving, or at least reconciling, multiple competing roles, in turn starting to forge new or distinct identities and belonging. They often found support, and a sense of that belonging, in informal relationships: they spoke at length about these relationships, which were often with other people in hybrid or similarly uncommon roles. These relationships, and even friendships, offered a sense of grounding, and opportunities to work through common problems or difficult experiences. Notably, the workshops and formation of the ‘embedded network’ that formed part of this project (see Chapters 1 and 6) seemed to demonstrate the emergence of a distinct occupational identity or sense of belonging around the embedded researcher role itself; for example, the researchers of Bridgetown and Coxheath came to see that they had much in common.

In summary, then, belonging across multiple sites, roles and identities posed specific challenges and additional work burdens. These were often actively managed, more informally than formally, but still left considerable unaddressed challenges and needs.

Functional activities

There were substantial variations in the nature of the work undertaken by the embedded researchers and in the scale of that work. The purpose of those activities also differed to some degree. Activities and projects included service evaluation, local and regional quality improvement, and small-scale research projects (often as part of research capacity- and capability-building). In those instances, much of the work was undertaken with a smaller, more local team. In some cases, the embedded researcher might even work one to one with an individual to support or guide a specific project.

Timescale similarly depended on the nature of the work. The heavily weighted service evaluation roles were structured around report deadlines (often annual and with accompanying interim reports). Other work, such as that relating to quality improvement, might be more flexible in its time frame and be part of larger, ongoing agendas or change programmes that took place over many years.

Researchers spoke little of formal training associated with their activities. In Porter, Bev and Katrina’s activities related largely to service evaluation, although they were also involved in recruiting for large-scale clinical trials (for which their service was often a patient recruitment site):

So, we’ll do an annual report on inpatient outcomes, outpatient outcomes, which we then share with the team, look at our outcomes, see what we need to be doing better, if we can do anything differently. So, we use that in conjunction with patient experience questionnaires . . . We’ll look at [them] and say ‘is there any way that we can improve on that?’.

Katrina, embedded researcher, Porter

Our bread and butter is service evaluation, so we’re getting outcome data for our service – that’s, that is what we have to do on a daily basis, but in conjunction with that, we do have other projects going on.

Bev, embedded researcher, Porter

For insight into the sheer range of activities undertaken by the embedded researchers, we can explore the work of Jane (Coxheath) and, to varying degrees, that of Anna (Bridgetown), Bella (Evansville) and Rachel and Victoria (both at Porter). To differing degrees, all five were involved in leading more ‘traditional’, original research, including funding applications, conference presentations and publications. Jane offered the most powerful example, with a helpful contextual insight into her activities and workload. Her work often related to relatively large, regional and national research projects, many of which she had secured funding for and that had been ongoing for months or years:

So, the work in the university, there’s two projects, but they’re not always primary research and they’ve been building on, or implementing or impact-based research . . . I’m now leading the work for Health Education England [relating to the] workforce transformation type agenda . . . that’s by July. The second piece of work is for [organisation name], so they want us to help them to develop a . . . career development framework for their mainly nursing staff at this stage, for health-care support workers across hospices . . . in the trust . . .

Two big things I’m working on, one is a single capability framework across the whole system . . . and then I’ve got three priorities, which is emergency department, general ward and children’s to apply that to, so that’s really important and hopefully will link to an IT [information technology] set-up that can be used . . . by Health Education England.

Then the other thing is . . . [a] collaborative research study across the trust to . . . and then I’ve got the ongoing stuff with the clinical leadership programme and the support of the consultant practitioners . . . There’s a conference that we’ve got in June . . .

Jane, embedded researcher, Coxheath

In short, the portfolios of functional activities of these embedded researchers were often sprawling, diverse and sometimes unmanageable, with variable (and often negligible) amounts of formal training. The activities frequently reflected a large span of scale: from local improvement projects to regional or even national initiatives; from the local, informal and unfunded, to generic knowledge generation from funded formal research.

Skills and expertise

As with the portfolio of functional activities, the skills and expertise needed by embedded researchers were many and diverse. The range described tended, in part, to reflect career backgrounds, local initiative specifications and evolving relationships with wider stakeholders.

However, common skill sets were identified, not only by the embedded researchers, but by members of their wider networks. Notably, there was considerable agreement across the varying levels of seniority; for example, managers largely noted the same necessary skills identified by junior members of the team, such as doctoral students. These skill sets could be summarised as follows:

• possessing expertise and in-depth research knowledge

• making research and research processes accessible

• forming complex networks, connections and collaborations

• building strong relationships and trust

• harnessing the knowledge and potential in others

• working across hierarchies

• being committed and driven, with great stamina.

Unsurprisingly, research expertise and in-depth research knowledge were seen as central to the embedded researcher role. This assumption was shared across almost all participants in the case studies. Embedded researchers themselves naturally saw this as important, and central to their ability to adapt to new areas of research, specialties and topics. Crucially, their research knowledge gave credibility to their role:

I think that’s where the current knowledge, the current skills, the links, the experience, the knowledge and the credibility comes from; that’s what the clinical teams need, because . . . she’s not just a clinician giving advice on research, she is an active researcher giving advice on research.

So, there’s respect for that?

Absolutely, and I think that whilst my focus and priority is on that advice that she gives, I fully get and accept and desperately think we need that half-and-half split because she needs to be a currently credible researcher to give, to give the value to that research advice.

Making research and research processes accessible was also seen as fundamental to the embedded role – particularly when working to change perceptions of research and subsequently build research capacity and capability in the NHS organisation. Research was often seen as ‘out of reach’ for many clinicians and managers, and, in some instances, was deemed irrelevant. The embedded researchers’ ability to change these perceptions was seen as a necessary strength:

You said you called [embedded researcher] an ‘ally’, can you tell me a bit more about that?

[The research governance teams] are gatekeepers, and the process that you have to go through is very daunting, and the form that I’ve just sort of tried to fill out . . . it’s not the easiest of forms to do. So feeling like you’re on your own again, a barrier that you’ve got to overcome, whereas [name], well she definitely is on my side, because she had e-mailed a quick reply, I was reading it one time, she said ‘Be careful how you word such-and-such or this will happen’, and she helped us a lot, you know. So she’s always there, sort of watching that I don’t trip myself up.

The ability to form complex networks, connections and collaborations was at the heart of the embedded role. Arguably, this work sometimes received too little weight or acknowledgement relative to its importance (and relative to the more concrete and more obvious research skills). The term ‘bridging’ was used, as was ‘conduit’; however, these suggest the forming of a connection between two parties: the reality is that many of the embedded researchers were at the centre of complex webs of relationships and networks:

I can connect those people because I know what’s going on . . . [before] there just hasn’t been the forum to bring people together . . . to make those connections for people . . . I kind of feel like I’m a bit of a matchmaker essentially, because I’m kind of going round getting all this information, putting it in, and then kind of regurgitating it out in a sort of useful manner.

Karla, embedded researcher, Porter

The ability to build strong relationships and trust was key to maintaining these complex networks, connections and collaborations. There was a strong sense throughout the data that the embedded researchers were seen (and certainly aspired to be seen) as trustworthy and genuine, with no hidden agenda:

People trust her, they’re not wary of her, they believe that she’s going to be there tomorrow and have that feeling about, you know, that solidarity. And I think I’ve got the ability to give people that feeling because I’m an experienced researcher and a nurse, erm, but [embedded researcher] has it . . . So, I think there’s a level of trust . . .

You know, there are barriers that she doesn’t have to go over because she naturally lives with those barriers. Are you with what I’m saying? It’s like she’s already inside the pen, she lives inside the pen.

Peggy, nursing professor and NHS director, Porter

The skill to harness the knowledge and potential in others linked to some of the preceding skills (e.g. building relationships and making research accessible). Drawing out the potential in others and challenging their thinking (with care) were skills that embedded researchers displayed often. This related to the empowerment of others, not just those in junior positions, but also those working in senior management and leadership roles:

So, in establishing all of my ideas, my thinking, I went and sat with [embedded researcher] and we looked at the ideas, and what I was saying, and we, we had a conversation and she was able to support that conversation, that then helped me . . . articulate and reflect on my vision and then develop my thinking, such that I was able to make the pitch for a Darzi Fellow[ship].

Violet, collaborating general practitioner, Coxheath

As the quotation above demonstrates, working across hierarchies was an additional interpersonal skill strongly valued by the embedded researchers and by their wider teams. The ability to work with a variety of individuals, with differing roles and seniority, was important for success. Within this, there was the necessary ability to adapt their approach and communication to differing levels and audiences, so that the embedded researcher was seen as credible, relatable and personable:

With [embedded researcher] they know that she’s there, she was part of them, she has that ownership, that belonging. She recognises their significance; she has that continuity that’s really important . . . and before the post she’s in now really because she was embedded even when she worked for [university] – she was embedded in there. So, it’s been over time, exactly, that she’s known now, and she’s understood . . . And she can talk to people at a whole range of levels and she has that ability as well.

Peggy, nursing professor and NHS director, Porter

What has run across the range of skills and expertise noted so far has been the need for embedded researchers to be committed and driven, with great stamina. These characteristics were seen as crucial, largely as a result of the extensive challenges associated with the embedded role (including role creation, development, workload and competing expectations, alongside the cultural and strategic barriers). There was a sense that the embedded researchers needed to be strong, resilient, adaptable and committed to their role. This was voiced by many of the embedded researchers, especially Anna, Jane, Victoria and Karen:

It’s very time-consuming, and having anything that’s a split sort of role it is exhausting. It’s always more than the sum of its parts really, so it is very dependent on someone who has the energy and the drive and the vision to see something – that’s, you know, that’s not so much the norm.

Karen, associate dean of research, Bridgetown

Overall, there was broad agreement about the wide and diverse skills needed, but the degree to which each skill was important varied according to how the initiative was configured, particularly when looking at strategic involvement and the need for methodological expertise. For example, those roles that included a high proportion of service evaluation required fewer formal methods training and strategic interpersonal skills – these skills were much more relevant for initiatives that required ‘speaking truth to power’ and working across strategic organisational barriers at senior levels. The soft skills of effective communication and relationship-building, however, were always in demand.

Relational roles

The themes described in Findings 3: cross-case variations in processes show the relevance to embedded initiatives of effective communication and relationship-building. This was seen as a fundamental quality and skill of the researcher: the ability to build and sustain relationships, work across hierarchies (by being relatable and adaptable), harness skill and potential in others, and build trust were all crucial and could be described as skill in creative mediation:

Jane’s very approachable; she doesn’t make you feel stupid, she listens, she’s an active listener and then she helps you assimilate it. So . . . her communication skills are brilliant . . . and obviously the knowledge is there.

Sally, former chief nurse, Coxheath

Diplomacy and negotiation formed a large part of this relational work and were also necessary for managing conflict and balancing competing agendas, expectations and priorities.

The key influences on the nature of the embedded researchers’ relational roles were their professional background and, most crucially, the functional contribution expected of them. For example, three embedded researchers in Porter, Katrina, Bev and Karla, whose roles focused largely on service evaluation, spent less time negotiating agendas and experiencing conflict through different priorities. The boundaries and nature of their work were more tightly and clearly defined from the outset. By comparison, Jane in Coxheath was senior in both her past and current roles, and her work had far fewer boundaries and an ever-expanding remit. Within this work, she had to juggle an array of conflicts, perceptions and agendas. As a result, her extensive experience in creative mediation – the ability to relate to others and work across rigid professional and philosophical boundaries and hierarchies – was much more relevant to the success of her role.

Being accessible and relatable was universally seen as important. The researchers had to ensure that they were not ‘too academic’ in their approach, particularly if they were to make research ‘accessible’ (and change perceptions of research). All of the embedded researchers needed this ability, arguably because there was often a sense of unattainability attached to the term ‘research’, rather than a problem with any of the specific processes in ‘doing’ research (i.e. the term itself is intimidating to many people).

Additional relational aspects of the embedded researchers’ roles were covered in Belonging and Skills and expertise.

Learning mechanisms

As noted in Chapter 4 on the formal evaluation and performance monitoring of embedded initiatives, success was seen as largely challenging to measure, partly because of the ambiguity of roles, but also because of the complexity of the work being completed. There was, therefore, variation in terms of achievement and what was subsequently learnt about what was, or was not, achieved.

For work such as service evaluation reports and specific quality improvement projects, the outputs were relatively easy to monitor and evaluate. Similarly, there were individual research projects that had clear aims or objectives and tangible outputs on completion, such as publications. Such achievements were, by nature, more explicit and therefore easier to ‘see’, making it easier to recognise, in the first instance, and learn from them. Jane in Coxheath and Victoria in Porter, for example, published widely and often attended conferences. These achievements were easier to identify, and learning how to make these accomplishments was relatively straightforward.

Less easy to acknowledge, monitor and learn from, however, were projects around research capacity and capability growth. Often there was no baseline of existing understanding or culture. At the same time, measuring cultural change, particularly when it related to changes in perception and engagement, was, by nature, difficult. Much of the work associated with culture change is subtle and even invisible. Subsequent achievements can be difficult to identify and acknowledge, and subtle small-scale changes are likely to be missed.

Anna in Bridgetown was working to establish a baseline of research activity (as shared by a member of her management team, Gillian) to try to mitigate some of these challenges and offer a starting point from which achievement could be measured:

The first instance would be about how we get people being that, as I say, research active.

Is that quite difficult to measure?

Absolutely, absolutely . . . That has been quite challenging because we don’t have a baseline to work from, so it’s not something that is routinely gathered, and so it’s . . . a piece of work for [Anna]; she’s been getting ethical approval . . . to do a survey with all the staff . . . It’s a formal piece of research.

As a case study that had ended, Evansville showed that learning could be carried over into new initiatives through the accumulated experience of the embedded researcher (Bella). Bella said one initial goal of the embedded research role had been to disseminate findings beyond the immediate team, to ‘create a kind of a research or an evaluation mindset within the [whole] organisation’:

Many times, [people were] just looking at their daily practice, their work, they’re not considering types of evidence out there, they’re not thinking about evaluating what they’re doing, they’re not thinking about quality improvement. So, part of a deal for our team was, you know, to show them different ways in which they could do that.

Bella, embedded researcher, Evansville

It was only when the role was redesigned, however, that the team started sharing its findings widely every 2 months, ‘even . . . emerging findings’:

Our findings [now] are going to different implementation groups across the trusts, it’s not just going to three or four teams, they’re being presented at their group executive level in 2 weeks. So . . . the chief exec[utive] knows exactly what we’re doing, and they know what’s coming out of our evaluation so . . . We learned from that, I think, and now we’re really careful not just to focus on data . . . but actually to be able to use this formative design a bit more practically. So, I think that was one of the big issues we had on the team and one of the reasons why I don’t think we [i.e. the original embedded initiative] were funded beyond the 4 years.

Bella, embedded researcher, Evansville

Learning within the embedded research initiatives proved difficult then, not least because of the frequent lack of clarity over intentions and the emerging nature of many of the activities. Formative learning was clearly prioritised, alongside the necessary informal support systems for the embedded researchers. Summative learning was less in evidence, notwithstanding the varied governance and accountability mechanisms that played a role in shaping the overall work programmes and the day-to-day activities.

Developing the design framework

As documented in Chapters 2–5, the supporting research comprised a wide review of literatures on knowledge co-production and on embedded research (workstream 1), a scoping exercise of embedded research initiatives in health settings across the UK (workstream 2), and a co-production workshop with embedded researchers and their managers (part of workstream 4). This was followed by more detailed exploration of four ongoing initiatives, including about 50 in-depth interviews and an additional workshop with follow-up discussions to validate our thinking and create and refine the supporting materials (workstream 3).

Developing other supporting materials

Throughout the project, considerable attention was paid to engaging and influencing activities (workstream 4; see Chapter 1 for an outline of its approach, audience and actions). Activities ran in parallel with workstreams 1–3, drawing on and contributing to those research activities.

A project website was constructed at an early stage,67 and a series of webinars was run to create interest and drive web traffic. As research-based materials (such as the design framework) became available, these were converted to web resources and released for wider community commentary. The collaborative workshops programmed into the lifetime of the project created opportunities for the co-production of resources, which, in turn, were used to enhance the resources section of the website. The planned workshop that could not run because of COVID-19 restrictions was replaced with podcast interviews with other members of the team to provide a readily accessible record of the thinking behind the design framework. Articles in widely read practitioner journals (Health Service Journal, Local Government Chronicle) created additional interest, spread the core messages from the research, drove further website traffic and created additional useful discussions that fed back into the creation of supporting materials. Blogs and an active Twitter account (@_embedded) offered further channels to stimulate interest, and allowed followers to engage with the supporting materials under development.

The design framework: an illustrated metaphor

The visual landscape seen in Figure 12 represents the features of an embedded research initiative. Drawing on the insights of the participants at workshop 1, we selected a garden as an overarching metaphor to represent the growing, emergent nature of embedded research initiatives and the active work that individuals and organisations need to put into planning and maintaining such initiatives.

FIGURE 12.

A visual landscape of the features of an embedded research initiative.

Each theme is represented as a separate area in the garden, with relevant visual metaphors as follows:

• Intended outcomes are represented by the range of desirable produce emerging from the garden as a whole.

• Power dynamics are seen as a river flowing through the whole space, with the scope both to power initiatives (the water wheel) and also (implicitly) to overwhelm (e.g. by flooding).

• Scale is hinted at by the idea of a wood containing trees of different size, species and maturity.

• Involvement uses ideas of the hive (honeybees) to suggest that collective engagement is needed to produce more than individuals can alone.

• Proximity hints at ideas of distinct choices (the signpost), purposeful navigation (the map) and boundaries to be negotiated (the fence).

• Belonging is represented by both a summer house (a structural space for belonging) and a picnic (reflecting informal social spaces for belonging).

• Functional activities suggests the range of activities needed for success, their interconnectedness, ideas of investment for the future, and the toil sometimes involved in the tasks.

• Researcher skill and expertise are represented by gardening equipment and tools.

• Relational roles playfully suggests that actors from very different backgrounds and abilities may need to find ways to get along.

• Learning mechanisms points towards growth (the baby birds), maturity and stillness (the wise heron) and calm reflection (seen here literally but intended metaphorically).

Questions for engaging with the framework

The integrated nature of the overarching metaphor in Figure 12 illustrates the complex interconnectivity of all its aspects, yet disaggregating the overall picture into its constituent parts also has value in teasing out distinct design components and ensuring focused discussion. Table 15 shows each of these aspects in turn and lists a series of questions designed to prompt contemplation and discussion of each feature. These questions can be used alongside the visual landscape to prompt further enquiry, articulation and discussion of key design and/or management issues at the outset and again as initiatives unfold.

Clearly, the questions laid out in Table 15 do not present the last word on how to explore the themes. As new or extant collaborations grapple with the concerns laid out, new ways of digging deeper will emerge appropriate to the specific initiative under scrutiny. To aid this, the framework on the Embedded Research website67 contains click-throughs to other resources, to which we now turn.

Other supporting materials from workstream 4

The design framework described above lies at the centre of a suite of practice-focused materials that aim to assist in the exploration of embedded forms of knowledge co-production. Other resources developed across the team included:

• An animation to provide a visually attractive and engaging view of the possibilities.

• Real-world case studies to showcase possible manifestations of embedded strategies.

• A network of interested actors through which views and resources can be exchanged.

• A ‘recruitment resources pack’ containing sample job adverts, job description and person specification, which can be adapted and adopted for different circumstances. The pack also includes guidance and training resources, to help the collaborating institutions consider what will make for a successful and sustainable initiative.

Given the practical nature and the target audience for the recruitment resources pack (specifically, managers, clinicians and potential embedded researchers), the recruitment resources are presented separately from the other supporting materials in Chapter 7.

Functional activities

Embedded researchers must be comfortable with a broad portfolio of work, and a variety of activities within that work. Examples that we found included building relationships; collecting and analysing data; facilitating educational activities; participating in meetings; and having the project management skills to plan, manage and lead their own work.

No matter how well written the job description is, these activities are often quite fluid and will evolve with the piece of work. An embedded researcher needs to be comfortable with this emergent nature. Recruiting managers should consider how to foster any training and development opportunities to help develop some of these skills in a newly recruited researcher.

Researcher skills and expertise

Researcher skills and expertise can be defined into three broad categories:

1. Topic-specific skills relate to any clinical or practice-related issue that the embedded research initiative might focus on (e.g. diabetes, neurorehabilitation or childhood obesity). Not all embedded initiatives will require topic-specific skills, but it is worth identifying early if a specialism will be an important contributor to a researcher’s success in the programme.

2. Methodological skills relate to the research ‘know-how’ of the embedded researcher. They include the ability to define and refine the focus of the knowledge-creation activity, to collect and analyse data, and to produce knowledge of different kinds.

3. Interpersonal skills and expertise include the facilitation skills, communication skills, relationship-building skills and emotional intelligence necessary in programmes that are complex, have multiple stakeholders and rely on being able to build relationships quickly.

Relational roles

Embedded researchers will play different roles in different organisations, depending on the subject of their research. Some researchers may offer a fresh pair of eyes and a new way of seeing things. Others might provide an additional pair of hands, producing knowledge and evidence to drive the organisation’s processes and activities. They could also offer specialist or expert advice. They may do just one of these things, or all three, at different stages of the programme. An embedded researcher can also be a ‘critical friend’, so maintaining a critical stance towards the health setting is important.

A number of relational factors will therefore contribute to a project’s success, including the extent to which embedded researchers view themselves (or are viewed by others) as insiders or outsiders in the health setting, the degree of flexibility and control they have over their work (including disseminating findings), and the extent to which they are able to access spaces within the health organisation.

Relatively simple logistical arrangements, such as the employing organisation, and how easily researchers are able to access space within a health organisation can affect these relational factors, and should therefore be considered in designing the programme of work.

Learning mechanisms

Embedded research initiatives use a variety of mechanisms to learn how things are going and whether or not they are achieving their intended outcomes. Ambiguity about the aims and objectives of an embedded programme will make this measurement hard.

The NHS and other health service organisations tend to use performance monitoring mechanisms including key performance indicators and annual performance reviews, whereas programmes that are funded and/or controlled by organisations with a strong research focus tend to make use of formal evaluations.

Other programmes may use more informal mechanisms for learning and reflection, such as group or individual supervision, team meetings, workshops and learning sets.

Depending on the programme of work, the embedded researcher will need to be comfortable with the arrangements for tracking progress, and will play a key part in ensuring that this progress is tracked.

Aims and objectives

Are you as clear as you can be about the aims and objectives of the piece of research? Do you understand the purpose of your piece of work, and is that understanding shared across all partners? Do you know how you intend to measure performance over the course of the work?

Sponsorship

There will potentially be a tension between academic and service needs. Is there a senior individual in each area of work who can sponsor the embedded researcher to ensure that this is a positive tension?

Management

Do you have a clear understanding of, and clear agreement for, the management of this individual, particularly if it will be a joint appointment or their post will be jointly funded by more than one organisation or funding stream? Are you clear on the logistics of a joint appointment: who will offer performance feedback, support and coaching, not only to meet the programme’s objectives, but also to support the academic career of the researcher? Will the researcher have sustainable employment in the long term, and which employer should they best be employed by so they can ‘speak truth to power’ if the research results are not as expected?

Belonging

How will you support the researcher to become part of their teams in each organisation in which they work? How will you support them in their handover between teams?

Scope and boundaries

Do you have a clear idea of the scope of the work and the activities that you want the researcher to carry out? Are you clear about the accountabilities within the role, and the expectations you have of the researcher and the piece of work? Is a blended team more suitable to what you want to achieve than an individual researcher?

Introduction and support

How will you introduce the researcher to, and integrate them with, the team? Embedded researchers often have to walk a difficult line between gaining the trust of the team and remaining objective about their research; how will you support them in this? They must blend the worlds of academia and delivery, which can leave them feeling that they do not quite fit in either; what support can you offer? This will be instrumental in helping the embedded researcher to thrive.

Training and development

Embedded researchers need to possess a number of skills and often navigate complicated organisational and professional situations. For an individual to thrive in this role, how can you support their ongoing professional development? (A more detailed list of the types of training that might help an embedded researcher to thrive can be found in the next section, with information on some providers.)

Job description

Sitting in front of a blank piece of paper to write a job description can be both daunting and time-consuming. The resources pack contains a ‘long-hand’ job description (Box 1), based on a review of a number of examples from embedded researchers already working in programmes of research. Guidance notes are included in italics in square brackets.

This job description is intended as a starting point – organisations are encouraged to adapt it to fit their programme of research and context. An editable version of the job description is on the Embedded Research website. 67

Person specification

The person specification in Table 16 is a basis to work from, designed to be a helpful tool rather than the definitive answer. Each category is classified as essential or desirable, but these classifications should be changed as required for the specific role.

Job advertisements

This section of the resources pack contains text for two draft job advertisements (see Boxes 2 and 3) that could be used to recruit an embedded researcher. Organisations may, however, prefer to write their own advertisement, tailored to their organisation.

Interview process

As these roles can be complex, with posts often funded from two or more organisations, the selection process needs to consider the needs of all funding organisations. This section sets out five suggested steps:

1. Invite representation from all funding bodies to be involved in the selection process. This could start with joint agreement of the design of the research (see Helping an embedded researcher thrive for questions to help with these discussions) followed by the development of an agreed job description and person specification. At this point, line management for the position should be agreed.

2. If numbers allow, a representative from each funding organisation should be involved in the interview panel, allowing for appropriate gender and ethnicity representation on the panel.

3. The person taking line management responsibility for the position should ideally chair the interview panel and ensure clarity on the employing organisation. The approach to line management and sponsorship from other funding organisations should be explained to interviewees. This will help foster a sense of belonging from the outset.

4. Consider involving a public/patient representative on the panel, to again foster the importance of this from the outset.

5. Develop interview questions based on the agreed job specification, to ensure a focus on testing against essential criteria, particularly interpersonal and communication skills.

Training and development programme

As discussed previously in this chapter, embedded researchers need a portfolio of skills to be successful in their role. These skills and personal attributes should form part of the continuous professional development of these individuals. This section of the resource pack contains suggestions for this process.

Many embedded researchers will be hosted by more than one organisation, as the bringing together of research and practice in a single role often means joint funding. Organisations should therefore:

• ensure that performance and development needs are discussed regularly with the individual researcher by both organisations they work in, that is the academic and service organisation

• produce a shared development plan that is owned by the researcher and recognised by both organisations.

The resource pack offers a list of suggested core development activities and some optional additional activities, drawn from the research and case studies in workstreams 1–3. The list is not exhaustive and is intended as a list of options that could form part of a researcher’s ongoing development, alongside other personally identified development needs.

This training may be delivered by a variety of sources; some suggestions are listed in the final section of the pack: ‘Useful organisations and further resources’.

Useful organisations and further resources

Finally, the resource pack contains links to organisations and further resources. These include sector-level bodies, such as the NHS Leadership Academy, The King’s Fund, the Local Government Association, the National Council for Voluntary Organisations, and Universities UK, and resources for networking with similar professionals through Health Education England Library and Knowledge Services.

The Embedded research website

The Embedded research website,67 developed in partnership with the Kaleidoscope Health and Care team, is the principal and enduring source of information for anyone wanting to consider and use the learning arising from the Embedded project. The website will be maintained by the University of St Andrews Research Unit for Research Utilisation team, which, over many years, has developed a significant international reputation for its work on knowledge mobilisation.

Most importantly, in terms of making a practical contribution to supporting embedded research in practice, the website67 hosts the tools and resources developed in workstream 4 and outlined in this chapter: job descriptions and person specifications for embedded researchers, advice about how best to recruit embedded researchers, and guidance to help new embedded researchers and their host organisations prepare for carrying out embedded research initiatives. These resources are available in a format that allows them to be downloaded and customised by those who want to use them.

The website also provides access to this final report, publications arising from the project in peer-reviewed and professional or trade journals, the framework developed empirically from workstreams 1–3, an animation introducing embedded research to new audiences, and podcasts and a range of webinars and blogs developed by the research team and our partners. New information and practical resources can be added to the website, adding value to the current content.

Twitter activity

The project Twitter account, @_embedded, which, as of 11 December 2020, has 325 followers, will remain operational and is a useful way of disseminating new learning and information about future events.

Publications

Eight papers have been, or are in the process of being, produced by the Embedded team (see Publications). Six of these are aimed at academic audiences and have been/will be published in high-quality peer-reviewed journals (three of which will be open access); two are targeted at practitioners and have been published in professional or trade publications.

Presentations and wider influencing

The Embedded team has presented the study’s findings at a large number of conferences, seminars and interactive ‘melting pots’, as summarised in Acknowledgements. During the COVID-19 crisis, many of these presentations were delivered online; links to the recordings, if available, are accessible on the Embedded research website. 67 In addition, the senior members of the Embedded team fulfil a range of leadership roles in the academic and health and care sectors and, in these roles, will continue to promote the insights about embedded research gained from this project.

Promoting better research and better research use

Making best use of health services research is about getting the right research done (work that focuses on service-relevant issues) and getting the research that is available to have influence and impact through changes to services for the improvement of care. Both of these require close collaboration with service personnel and service users if they are to be achieved.

Many approaches to these challenges have been explored (Box 4). Some have been about strengthening practitioners’ research skills, building local research capacity and developing greater research awareness. 182,183 Others use brokers or intermediaries to bridge the worlds of research and practice, realising that active processes of facilitation work better than passive dissemination. 3,182 More recently, we have seen initiatives putting patients and service users at the heart of research teams,70,184 and the development of research–practice partnerships, which can exist in many guises. 183,185 Finally, taking the idea of ‘sustained interactivity’ further,9 we find initiatives that seek to ‘embed’ researchers in service settings, where they can broker external research-related knowledge, create and co-produce new knowledge in situ and build the capacities to negotiate and apply such knowledge to improve care. 158,184,186

Although each of these models attempts to mobilise knowledge by closing the gap between the researcher and practitioner communities, there are also many differences, for example the individuals involved (e.g. researchers, health professionals, managers, service users); the nature of the interactions and the settings where these take place; the nature and extent of collaboration, and the type of activities that support this; and the character of the boundaries that need to be bridged (cultural, organisational and epistemic). Each of these can vary hugely, and their details are rarely well described in accounts of various models.

Partnerships are central to most of these models, but the structures and mechanisms for promoting and supporting such partnerships can also vary. Dimensions of effective research partnerships that have been highlighted in the literature include a sharing of power and influence within the partnership, relationships based on strategic programmes rather than individual projects, the desirability of working on common areas of interest, the need for early demonstrable advantage to the partners to justify their efforts, the importance of demonstrating a genuine commitment to partnership over time, the importance of researchers valuing a broad notion of ‘knowledge’ and ‘evidence’, and the need for practitioners to value scientific evidence. 187–192

Much of the supporting literature57,193 has focused on the attributes needed for partnership roles and on the consequences for individual post-holders. Building on this, reviews by Bullock et al. 12 and Phipps and Morton194 have considered the characteristics and capacities of individuals who seem to be effective at working in partnerships across the academic–practitioner boundary. These include good communication and negotiation skills, flexibility, the ability to engender trust, entrepreneurship, creativity, and a sensitivity to context.

Overall, many different models for better connecting research and practice through partnerships have emerged, and there is a need to deeper explore how these are put into operation and their potential. What has been published to date mostly comprises descriptions of specific initiatives or wish lists for the personal attributes of their protagonists, but little in the way of support for more structured analysis across schemes or practical guidance about set-up and management. There is a clear need, therefore, to develop better theoretical and empirical underpinnings for the different models, and to use these to help the construction of practical tools and resources. 32,38

Alongside these varied approaches, and the accompanying research effort to tease out their roles and contributions, we can see a growing number of local initiatives that deploy embedded researchers. The distinctive features of this approach are elaborated on in Box 5. 158,184 For those who judge the conventional research approach to be a distant and tardy process, insufficiently focused on utility, embedding researchers is intuitively appealing; consequently, the approach is growing in popularity in many health sectors. Indeed, we found around 50 such schemes in the UK NHS (see Chapter 3). Nevertheless, even prior to this most recent work, it was clear that challenges remain, chief of which were the problems of dual identity or affiliation, the potential for conflicting objectives between multiple institutions and the challenge for the embedded researcher of retaining a ‘critical’ academic perspective. 158

Recognising that embedded researcher initiatives were gaining traction in the UK and elsewhere, this project placed such schemes at the centre of its research focus. Before recapping on the study aims and objectives, and then setting out the key findings of the work, we first briefly rehearse the logic of knowledge co-production that lies at the heart of such embedded models.

From knowledge transfer to embedded co-production

The increase in interest in embedding researchers reflects, at least in part, a recognition of the importance of ‘co-producing knowledge in context’ as a means of crafting more applicable research knowledge that is more likely to be actioned. Rather than research and practice being construed as separate processes operating sequentially (research fed ‘into’ practice), the production and utilisation of research evidence are seen as complex, interdependent and situated activities (research ‘in and with’ practice). 11 The emphasis is on dialogue about how research-informed knowledge is shaped and understood, on encouraging productive ongoing relationships, and on creating environments conducive for change. 14

This reframing suggests that researchers need to be willing to actively negotiate knowledge among managers, practitioners and (crucially) patients and service users; they need to recognise and accommodate power differentials in who dictates how knowledge is defined; and they must adopt a pluralistic orientation to knowledge to achieve change. 26,195 Co-production models of knowledge mobilisation are based on the assumptions that research knowledge usually needs to be adapted if it is to have impact, and that all participants need to be involved in its creation, interpretation and use.

Participatory approaches, such as co-production through embedded research, attempt to mobilise knowledge by encouraging greater interaction and dialogue between researchers, practitioners and people who use health services. Beyond these basic principles, there is great diversity over, for example, the individuals involved, the academic interests or disciplines engaged, the level of embeddedness of individuals in the practice setting, the structural arrangements for such embedding, the nature and degree of co-production, and the type of activities that take place. Until recently, there has been little in the way of systematic examination of either the nature or the impact of the different approaches to embedding, and this study was an attempt to address such knowledge gaps.

Study aims and objectives

As detailed in Chapter 1, the Embedded project aimed to increase the influence of health services research on decisions about the improvement and redesign of NHS services by:

• developing insights and understanding about the nature, challenges and effectiveness of co-production initiatives in which researchers are embedded within service settings

• producing practical guidance on the design and implementation of embedded models of co-production for managers and clinicians in the NHS, their academic partners and people who use services.

In addressing these aims, the project focused on the following specific objectives:

• to review the theoretical and empirical health services, management and organisational literature relevant to embedded research initiatives and knowledge co-production, and identify the relationship(s) between the two (workstream 1)

• to gather examples of embedded models in operation around the UK’s health services and public health sectors, focusing on examples where embeddedness and co-production co-exist, and to describe the features of these models, including their history, context, participants, scale, scope and content (workstream 2)

• to undertake in-depth case studies in four of the examples identified, in order to understand their mechanisms, effectiveness and challenges (workstream 3)

• to provide resources aimed at assisting the recruitment of embedded researchers, alongside recommendations and guidance for their training and development, customisable for the different ways in which embedded co-production may be framed and specified, to allow those interested in developing and using such approaches to understand the design choices they face (workstream 4).

Progress against objectives

All of the aims and objectives as set out previously were met in full, with one exception covered shortly. Chapters 2 and 3 provide a full account of the two literature reviews (on knowledge co-production and on embedded research initiatives, respectively). The findings from the scoping review of UK health-related embedded research initiatives were used to augment and enrich the literature-based accounts of such schemes, and, as such, feed into the derivation of the 10 domains that were used to characterise embedded initiatives (see Chapter 3). The four in-depth case studies are presented descriptively in Chapter 4, and analytically in Chapter 5. Finally, findings from across all four workstreams are brought together in Chapters 6 and 7 to provide the promised practical guidance on the design, implementation and management of embedded initiatives in UK health settings. Subsequent sections in this chapter reflect on these findings in more depth.

The one aspect of the overall aims to which we were able to make only indirect contributions was on the issue of scheme effectiveness. As expected, published data (in the literature reviews) and systematic analyses (in the scoped extant initiatives) were very scant. Thus, we were much more able to provide rich accounts of the nature and challenges of embedded co-production than we were to provide robust evidence on their effectiveness (or otherwise). That said, the more structured ways of describing and analysing embedded co-production enabled by our analysis point to many areas where scheme rationale and coherence can be assessed, as well as contributing to the capacity for shared goals and understandings across diverse stakeholders. Such indirect assessments of effectiveness are likely to prove of great utility while we await further robust studies of scheme outputs, impacts and outcomes.

Deviations from the original proposal

Deviations from the funded protocol were minimal, and all workstreams unfolded largely to plan. There were some minor methodological adjustments to the case study data gathering, including less reliance on diary methods, but these were inconsequential (see Chapter 4 and Appendix 3). It also became clear that the extent of knowledge co-production in the embedded schemes was often difficult to discern, and so our focus tilted more towards embeddedness per se, rather than co-production (although obviously these two are often linked). Finally, there were some adjustments to the tools, resources and templates developed to support practical scheme development: recognising the sheer diversity of schemes in operation and planned, these now provide guides and customisable resources rather than definitive items (see Chapters 6 and 7).

One area where progress was limited was our goal of creating an active network for those engaged in developing or running embedded research initiatives. In general, this proved relatively muted in operation, for what appeared to be two main reasons: first, the sheer diversity of approaches to embedding researchers sometimes precluded shared interests, terminology and concerns; and, second, potential network participants consistently noted that interactions depended largely on saliency (i.e. engagement was sporadic depending on what participants needed to know at specific points in time). Despite initial enthusiasm from participants, and several attempts to create and facilitate the network, including experimenting with different technologies (e-mail discussion lists, Google Groups and WhatsApp chats), it never reached self-sustaining status.

The only other significant deviation from the original proposal occurred towards the end of the project (March 2020), when some of the engagement activities (notably, the final workshop) had to be reworked in the light of the COVID-19 crisis. However, it proved possible to achieve the aims of these activities through other means, for example by tapping into professional networks, having virtual conversations with the more active members of the embedded network and attendees at prior workshops, and drawing on the materials produced at workshop 2. Hence, the COVID-19 disruptions did not hamper the overall achievement of the project objectives.

A language for knowledge co-production

In recent years, attention has turned to how closer relationships and partnerships can be assembled that enable researchers and non-researchers (including policy-makers, practitioners, service users, carers, the public) to create knowledge collectively. For those crafting policies, designing and managing services and delivering care, co-productive relationships around knowledge offer the prospect of more relevant, timely, contextually sensitive (and, therefore, usable) knowledge directly applicable to organisational needs. 33,196 For researchers, knowledge co-production is seen to offer easier access to research sites; stronger and more effective research collaborations; more engaged scholarship;167 and greater engagement, influence and reward for their work. In addition, there is the possibility of achieving and evidencing ‘impact’ with academic work, neatly fitting with the increasing rhetoric and use of metrics around this topic. 197 For similar reasons, knowledge co-production also clearly holds some attractions for funding bodies. 127

Co-production, then, has risen quickly to prominence as an approach to knowledge-making. Promising to address many well-worn problems of creating actionable knowledge that is fit for purpose, it is invested with great hopes, alongside some emerging fears and disputation,82,198 across many disciplines. Our review and synthesis of the burgeoning literature (see Chapter 2) offers a means of exploring and disambiguating the conceptual underpinnings in a way that also provides practical tools and resources for collaborative conversations.

What we found, from reading across the literature and developing a framework analysis (see Chapter 2), was that issues and approaches in knowledge co-production could be thought of in five main domains of meaning: politics, knowledge, identity, space–time and aesthetics. Drilling down, each of these domains yielded two subthemes to provide a finer-grained analysis of the issues. Furthermore, we found that each of these domains could be overlaid with a graded spectrum of co-production ‘styles’, from relatively conventional research processes, through provisional, moderate and committed, to, finally, radical knowledge co-production. The exploration of meanings in each of these domains and across these spectrums, and the surfacing of very divergent exemplifications of co-production, provide some clear conceptual guidance and more precise language to aid in the disambiguation of both the rhetoric and the practice of knowledge co-production.

Disentangling distinct conceptual concerns in this way will, we hope, lead to further discussion and insights on the nature and role of co-production processes, helping to prompt more focused empirical and evaluative work. More pragmatically, we hope that the framework we have presented will be used by those involved in embedded initiatives (and, indeed, in knowledge co-production achieved through other means) to articulate their understandings of their own and each other’s approaches. This, in turn, may help to clarify, and support discussion of, the implications of their respective stances, and so facilitate better communication around the difficulties and challenges of such collaborations.

As well as aiding conceptual clarity and being of practical use, our analysis moves to forestall a growing risk that knowledge co-production could become unattractive as a result of its complexities, ambiguities and difficulties, which can all be germinal points for misunderstandings, disappointments and disillusionment. 198 Debates about knowledge for practice and policy are, we think, well rehearsed,4 and new grounds for conversation are needed if we are collectively to create a more progressive and enlightened culture around knowledge production and use. In short, we must be able to make the most of different possibilities for co-producing knowledge, and the first step to capitalising on them is to find ways to think and speak about them with greater clarity. 198 The work presented in Chapter 2 begins the task of arraying these different possibilities so that they can be systematically and transparently explored. All of this has great relevance to embedded research initiatives, many of which have co-production at their heart (at least rhetorically, if not always so obviously in practice).

Crucially, our work in the review and synthesis was not an attempt to solve the problems of co-production, or even necessarily to promote its application (although it is clear that we think it has some potential). In exploring the growing literature, we were acutely aware of the frequently aspirational and rhetorical uses of language in this field. During our analysis, we sought to lay out constellations of ideas and themes, with their associated tensions, overlaps and consequences, without lapsing into judgement or advocacy. The value of this analysis lies, we believe, in its capacity to provide a useful framework for more thorough conceptual work and better communication over practices in this area.

Overall, knowledge co-production can take many and diverse forms, from approaches more akin to conventional collaboration to those with much more radical intent. To date, many embedded research initiatives do not appear to have fully understood or engaged with this diversity and there may be advantages in doing so using the conceptual groundwork we have laid out in Chapter 2.

The landscape of embedded research initiatives in the UK

Embedding researchers in service delivery, public health or service commissioning settings is a key means of developing knowledge co-production. Knowing that embedded research initiatives (or ‘researcher-in-residence’ schemes) were springing up in UK health settings made an analysis of such schemes a timely proposition. The combination of literature review and scoping of extant schemes allowed us to develop a bounded account of what constitutes embedding and a structured way of describing the components of such schemes (see Chapter 3), even when the contours of these components in practice are more implicit than explicit (such as addressing power dynamics).

Reading across the 45 embedded researcher schemes uncovered in the UK (those that met our criteria as set out in Chapter 3), a number of features of this landscape became clear. First, schemes were in place across the UK, and were located in primary, secondary and community settings. It was clear that this approach to the knowledge–practice puzzle held some wide and enduring attractions. Second, the scale of embedded research initiatives was highly variable, ranging from single short-term projects to longer-term programmes of work or strategic partnerships, sometimes involving multiple embedded researchers. Relatedly, some of these initiatives were funded for fixed periods, some had secured sequential funding as they evolved, and others were in receipt of more stable ongoing support. Third, around half of the schemes used university-held contracts for their embedded researchers, around one-quarter used NHS contracts, and joint appointments were relatively unusual (only about 10% of schemes). Finally, it was clear that some initiatives were carefully planned from the start, but many more were evolving and emergent, with changing intentions, structures and processes.

The formalised accounts in the published literature (which tend to focus on a relatively established or successful subset of schemes) were usefully enriched by the intelligence gathered on the wider hinterland of schemes in the UK. From the scoping work, we gained sight of internal scheme documents, and interviewed embedded researchers and scheme managers, to gain insights into the intricacies of scheme design and delivery. This work, when combined with the literature review, led to the exposition of 10 domains (grouped under the headings of scheme intents, structures and processes) that provided a comprehensive way of articulating the contours of embedded researcher initiatives (see Chapter 3). What was clear from this analysis was that there were many different ways of constructing embedded research initiatives, and that there was real diversity of approach across the field, as well as a frequent reshaping of approach in ostensibly a single initiative over time.

This research provides then, for the first time, a robust theoretically and empirically informed tool to describe and analyse embedded research initiatives. Such a tool can be used for various purposes: for research, to delineate embedded researchers as interventions that can be compared and evaluated; for practice, as a design aid to the development of new schemes (see the extended account of such a development in Chapter 6, and later discussion in this chapter); and for management of extant schemes, by aiding dialogue between stakeholders. It was also clear from the later case study work that significant tensions could arise between and within stakeholders in embedded research initiatives; the tool described here can provide a useful framework for exploring (if not always resolving) such tensions.

Finally, the work in understanding the landscape of embedded research in UK health settings underpinned the workstream 3 case studies in various ways. It aided the identification of potential study sites: the scoping work enumerated all the sites known to exist and provided sufficient information on the intent, structure and processes of those sites to allow for purposeful selection (see Chapter 4). Moreover, the 10 domains surfaced through the literature review and scoping interviews provided a means for structured engagement with stakeholders: shaping the interview schedules (see Appendices 4 and 5), the use of the partner identification tool (see Appendix 1) and the focus of site observations (see Report Supplementary Material 4). Ultimately, the data analysis of the case accounts (both descriptive and analytic) drew on and expanded the insights articulated in the earlier workstreams; it is to this that we now turn.

The dynamics of embedded research initiatives

We purposively selected four embedded researcher initiatives (denoted as Bridgetown, Coxheath, Porter and Evansville). These showed marked differences in the embedded researchers’ backgrounds, motivations and practices, yet a common thread was a desire to ‘make a real-world difference’, to get research ‘out of the ivory tower’ and to improve local services. Using the design domains surfaced in workstreams 1 and 2, we also saw much diversity in the scheme intentions, structures and processes. Taken together, these provided many insights into the wide range of embedded tasks and activities undertaken in the roles.

There were common themes across the schemes in their basic intentions. The embedded researchers (and members of their networks) aimed at mediating between different forms of knowledge, negotiating organisational, cultural and epistemic boundaries to promote co-produced, shared and actionable understandings. There were also significant differences between schemes (indeed, sometimes within schemes, e.g. in Porter). The degree to which knowledge co-production was evident varied considerably: even though these cases were all selected in search of co-production, the approaches deployed were more usually provisional or moderate (see Chapter 2) with more radical intents towards knowledge co-production largely absent. The degree to which active co-production figured was often dependent on the framing and structuring of the embedded researchers’ roles: less bounded roles usually offered greater scope than those roles with narrow and concrete goals.

Often there was no single or sustained intent, at least explicitly. Intentions evolved or fluctuated over time, sometimes only crystallising as the scheme matured. The intents/purposes were also influenced by key partners, not only at the design stage, but as schemes unfolded. The individual skills and motivations of the embedded researcher were also influential, especially in shaping some of the changing goals and increasing ambitions of the schemes.

Most intentions (as articulated by the embedded researchers, but also by their service partners and associated networks) were related to creating situated knowing by brokering external knowledge and combining that with locally collected data, building research capacity (to shift capabilities from academic institutions to front-line staff), and enhancing a reputation for research-informed care. Because of this range, the embedded researchers were often left to juggle, prioritise or reconcile competing and changeable expectations about what being embedded actually entailed. As a result, embedded initiatives (and especially their embedded researchers) needed advocacy at strategic levels: people who could ‘see the big picture’, shape the narrative and influence expectations. Embedded researchers also needed support (from academic partners) to maintain critical distance and objectivity, with local ‘capture’ being an occupational hazard.

A common theme under ‘intentions’, often raised obliquely, was the need to address power dynamics. The issue of power was seen as a potential minefield and was rarely addressed directly in the articulation of scheme intents. Nevertheless, a restructuring or rebalancing of power across different stakeholders was often implicit, not just in scheme intentions, but also in how these intentions were put into operation. However, understandings of power were, perhaps unsurprisingly, fairly rudimentary, and this remains an underdeveloped aspect of embedded research initiatives and of knowledge co-production in general.

Looking across these insights, it is clear that the intentions of embedded research schemes are far more complex than initially might be assumed. The diverse and dynamic nature of these goals makes for very different schemes under the broad rubric ‘embedded research’, and this diversity is seen equally often in the assembled structures through which embedded research is to be delivered.

Core to the operationalisation of an embedded research scheme is the creation of opportunities for sustained interaction between the embedded researcher and actors in the non-academic setting. Practical matters such as contractual arrangements, line management and physical location all contribute to proximity, visibility and perceived contributions. Such structural arrangements also have implications for more nebulous concerns, such as a sense of belonging or the maintenance or blurring of professional identities. There was much ‘hidden labour’ by embedded researchers in negotiating these concerns, and a real necessity to draw on wider networks and senior advocates to help achieve ‘buy-in’, ‘open doors’ or ‘provide air cover’.

The structural arrangements, and the softer consequences of these noted previously, often went through a recognisable trajectory: an initial incubation period exploring the possibilities; a degree of formalisation as the embedded researcher came into post; developmental work to ‘flex’ the arrangements as the scheme bedded in and responded to local contingencies (not least of which are the skills and aptitude of the embedded researchers themselves); and, finally, some consolidation and addressing of sustainability issues, or (for fixed-term initiatives) a managed completion and attention to legacy issues.

The dynamic and contingent nature of these structural arrangements, although a key element of the model, poses real challenges: when schemes are (explicitly or implicitly) in a process of ‘becoming’, there is a real need for ongoing dialogue among all stakeholders to keep coherence and alignment. Changes of personnel in the service setting, and evolving knowledge needs, reinforce the necessity of structured engagement and shared understandings. The insights gleaned from the literature reviews and the empirical work, and the tools and resources laid out in Chapters 6 and 7 (to be discussed shortly), could be seen to assist such processes.

Whatever the structural arrangements, embedded research initiatives delivered value through the activities and processes that they pursued. These varied dramatically, but included (to different degrees) activities aimed at research capacity development, activities related to research itself and activities in support of knowledge utilisation and service improvement. Either directly related to these ‘goal-supporting’ activities, or more indirectly necessary to build visibility and support for the initiative, were diverse activities aimed at creating, maintaining or strengthening networks, communications and relational bonds. Such relational processes were at multiple levels, including the strategic (securing senior management and clinician buy-in), cross-professional (building support for new research or improvement projects) and peer to peer (maintaining academic support networks and searching for informal support from people in similar roles).

The wide range of supporting processes and the emphasis on relationship-building often placed significant strains on embedded researchers. This draws attention to an apparent paradox at the heart of embedded research schemes: the relatively simple idea of placing research expertise at the sites where research-informed knowledge is most needed is gainsaid by the complexity of the structural and processual arrangements needed to support such placements. This further reinforces the need for training to support an embedded researcher’s own capacity development, and organisational strategies to ensure that appropriate support functions are in place. Again, the tools and supporting materials described in Chapters 6 and 7 may have a productive role to play.

Given the wide-ranging (and sometimes implicit) nature of embedded scheme intentions, and the varied and sometimes nebulous nature of the processes used to achieve these, it is unsurprising that most schemes struggled to articulate or evidence success. Although the enthusiasm for, and belief in the potential of, such schemes was widely evident (and there is a strong theoretical rationale based on critiques of ‘knowledge transfer’), systematic (as opposed to perceptual or anecdotal) evidence of effectiveness was harder to come by. Moreover, the scope for assembling such evidence varied as a function of the boundedness and definitional clarity of the schemes. Initiatives that were relatively narrowly defined (in terms of scope, activities, skill set, expectations, etc.) tended to have concrete deliverables that were more easily achieved and acknowledged. Embedded roles with more ambition and broader goals (such as increasing absorptive capacity or changing the culture around knowledge and collaboration) had more ambiguity and fewer boundaries, and, therefore, were much harder to assess, monitor and manage.

Overall, the case accounts and the insights drawn from them add nuance and depth to the 10 domains of embedded research uncovered through the literature work and scoping review. By themselves though, such insights sit more in the research domain, perhaps not so readily accessible to scheme protagonists. A core plank of the Embedded project was to ensure that robust insights rigorously derived through research were made widely available through practical tools and resources, and it is to these that we now turn.

Tools and resources to support embedded research schemes

As befits a project concerned with knowledge co-production, we adopted a collaborative, creative and engaged approach to translating the research insights into practical tools and resources (see the account of the overall engaging and influencing strategy in Chapter 1, the specific account of tools and resources creation in Chapters 6 and 7, and the recruitment resources pack in Chapter 7 and on the project web page [www.journalslibrary.nihr.ac.uk/programmes/hsdr/165221/#/ (accessed 18 February 2021)]. This led to a design framework (with visual metaphors, dialogic questions and interactive web resources) and various other supporting materials (e.g. an introductory animation, case studies of existing schemes and a recruitment resources pack). We anticipate that, collectively, these tools and resources will support the development of new embedded research schemes, their ongoing management and evolution, and (importantly) renewed efforts to examine their effectiveness both formatively (as part of within-scheme learning) and summatively (as part of a wider research effort to assess impacts).

In terms of developing new schemes, much of the literature on embedded research highlights the importance of agreeing and communicating the intention, structure and processes of initiatives early and clearly. 65,162 Such calls tend to be born of the frustrating experiences of embedded researchers who are often faced with the need to manage competing demands and expectations and respond to the differing needs, priorities and values of the individuals and organisations involved. These dynamics were also readily seen in our case studies. We suggest that many of these frustrations and tensions stem from the difficulty of identifying and discussing the multiple features of an embedded research initiative, especially at its inception. A further layer of tension is introduced by the difficulty of reconciling some aspects of embedded research with one another (e.g. an initiative premised on disrupting power dynamics will need to pay particular attention to the contractual arrangements, as these may work with or against existing power relations). We propose that our framework provides a way of assessing the internal coherence of planned initiatives and the extent to which the various features have been considered and discussed sufficiently by those involved.

Moreover, because many embedded schemes evolve over time, the framework provides a means of revisiting design considerations in an ongoing manner, hopefully contributing to better communication and alignment across stakeholders. By focusing not just on the main design parameters (intentions and structures), but also on the more dynamic array of processes (what embedded researchers actually do), it should allow better dialogue between embedded researchers and other stakeholders as schemes mature or become reconfigured. Local learning too may be facilitated.

Many embedded research initiatives appear to lack clear mechanisms for learning and evaluation. This is perhaps unsurprising, given that the difficulty of evaluating such complex and relational knowledge/practice initiatives is well documented. 199,200 It is, however, becoming increasingly accepted that evaluating complex social initiatives depends on the ability to articulate and link the intended outcomes, activities and resources associated with the initiative. 199,201 This can inform, not only summative, but also developmental approaches to evaluation, which may be particularly valuable given the fluid and emergent nature of embedded research initiatives. We suggest, therefore, that our tools, resources and supporting materials can provide a basis for articulating an embedded research initiative’s intended outcomes, activities and resources and for building a coherent logic model to guide evaluation and learning. Such evaluative work is needed not only to support scheme evolution, but also to create an evidence base to underpin the selection of embedded approaches in the first place.

In these ways, we hope that our tools and resources can make a substantial contribution to the maturation of the field. Moreover, all the tools and resources described in Chapters 6 and 7 (and discussed here) will remain available67 hosted through the Research Unit for Research Utilisation179 at the University of St Andrews (project co-applicants and report authors VW and HD are co-directors of this long-established research unit). In this way, we hope to ensure the enduring accessibility and ongoing application of the insights detailed in this project report.

Reflections on patient and public involvement in embedded research

Data from the scoping of UK embedded research initiatives, the findings from the literature review, and the detailed work in the four case studies presented a picture of very patchy PPI. There was a wide range of PPI activity in the initiatives that we explored, ranging from a ‘patient panel’ supporting the overarching initiative (seen in Evansville; see Chapter 4) through to minimal involvement, with PPI described as not needed or not useful. In general, PPI was most often seen at project level (consistent with current research norms), but was rarely seen at the level of the embedded initiative itself. That is, patients and the public were far less likely to be involved in conversations about the overall design of embedded co-production than they were to be engaged in specific research or improvement projects. Even when PPI was seen, there were many different approaches to the role of lay representation, including drawing on existing NHS arrangements or using local charities to act as liaison. Moreover, the style of engagement also varied, from active participation in project work to more passive engagement, such as simple consultation about patient information.

Throughout the Embedded project, and as they learned about existing PPI arrangements in embedded schemes, our own project PPI group met to explore what a more effective and comprehensive set of arrangements for PPI in embedded research initiatives might look like. This group (see Acknowledgements) had wide and diverse experience of PPI in health services.

First, the group explored and differentiated active from passive PPI, under the three headings of intent, structure and process surfaced by the review and scoping exercise (see Chapter 3). As shown in Table 17, a spectrum of PPI arrangements can be envisaged from more passive to more active. Relating these features of PPI to the design concerns for embedded research initiatives allows us to see how building in more active PPI begins at the design stage. Thus, the passive/active ‘anchors’ in Table 17 provide a framework for integrating PPI concerns into the design discussions.

Discussions in the Embedded project PPI group concluded that the limited and patchy engagement of lay perspectives in many embedded research initiatives was a missed opportunity, but that there were few easy answers and no ‘off-the-shelf’ models. In particular, the group recognised the complexity and challenge of bringing together researcher perspectives with health service perspectives, and acknowledged the essentially relational nature of embedded co-production. This challenge can be encapsulated as that of building more complex and multifaceted relationships that include patients and lay representatives in equal dialogue with embedded researchers and service actors. That will require firm commitment as an intent, with redesigned structures and clearly set-out processes: using Table 17 in tandem with the embedded design framework (see Chapter 6) to build in deeper PPI. In addition, the group identified the need for more innovative recruitment to PPI roles to ensure that those participating truly reflect the diverse populations beings served.

These discussions in the Embedded PPI group led to the sketching out of a more radical vision for PPI in embedded research initiatives (Table 18). Again, drawing on the design framework (see Chapter 6), this sets out some core presumptions that would underpin more radical and embedded PPI. These could be seen as touchstones for discussions, or as more concrete goals for redesigned PPI in embedded initiatives.

In conclusion, the lack of nationally available models of PPI for embedded co-production has led to diversity of practice and sometimes a lack of focus on this crucial part of knowledge co-production. The work of the Embedded PPI group and the insights generated from the research data have been combined to sketch out a more radical vision for PPI in embedded initiatives, with Tables 17 and 18 offering a route map through discussions for implementing that more radical vision.

Presentations on embedding and knowledge co-production

Marshall M. Increasing Research Impact: The Researcher-in-Residence Model. Keynote address at the NIHR School for Primary Care Research research showcase, London, 13 November 2018.

Marshall M. On the Role of General Practice-Based Primary Care in Challenging the Traditional Medical Model of Care and Promoting One that More Effectively Addresses the Social Determinants of Ill Health in Our Communities. Primary Care Forum, Singapore, 25 October 2018.

Fulop N. Learning from Embedded Research. AcademyHealth (U.S. national health services research network) annual conference. Washington, DC, 2–4 June 2019.

Marshall M. On Improvement Science. National Healthcare Group Polyclinics, Singapore, 29 March–6 April 2019.

Mear L. How to Embed Research. Royal College of Physicians Research Effect Conference, Liverpool, 28 November 2019.

Mear L. The Potential of Embedded Research. AHSN Chief Officers Meeting (online meeting), 10 December 2019.

Reid B, Ward V, Davies H, Tooman T. Knowledge Co-Production: A Vocabulary of Concepts. Presentation at Researching Knowledge Co-production: What Do We Know and Where Do We Go Next? Research Unit for Research Utilisation, University of St Andrews, St Andrews, 8 October 2019.

Reid B, Ward V, Tooman T, Davies H. The Design Features of Embedded Research Initiatives. Poster presentation at the UK Knowledge Mobilisation Forum, Newcastle, 20–21 March 2019.

Ward V. The Features of Embedded Research Initiatives and a Framework to Support Their Design and Operationalisation. Presentation at a Local Authority Champions of Research (LACoR) project workshop, London, 19 September 2019.

Kirk K, Waring J, Ward V, Fulop N, Mear L. Embedding Researchers into Organisations: Studying the Features of Embedded Research Initiatives. Health Services Research UK, online conference, 1–3 July 2020.

Various other events for which the team had submissions accepted for presentation were cancelled because of COVID-19 (e.g. the Institute for Healthcare Improvement Research Symposium; the NHS ConfedExpo; the Organisational Learning, Knowledge and Capabilities conference).

Webinars on embedded research

The project webinars and ‘melting pot lunches’ are listed in the Resources section of the Embedded Research project website. 67

Selection of in-depth cases

The workstream 3 sampling strategy aimed to identify and select exemplar cases of embedded initiatives that were ‘most likely’ to co-produce knowledge, while taking into account key differences in their configuration that might explain how and why such co-production varied. The selection of in-depth cases was informed by the learning of workstream 2 (see Chapter 3), especially the national review of current initiatives and the emerging typology of co-production initiatives for embedded research.

The initial selection process focused on the following criteria:

• the intent of the embedded initiative (the purpose of the initiative)

• the structure of the initiative (including setting, project scale, employment contract, and time frame and the maturity of the project)

• the processes/outcomes of the initiative.

Guided by these conceptual and empirical sources, the sampling process first involved reviewing and shortlisting initiatives identified during workstream 2 (n = 45). Katherine Kirk and Justin Waring independently reviewed and categorised the initiatives according to the aforementioned criteria.

Further review considered the importance of the time frame and maturity of each initiative, especially whether or not the initiative was early stage, mature or had ended. This factor was seen as important in addressing the objective of understanding how embedded research initiatives might change over time and face particular challenges at different stages of their life cycle. Given the time constraints of the Embedded study, it was not feasible to carry out fieldwork with an initiative over a sustained period in excess of 18–24 months; therefore, the decision was made to select cases that were at different stages of their life cycle to compare the experiences of mature cases with those of cases in their early stages.

Next, initiatives were reviewed according to their espoused approach to co-production, seen as a core conceptual precept of an embedded research initiative. This included prioritising initiatives that took a ‘moderate’ or ‘committed’ approach over those initiatives that appeared to be carrying out more instrumental co-production or orthodox research.

Finally, we considered whether or not the initiatives focused on a particular service sector (primary, acute or community), the contractual or employment position of the embedded researchers, and whether the initiatives were primarily led from the NHS or university setting. An additional consideration in the shortlisting was the extent to which a basis of comparisons could be realised, in as much that initiatives could be compared as similar on one dimension, such as their approach to co-production, but different on another, such as service setting.

Justin Waring and Katherine Kirk independently identified a total of seven potential cases, of which there was agreement on six. In consultation with Vicky Ward, this list was reduced on the basis of the relatively low levels of involvement of potential cases during workstream 2 (Weedon and Usk) or their direct association with members of the Embedded research team (Sherwood Park). The selection process was then independently reviewed by Naomi J Fulop to question and confirm the shortlist, resulting in the four shortlisted cases (Table 20). E-mail invitations were sent to Porter, Bridgetown, Coxheath and Fulford cases with positive replies received from all except Fulford. Subsequent meetings were held with the lead from each of the three remaining cases [via Skype™ (Microsoft Corporation, Redmond, WA, USA) or in person] to discuss the possibility of becoming a case study site. Following these meetings, all three sites were keen to take part in the study.

After further discussion with the Embedded team, the decision was made to include two additional cases. The first of these was a pilot case to be recruited explicitly for the purpose of testing and refining the research methods. The primary basis of sampling the pilot was opportunistic access via established university–NHS research links. The other additional case study site (Evansville) was selected on the basis of the initiative being concluded for at least 1 year, thereby allowing us to investigate the longer impact and sustainability of embedded research, for example whether or not relationships were sustained beyond the specific project or portfolio, and how learning became adopted or sustained over time. Evansville was selected as the retrospective case; although this limited our data collection to more reflective forms of interviewing, rather than real-time observation or shadowing, it was seen as offering important insights about legacy and sustainability.

Within-case sampling considerations

In the first instance, we contacted the lead or main identified embedded researchers from each initiative on the basis that these people would be the primary focus and point of contact for in-case sampling. For Porter, contact was made via a gatekeeper (the head of R&D).

Through preliminary discussions with each individual, and by using the partner identification tool (see Appendix 1), additional stakeholders for each initiative were identified, with a focus on the main or key people involved. Ultimately, we sought to identify those practitioners, managers, commissioners and patients who, in different ways, supported, worked with and interacted with the embedded researcher: those people who the embedded researchers saw as important to their role. Appendix 2 offers a detailed view of the participants from each site. These people were contacted by e-mail and invited to participate in the study.

Interviews

Semistructured qualitative interviews were the primary method of data collection for workstream 3. These were designed to explore with participants their views and experiences of each embedded research initiative, focusing on key stages and activities in the development and function of each initiative, investigating the contribution of key people, meetings or activities, and discussing participants’ views about the types of knowledge or evidence co-produced and how it was translated into practice.

The interviews were semistructured through the use of two topic guides (see Appendices 4 and 5), and the more structured partner identification tool (see Appendix 1). One interview schedule was developed for use with the embedded researcher(s) to understand their particular career biography, profile of activities, relationship-building and management issues, and views about co-production. As outlined previously, each embedded researcher was interviewed on at least two occasions, to understand changes in their role over time, the development of their project and their reflections of the Embedded study. The second interview guide was designed to explore the views and experiences of those individuals who and groups that worked with the embedded researcher or as part of the wider initiative, to understand their views of the initiative. Given the diversity of people interviewed, this topic guide was much more open and relied on the researchers to respond to issues and topics in situ.

Although interviews followed a topic guide, each was relatively open, enabling participants to develop rich narratives of their experiences, as well as opportunities to raise in-depth, emotive and personal experiences; as mentioned previously, all interviews relied on the researchers to actively listen and respond to issues and topics. Given the longitudinal approach to data collection, and the time demands placed on participants, it was important to build strong rapport and positive relationships. For example, one embedded researcher was interviewed on five separate occasions, totalling > 4 hours.

Most researcher interviews were undertaken face to face at a location that was most convenient for them. We held periodic follow-up telephone conversations to clarify issues. Interviews with members of the wider network were often undertaken by telephone, again working around their schedules and resources.

Partner identification tool

The partner identification tool (see Appendix 1) was informed by social network analysis to help participants reflect and identify people they worked with through also thinking about the extent of their proximity or closeness of their relationship, and also whether people aligned or were based in different sectors. The model therefore comprised concentric rings, with the inner rings representing more proximal relationships and the outer rings representing more distal relationships. The tool was also designed with four unlabelled quadrants, with the expectation that participants could reflect on the grouping of their connections and determine the best way to label them.

The tool prompted participants to first identify people they engaged or related with around a given issue or activity, to think about the quality or frequency of these relationship, and to consider ways in which this ‘alternate’ person might be categorised. For workstream 3, therefore, the use of this tool served two key purposes: it helped the team to identify potential participants related to the work of each embedded researcher, and it helped them to understand the participants’ reflections or views of these relationships.

In practice, the field researcher introduced this tool as part of the introductory interview with each embedded researcher. The tool was completed as part of the relatively free-flow dialogue between researcher and participant, which enabled the researcher to seek clarification of the answers given, and for participants to explain their answers. Once completed, the embedded researcher was asked to further explain their choices for the allocation of individuals and groups, the nature of the interaction and communication with them, how they related to one another, how boundaries between the groups were negotiated, any sources of conflict, and knowledge-sharing across boundaries.

Observations

The study was designed with the goal of carrying out a series of relatively focused observations with each embedded researcher during each site visit. The primary purpose of these observations was to deepen insight into the embedded researchers ‘at work’, including the types of activity carried out and the relationships developed. This included observations of project meetings, staff consultation events, training workshops and research seminars. Report Supplementary Material 4 describes the range and number of activities and events observed in fieldwork for each case study.

We also shadowed the individual embedded researchers on their day-to-day activities. This was often difficult to organise owing to the variable and diffuse nature of participants’ work patterns. For example, during site visits, it was common to convene a one-to-one meeting, carry out a semistructured interview and observe an event or meeting, but then the embedded researcher would need to dedicate ‘quiet time’ to answering e-mails, which offered little utility in terms of observation.

Although much of the observation was undertaken with ease, observation at Porter was considerably more challenging to facilitate. Despite observing a large quality improvement conference hosted by Porter, we experienced difficulty accessing other opportunities. The main concern held by the embedded researchers related to potentially sensitive organisational data (based on recent reports and findings from regulatory bodies). Therefore, with this case, the study relied more on interview data to develop its analysis.

Reflective diaries

Given that site visits could be organised several months apart, the study was designed to make use of reflective diaries for embedded researchers to record reflections on their work, thus capturing data and also informing subsequent interviews. Initially, pen-and-paper diaries were proposed, but, after discussion with the wider Embedded team, we decided that a voice-recorded diary (for later transcription) was more likely to be user friendly. A short guide was produced outlining the purpose of the diary method, which asked the embedded researchers to describe their activities and tasks, the types of knowledge employed, the relationships involved and any challenges or issues faced (a flexible, semistructured approach was adopted from the outset). During the initial site visit and introductory meeting, each participant was invited to use a voice-recorder, and given a short instructional guide on the purpose and use of the diaries. All agreed to participate in the diaries, with six using the recorder provided by the research team, and one using their personal phone. The recordings were collected before or during subsequent site visits.

Despite our efforts, some researchers found the diaries difficult to engage with because of excessive workload. Engagement was partial and somewhat superficial, and we recognised that the data from the diaries were likely to be of limited use. To maintain and continue to grow the warm relationships with the researchers, we focused our attention on methods that supported generation of the best-possible data. Despite these difficulties, Victoria and Bev (Porter) and Jane (Coxheath) completed diary entries that informed subsequent interviews with these participants.