A Formative Evaluation of Collaborations for Leadership in Applied Health Research and Care (CLAHRCS): Institutional Entrepreneurship for Service Innovation

Article history

The research reported in this issue of the journal was funded by the HS&DR programme or one of its proceeding programmes as project number 09/1809/1073. The contractual start date was in November 2009. The final report began editorial review in July 2013 and was accepted for publication in December 2013. The authors have been wholly responsible for all data collection, analysis and interpretation, and for writing up their work. The HS&DR editors and production house have tried to ensure the accuracy of the authors’ report and would like to thank the reviewers for their constructive comments on the final report document. However, they do not accept liability for damages or losses arising from material published in this report.

Declared competing interests of authors

none

Copyright statement

© Queen’s Printer and Controller of HMSO 2014. This work was produced by Lockett et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

Institutional entrepreneurship and Collaborations for Leadership in Applied Health Research and Care

The ‘translation gap’ between academic research and routine practice in health-care provision is a longstanding global problem8,9 which has given rise to a plethora of translational health research interventions, for example, in the USA, the Veterans Health Administration’s Integrated Health and Research System,10 American Quality Enhancement Research Initiative, and Clinical Translational Science Centres;5 in Canada, the Canadian Health Services Research Foundation;11 and in the Netherlands, the Dutch Academic Collaborative Centres for Public Health. 12 As described above, England has followed suit with investment in BRCs, biomedical research units (BRUs), AHSCs, academic health science networks (AHSNs) and CLAHRCs,4 the last of which we focus on.

Translational initiatives are positioned in a landscape governed by multiple institutional forces from professions with different priorities and values. Academics, for example, are required to meet the academic credentials that underpin their legitimacy and credibility, and clinicians are tasked with translating research into practice to improve patient care. These two professions must, therefore, collaborate successfully to ensure that research is effectively implemented into practice and patient care is improved. However, the paradigm of translational research that underpins translational and collaborative initiatives has not sufficiently considered or reflected the complex realities of these different professional environments.

Existing studies highlight that the uptake of evidence into practice is more complex13 and that the translation of evidence-based innovation is a non-linear process overshadowed by cultural changes and political forces which are intertwined across various organisational and professional boundaries. 14 Such translational initiatives are challenging because they seek to bring together and bridge two institutional worlds, health care and academia, with different structures, cultures and norms. 15,16 Furthermore, Martin et al. 17 have highlighted the role of differences in institutionalised power that can facilitate resistance to policy. Furthermore, Albert et al. 18 offer insights into the particularities of different research practices in the health domain in Canada suggesting that the interaction between different actors in the translational field is affected by an actor’s position and affected by epistemic culture and what constitutes as legitimate science.

Translational initiatives pose a potential space for conflict between different actors, who may interpret such ventures in different ways, resulting in varying practices, systems and ultimately outputs. We consider these conflicts that are nested in the T2 to be institutional in nature. Research, therefore, is required to understand how to support the translation of clinical research into practice where such spaces host knowledge that is multidisciplinary and requires different communities to interact, including clinical scientists and social scientists. 18,19 As CLAHRCs are tasked with overcoming such institutional problems of translating research into practice, through reshaping existing institutions that frame KT, they are an ideal platform to examine such important institutional issues.

To examine the work undertaken by CLAHRC actors to encourage institutional change in promoting CLAHRCs, we have drawn on the emerging theory of institutional entrepreneurship, a subtheme within neo-institutional theory. Drawing on the work of Lockett et al. ,20 based on a recent Department of Health (DH)-funded study of mainstreaming genetics innovation,21 we argue that the theory of institutional entrepreneurship is an important tool for understanding change in health care.

Our focus is on identifying and analysing the actions of the institutional entrepreneurs (IEs) in developing and implementing the CLAHRCs. Consistent with the emphasis on the need for a broad perspective on institutional working by institutional entrepreneurship research,22,23 and the NIHR Service Delivery and Organisation’s (SDO) [now encompassed within NIHR Health Services and Delivery Research (HSDR) programme] call to pay closer attention to the involvement of a wider array of field-level actors and activities;24 and with the introduction of the CLAHRCs, we view institutional entrepreneurship as transcending any one specific role. IEs may be drawn from a range of different stakeholder groups including CLAHRC directors, scientific programme managers, commissioners, clinicians and service users. A broad perspective on institutional work (IW) enables us to encompass internal and external organisational issues both within and across the NHS and universities.

Employing the concept of institutional entrepreneurship to the CLAHRC initiative, the proposed aims of our report were:

• to provide a formative evaluation of CLAHRCs in relation to the generation of applied research, and the impact on practice and capacity building across CLAHRCs as they were envisaged and enacted

• to apply institutional theory to identify and examine the challenges facing CLAHRCs

• to apply the concept of institutional entrepreneurship to make a theoretically informed analysis of how to engender and sustain the translation and exchange of research knowledge into service facing innovation in CLAHRCs.

Feedback and engagement with user groups

Engagement with CLAHRC stakeholder groups was a major objective of our research (see Chapter 3). At all stages of our research process, we engaged with stakeholders, from the shaping our original application for funding of the research through to the final writing of this report. The major forms of engagement were as follows:

• Scientific and stakeholders’ advisory panel (SSAP). This group was able to meet only twice during the research process as a result of problems in scheduling meetings. The meeting of the SSAP ensured that scientific and user input were garnered into the research direction and interpretation of emerging research findings. Moreover, members of the SSAP were consulted via e-mail and telephone as issues arose outside formal meetings. This included discussions around the findings and analysis of the research, where feedback was sought and subsequently fed into the report.

• Feedback to or from collaborating sites. Formal and informal feedback sessions were conducted at four of the research sites, through the direct reporting of research findings to CLAHRC directors and deputies, on an ongoing basis. In addition, a number of workshops and presentation events were held in six different CLAHRCs (with as many as five meetings in one CLAHRC) to feed back our results to the wider CLAHRC communities in each region, including advisory boards, learning events and stakeholder boards. All of the feedback sessions enabled us to validate our emerging findings and to provide new learning for those involved.

• Feedback at CLAHRC directors’ meetings. In addition to individual feedback to individual CLAHRCs, feedback sessions were conducted at periodic CLAHRC directors meetings and wider CLAHRC-wide events. Again, these sessions enabled us to validate our emerging findings and to provide new learning for those involved.

• National workshop. A 1-day national workshop was conducted in November 2012 to disseminate findings and obtain feedback on our emerging findings. The event included a panel discussion of the emerging results, with the panel comprising four current directors and one ex-director of a CLAHRC.

Report structure

Chapter 2 provides a narrative synthesis of the key concepts related to (1) KT in health care and (2) institutional entrepreneurship. From our synthesis of the literature on KT in health care we conclude that the extant research is under-institutionalised in nature, which motivates our review of the institutional entrepreneurship literature.

In Chapter 3 we present our methodological approach, which encompasses issues of data collection and data analyses. Specifically, we present our mixed methods outlining our approach to qualitative case studies and social network analysis (SNA), and our overarching model of institutional entrepreneurship in CLAHRCs.

In Chapter 4 we outline the founding conditions of each of the CLAHRCs. Building on the tradition of Pettigrew et al. ,25 whose work on strategic change in health care highlighted the importance of history and context, we examine the social positions of the key actors involved in attempting to engage in institutional change, the local field conditions in terms of the extent to which there was pre-existing activity in the local region, and whether the bid formation involved a collective or more autonomous process. Importantly, we argue that it is the founding conditions that shape the local context and influence the nature of institutional change.

Chapters 5–7 outline three distinct phases of institutional entrepreneurship work: envisaging, engaging and embedding. Envisaging (see Chapter 5) relates to the important first stage in any change process in which actors formed an ‘embryonic’ vision, based on the interplay between themselves and the context in which they are situated. 26 Engaging (see Chapter 6) relates to the mobilisation of support from the IEs’ allies27,28 and the cultivation of co-operation and strategic alliances. 29–31 Embedding (see Chapter 7) involved the education of actors both within the CLAHRC and in practice with the skills and knowledge-based tools needed to support the creation of the new institution. 32,33

In Chapters 8 and 9 we examine how CLAHRC actors changed their patterns of interaction over time and, then, reflected on the effectiveness of their work. In Chapter 9 we draw on our SNA, based on the data collected in two survey waves in 2011 (wave I) and 2013 (wave II), to examine how successfully different CLAHRC actors bridged the divide between research and practice and the extent to which the patterns of interaction changed over time. In Chapter 10, we examine how the actors who managed and led the projects reflected on the way CLAHRCs were set up and run, and how they sought to rebalance the activities necessary to improve translation initiatives.

In the penultimate chapter we link our findings back to the KT literature. Here, we present our development of five schematic archetypes of KT. The archetypes are not representative of all the characteristics of one particular CLAHRC partnership, but rather a culmination of distinctive strategies used by CLAHRC entities into an archetype. Finally, in Chapter 11, we present the conclusions from our study.

Knowledge translation in health care

A critical concern with KT is that advances in research knowledge can take years to be implemented into practice, and change realised. Given the pace of innovation and research in the health-care field, this ‘knowledge gap’ has generated significant attention within health-care research and policy, and has been the subject of numerous reports7,40 editorials commentaries2,41 and papers. 42,43 Thus, managers, clinicians and researchers are finding themselves increasingly called on to actively participate in the process of KT. This interdisciplinary field draws heavily on perspectives from clinical epidemiology, but also integrates scholarship from innovation studies, management, psychology, public health and sociology. 44 Given the increasing attention on KT in health care, it is important that scholarship crosses disciplinary boundaries and taps into existing resources, so that concepts do not have to be ‘reinvented’ in neighbouring fields. In the section Institutional theory and institutional entrepreneurship we argue that institutional theory provides helpful analytical concepts with which to understand the disciplinary knowledge silos and contrast ways of organising for knowledge production and its application.

A number of models and theories have been developed to overcome the barrier of translating knowledge between research and practice. We review three dominant approaches used in addressing the KT gap. 38,45 Given the burgeoning number of articles in this area, our purpose was not to provide an exhaustive review (which can be found elsewhere)26,27,38,39 but rather an overview that highlights and grounds key debates in the literature.

Institutional theory and institutional entrepreneurship

As outlined in Chapter 1, we frame the T2 as being institutional in nature. Based on our review of the literature on KT in health care, we argue that many of the models of KT are under-institutionalised and, as such, fail to account for important institutional constraints that shape actors’ work in closing the T2. In this chapter we review the literature on institutional entrepreneurship and frame the discussion within the broader literature on institutional theory and IW.

Traditionally, institutional theory had developed to provide insight into how deeply embedded beliefs, roles and patterns of interaction could structure social practice and compel individuals and organisations into forms of conformity. 78,79 In particular, it has been used to explain how exogenous institutional forces structure organisational processes. For Scott80 these consisted of three elements or pillars: regulative elements, consisting of formal rules, laws and public policies; normative elements, including norms, conventions and practices; and cognitive elements comprising beliefs and understandings as well as scripts and schemas. 81–83

Institutional theory had particular resonance in the study of organisational change and continuity. Organisations are located in organisational fields, which are characterised as clusters of organisations and occupations whose boundaries, identities, and interactions are defined and stabilised by shared institutions. 80 Seen in this way, institutions are resilient social structures, sometimes enshrined in law, that specify field rules, membership, and the appropriate behaviour of its constituents. 84 The more developed a field, the more likely institutions will have become entrenched. A mature field will tend to have a stable membership with a strong mutual understanding of which organisations occupy the field,80,85 and organisational forms will converge to be consistent with the field’s institutions. 78

Qualitative methods

We employed a qualitative, induction-driven research design to enable contextualisation, vivid description and an appreciation of subjective views. 124,125 Drawing on institutional theory, with a specific focus on institutional entrepreneurship and IW, we examine the work of a range of different institutional actors as they engage in the CLAHRC initiative. In conducting our research, we employed a multiple case study format as it enabled a more robust basis for theory building,126 and often yielded more accurate and generalisable explanations than single case studies. 127

Qualitative data analysis

Data analysis was iterative and undertaken in an inductive manner, but was informed by key concepts in the literature. 132,133 Each interview transcript, set of observational notes and archival document was read several times, generating and coding themes according to both issues identified in the literature and features of the data that emerged inductively. Analysis was conducted with the assistance of NVivo 8 (QSR International Pty Ltd, Doncaster, VIC, Australia).

Our data analysis involved three stages. Across all stages, two members of the authorial team who had conducted the fieldwork undertook initial coding of the data. In advance of the analysis, we assembled all of the documents, interview transcripts and field notes for each of the cases into a single data file. This enabled us to share data across the research team. In order to understand the complexity of each project,134 we coded the data on a within-case basis. 132 We began by analysing the data collected in stage one, involving all nine CLAHRCs, with a focus on the initial founding conditions of the nine CLAHRCs and their models for closing the T2. We then analysed the four in-depth cases, where we focused on examining how the CLAHRCs were introduced over time.

Across both stages of analysis, we began with a fine-grained reading of the data. 135 After inductively creating a list of first-order codes from the case evidence, we consolidated all of our codes across the nine and four cases, and progressed with axial coding, structuring the data into second-order concepts and more general aggregate dimensions. 136 In doing so, we engaged in deductive reasoning whereby we linked our inductive codes with existing concepts and frameworks. 137 Although we accept that our accounts are one of many potential interpretations,137 we worked in two ways to ensure that we did not retrospectively fit the data to service our theorising. 138 First, we triangulated between data types. Second, we triangulated across analysts with one member, remaining independent of the data, able to challenge and interrogate the coders’ knowledge and interpretations. 139 Our coding was based on interview and archival data, and we included codes in our work only if we had at least four archival and/or interview sources for each of our cases where relevant. The observational data were employed to contextualise and corroborate the interview and archival coding.

In order to avoid identification of individuals or CLAHRC cases, we reveal the social position of the interview respondent only. To define their specific role in a CLAHRC (e.g. director, etc.) would pinpoint the respondent and organisation in question. The process through which we classified actors by their social positions is outlined in Chapter 4. Our approach aligns with our research protocol following ethics approvals, and a need for particular sensitivity given ongoing CLAHRC refinancing.

Consistent with the preceding point, in presenting our qualitative analysis we do not draw explicitly on our observational data, as many of these data (1) were not intended for public consumption, i.e. were a commentary of others; (2) were highly personal views that were communicated in confidence; or (3) revealed the details of meetings, etc., which may risk revealing the identity of respondents. As such, we drew exclusively on data from formal interviews in the text, but employed the observational data as a means of informing our analysis.

We began by examining the founding conditions for each of the nine CLAHRCs in terms of the local institutional conditions, the social positions of the main actors involved and the nature of the process through which the CLAHRC bid was developed, the analysis for which is presented in Chapter 4. Founding conditions constitute a key concept in institutional entrepreneurship theory, which are used to explain variation of institutional entrepreneurship work and outcomes.

The next stage was to take the data for the nine CLAHRCs and examine how the founding conditions shaped the IW undertaken by the CLAHRC actors. We identified distinct theoretical categories of IW that was undertaken, across the nine cases initially, and then in the four in-depth cases following the later-stage developments. All of the different forms of IW relate to the process of enacting institutional entrepreneurship for institutional change. The themes were developed inductively through first-order coding, which then progressed to axial coding, working back and forward between the data and theory, as outlined above. First, this work was related to the way in which actors interpreted the CLAHRC mission and responded accordingly, as shaped by the founding conditions. We termed this work the ‘envisaging’, which we defined as the process through which actors developed an ‘embryonic’ vision of change, based on the interplay between themselves and the context in which they are situated. 26 This work is presented in Chapter 5. Second, was the work that actors undertook in signing up stakeholders of the CLAHRC, which we term ‘engaging’ and present in Chapter 6. Third, was the work around the sustaining of the CLAHRCs, which we term ‘embedding’ and present in Chapter 7. Finally, there was a distinct area of IW that involved the rethinking of initial decisions and learning from the process of establishing the CLAHRCs, which we term ‘reflecting’, and is presented in Chapter 9. All of the different themes are expanded on in the introduction sections to the relevant chapters. Across these different areas of IW, we were able to identify distinct differences in the nature of the work undertaken by actors, as shaped by the institutional antecedents of the local institutional context and the social position of the actors involved.

The final stage of our analyses involved re-examining our data to understand the temporal sequencing of the theoretical categories of IW and the nature of relationships between them. As is common in process-based studies, it is difficult to establish whether or not a process is entirely linear;140 however, we present the second-order codes in the temporal sequence in which they generally emerged in the case histories. Employing both inductive and deductive reasoning, and travelling back and forth between data and theory, we aimed to develop an understanding of how an actor’s social position shaped the envisaging process. 125,132,135 Our emerging theoretical arguments were based on the interplay between theory and data, drawing on both within-case and cross-case analysis. 141 Based on our analysis of the temporal sequencing of the different forms of IW to promote KT we developed a process-based model of institutional entrepreneurship as presented in Figure 1.

FIGURE 1.

A process model of institutional entrepreneurship.

In addition, and based on the work of the different IEs, we identified five different archetype models that were employed by actors to try to close the T2. In Chapter 10 we explore those models and the issues arising from each. In doing so, we emphasise that the models do not represent any one CLAHRC, but rather the elements of the different models that may be exhibited in any CLAHRC.

Patient and public involvement in the research

Patient and public involvement (PPI) in the CLAHRCs was not a theme which we focused on in the project. We recognise, however, that PPI is important to inform and contribute to research,142–144 especially where translational research is concerned. 145 In terms of PPI in the project, two service users were consulted (we use the pseudonyms service user 1 and service user 2), who were ‘experts’ in two different long-term health conditions and were both familiar with CLAHRCs. One service user was consulted at the start of the project to discuss, clarify and provide feedback on our initial thoughts of CLAHRCs. A second service user was consulted for their opinion on the methods employed, specifically on the selection of the four in-depth CLAHRCs and the appropriateness of the interviewees. The second service user was consulted again towards the end of the project for their feedback on the findings of the work and on any further avenues the project should consider taking.

At the start of the project, a discussion took place with service user 1 to discuss and refine our initial thoughts of the CLAHRCs and the view that CLAHRCs were set up differently reflecting the social position of the IEs and focal actors. Service user 1 was asked his view on how CLAHRCs were set up, their mission and the balance between research and implementation:

Each theme is supposed to have a research element and the research element is then supposed to translate into practice through the commissioning of services. Those services should have, research and implementation and both should be brought together and users should be part of that too. That is my understanding of really what the CLAHRC mission is.

Service user 1

Following this initial consultation with service user 1, we proceeded to carry out the data collection across all of the nine CLAHRCs. In choosing the four in-depth CLAHRCs, we consulted service user 2 on his views on the selection of the in-depth CLAHRCs.

I think that it is good picking the different CLAHRCs, and talking to the different directors and other main people, it will provide interesting variations.

Service user 2

Furthermore, service user 2 advised us to consider questioning interviewees on the mission of CLAHRCs and how they were rolled out. His view was that CLAHRCs were led by many ‘powerful researchers’, and that CLAHRCs were ‘to some degree all about research’ – a finding that emerged from the data.

As we began to structure our findings, we consulted service user 2 to discuss and validate the findings. This enabled us to organise the research findings and draw out important points. One of the findings discussed with service user 2 was the variation across CLAHRCs, particularly in relation to the balance between research and implementation.

CLAHRCs talk about getting research quicker into practice but as your findings found not all achieved that. And that’s what I thought CLAHRCs were for, we do the research and then we get it into practice quicker than normal research.

Service user 2

Consulting two service users on different aspects of our research enabled us to think about issues more broadly, refine preliminary results and organise our findings more appropriately. Furthermore, PPI during the project helped us to frame practical recommendations for CLAHRCs and provided useful insights into future avenues of research, specifically around PPI in translational initiatives.

Social network analysis

We complemented our in-depth qualitative research by employing a SNA of the development CLAHRC actors’ ego networks of interaction over two points in time, for the four in-depth sites. Our SNA complemented our in-depth qualitative case studies through providing quantitative evidence as to the extent to which CLAHRCs had enabled the new patterns of working to bridge the T2.

Ego networks relate to an individual actor’s network of relationships and enable us to examine variation across actors’ networks, with a particular focus on the extent to which they bridge the research–practice divide. We examined actors’ ego networks at two points in time: (1) early on in the development of CLAHRCs, and (2) during the run-up to CLAHRC refinancing. In doing so we wanted to gain insights into actors’ ego networks across all levels of the CLAHRC, including those actors engaged in senior and more front-line roles.

To carry out the SNA, we used a web-based sociometric survey [Network Genie146 (Tanglewood Research, Inc., Greensboro, NC, USA)] to capture actors’ personal characteristics and networks, which was e-mailed to a list of CLAHRC staff as agreed with the directors (or deputy directors) of the four CLAHRCs. Each actor was then sent a link to the survey, and we then followed up with a number of additional reminder e-mails. Network Genie enables us to ask actors (the egos) about the people they interact with (the alters). The questionnaire is automatically generated by each actor based on the names they select of people they interact with. The number of names provided for each CLAHRC ranged from 35 to 48, and included actors from a range of different roles including CLAHRC senior managers (both HEI and NHS employees, clinical and social scientists), theme leads (clinical scientists and social scientists) and other NHS staff involved in CLAHRCs, including secondees and researchers. We present an abridged version of the SNA instrument in Appendix 1 because of the problems of presenting a web-based survey.

The first wave of data collection in 2011 (wave I) produced 81 complete responses and the second wave, in 2013, (wave II) produced 86 responses. Sample sizes for each of the four CLAHRCs are presented in Table 1. In wave I we asked actors to outline their networks and patterns of interaction at the inception of CLAHRCs, to capture actors’ actual ego networks as CLAHRCs were first established (i.e. looking backwards). In wave II, we captured actors’ current ego networks (at the end of CLAHRCs 5 years of funding).

Our aim was to examine how individuals’ professional characteristics influenced the four different outcome measures of social interaction for understanding the KT processes in CLAHRCs: (1) formation of networks across academics and clinicians, (2) integration of decision-making practices among CLAHRC academics and clinicians, (3) formation of networks across members of research and implementation themes, and (4) formation of networks across members of clinical and non-clinical departments involved in CLAHRC.

The professional characteristics we focused on were the respondents’ professional background (i.e. academic or clinical), their professional status (i.e. senior vs. junior), the status of professionals in an actor’s ego network, the number of professionals in their network with whom the respondent had not worked with before joining the CLAHRC and the number of professional connections from the same professional category.

Social network research has tended to focus on whole networks, and the extent to which actors find themselves in social structures characterised by dense, reciprocal, transitive or strong ties. These approaches may tell us some interesting things about the entire network and its substructure, but they do not tell us very much about the opportunities and constraints facing individuals. Thus, to understand the variation in the behaviour of individuals, we need to take a closer look at their local circumstances. Describing the variation across individuals in the way they are embedded in local social structures is the goal of the analysis of ego networks.

We collected actors’ ego network data using Network Genie, which asks actors (the egos) about the people they interact with [in our case for the purposes of KT (the alters)]. The typical way to generate ego network data is to create an exhaustive list of alters with whom the respondent has some type of relationship. Termed a name generator, the respondent was asked to list alters who occupy certain social roles, those with whom he/she shares interactions, or those with whom he/she exchanges resources. This approach is used in many classic studies of ego networks. 147

To analyse the SNA data, we employed regression analysis and bivariate analyses where we were limited by sample size. Our analysis consisted of cross-sectional regression models for both waves of data collection independently, thereby providing two snapshots of patterns of interaction. In addition, we conducted longitudinal analyses for the changes in behaviour over time. Specifically, we explored the effects of CLAHRC participants’ professional and organisational characteristics on the change in the measures of the bridging of academic–practitioner networking and decision-making gap, and the formation of connections among members of research and implementation themes and members of clinical and non-clinical departments. The criterion change over time in all cases is measured as the difference between criterion scores in waves II and I (C_Change = C_{wave II} − C_{wave I}).

We drew on and adopted SNA and in-depth qualitative research to explore institutional entrepreneurship across the different CLAHRCs in facilitating KT. In the following chapters we present our findings, beginning with the founding conditions of CLAHRCs.

Social positions of key actors

The CLAHRCs were established to bridge a pluralistic institutional field, spanning both research and practice. As such, the social positions of the main players in each of the nine CLAHRCs varied and shaped how they viewed the CLAHRC initiative. However, a clean categorisation of actors’ social positions, in terms of their primary role or employer, is complex, particularly for clinical academics, which were the largest group of interviewees. In analysing our data it became clear to us that roles were often shared or hybrid in nature, and actors tended to have a dominant orientation, towards the institutions of HEI or the NHS.

Clinical academics were employed by the HEI or the NHS partner and, at times, held joint positions in both research and clinical practice, medical practice and therapy. The data suggest that clinical academics, despite their employer or whether or not they held a joint position, exhibited a dominant orientation towards either research (HEI) or practice (NHS), which was most likely a reflection of their professional backgrounds and the associated norms and values linked to this.

A number of those interviewed were NHS-based researchers but were employed by the HEI, whereas others were employed by the NHS but were part of research projects led by the HEI. In such cases, their dominant orientation towards research or practice was usually linked to the researchers’ CLAHRC role and associated activity rather than the institution they were employed by and in some cases even their professional background.

Finally, a number of people were seconded from the HEI to the NHS or from the NHS to work for CLAHRC in a different role. For example, one interviewee working in clinical practice had been seconded to work as a manager in CLAHRC from the NHS and, in another case, an academic from the HEI partner was seconded to work in the CLAHRC as a manager for the duration of CLAHRC. At times, these arrangements were part of the financial agreements resulting from the interpretation of matched funding by CLAHRC actors. The data, however, suggest that CLAHRC managers were largely NHS-facing because of the nature of their role in CLAHRCs.

Based on the discussion above, we suggest that it is important to combine an actor’s primary role and their dominant orientation to be able to classify actors by their social positions. While acknowledging the diverse professional backgrounds and employment arrangements of those involved in CLAHRCs, and to retain anonymity of those involved, we broadly categorised those interviewed into the following positions:

1. Clinical academic – dominant orientation towards HEI (research).

2. Clinical academic – dominant orientation towards NHS (practice: medical or therapy).

3. Social science academic – may be located in a business school or health sciences department. To retain anonymity we have called these actors social science academics and did not state if they are located in a business school or health sciences department.

4. CLAHRC managers – (not influenced by who they are employed by, as some are seconded from either the NHS or the HEI to work for CLAHRC).

5. Knowledge broker, implementation lead, practitioner researcher or researcher – enacted a hybrid role so that they could act as translators across different epistemic communities in the HEI and NHS.

6. Other – engineering academics.

For the purposes of analytical parsimony in the remainder of Social positions of key actors, we collapsed the seven categories into three main generic social positions: HEI-facing clinical academic, NHS-facing clinical academic and non-clinical actor. We did so because our data suggested that the vast majority of actors were broadly clinical academics [including HEI (research)-facing clinical academics and NHS (practice)-facing clinical academics]. The non-clinical CLAHRC actors encompassed social science academics, engineering academics, knowledge brokers, researchers (largely those employed at a junior and mid-career level for the duration of CLAHRCs) practitioners and managers.

The local field conditions

The local field conditions helped shape the way in which CLAHRCs were founded. This meant that pre-existing relationships with NHS partners, academics and other organisations, as well as projects, played a role during the putting together of each CLAHRC’s bid. CLAHRCs were seen as a well-resourced opportunity to fund existing research and networks, and were used pragmatically to build on existing research and expertise in both research and clinical practice. It was important to leverage existing, more mature research for translation to be effective but also possible. Furthermore, academics often viewed the CLAHRC as an ideal opportunity to showcase their academic expertise.

There is a combination of that which is pragmatic, it fits, it is a worthy candidate for this resource, but the resource isn’t likely to be wasted because it is building on a heritage and foundation of good quality science and that is important. It is also a strategic view as well on the part of [director] and a senior group of influential pro-vice chancellors.

Social science academic, case H

In one CLAHRC, such antecedent conditions included strong service user networks, but this might be characterised as unusual (we noted that all CLAHRC leaders claimed strong user networks in bids, although, interestingly, they did not commonly privilege this in their interview accounts).

When we set up our original research unit pre CLAHRC, it included people interested in involving patients in research design. We also had a very longstanding patient organisation that was well funded. The net result is that patient–public involvement is not as new in our CLAHRC as others.

Clinical science academic 1, NHS-facing, case G

Accordingly, in the next sections we focus on the pre-existing relationships that were most influential as CLAHRC founding conditions.

The process of bid formation

The process of bid formation differed across CLAHRCs, particularly in relation to the extent to which the process was a collective one managed across a range of different actors. In the majority of cases the initial bid was written employing a collective approach, at least in the initial stages of bid construction. In other cases, a much smaller group of individuals wrote the bid, which was more of an autonomous approach. We suggest that the nature of the bid formation process was shaped by the social position of the local actors and the local-level field conditions.

The most common approach to bid formation was collective in nature, and was driven by a number of factors, including the status of the CLAHRC director in relation to other ‘big players’ in the locality, the extent to which there were pre-existing relationships between HEIs and NHS in the locality, and the level of existing activity that could be encompassed as CLAHRC activity.

There were people that were brought in because it was clear that we had to focus on the applied clinical research and we basically tried to include the people that had a very strong track record.

Clinical science academic 1, HEI-facing, case I

It was common that, in each region, a range of meetings were held, which brought together key actors from HEIs and the NHS over a period of 9 months leading up to the bid. In some cases, as well as pre-existing relationships and activity in the local landscape, there were also existing structures and groups that automatically fed into the CLAHRC bid, making the bid process smoother.

We had a readymade group and structure for creating the connections that were necessary to do this bid and immediately mobilising that through the institute that already had a facilitated infrastructure.

Clinical science academic 1, HEI-facing, case C

An important factor in the promotion of the collective process was that many HEI-facing clinical academics were attracted by the amount of research funding on offer, which provided them with the incentive to engage in a process to ensure that ‘their research projects’ were included in the collective formation of the CLAHRC. Furthermore, during the bid-writing process it was natural for those leading the CLAHRCs to look internally to what their strengths were and the needs of the local population and health landscape, and then structure the bid around these areas. Many HEI-facing clinical academics leading the CLAHRCs mobilised other clinical academics together to integrate research projects into the bid.

In some CLAHRCs and in the beginning at the bidding process, the director would ask certain people if they could put together a research project. At times research projects were already in the pipeline or were already running, so they would just put those ideas forward.

CLAHRC management 1, case I

In particular, we note that many HEI-facing clinical academics had a vested interested in ensuring that their research projects were part of the CLAHRC bids and, for this reason, sought to influence the process of bid formation in their favour. Their ability to shape the bid-writing process was influenced by the extent to which the lead bid writers perceived that they needed the ‘big name’ HEI-facing clinical academics on the bid in order to demonstrate research excellence to the NIHR.

In a number of regions there were well-established relationships across HIE and NHS organisations, which in some cases involved existing hybrid organisational forms. In regions where well-established relationships were present, gaining early involvement of NHS partner organisations was straightforward, particularly when the NHS organisations were deemed to be ‘research savvy’. In the absence of such relationships, HEI-facing clinical academics found it more challenging to engage with the NHS partners during the bid processes because there were differences in opinion about what the CLAHRC was set up to achieve. These differences reflected common issues arising from the T2.

The more autonomous process of the CLAHRC bid formation was less common. This type was associated with the strong social position of the CLAHRC director, either in his or her local region or nationally, and a lower level of vested interests stemming from pre-existing relationships and existing activity in the local region.

The director has an excellent reputation in terms of the national collaborative of programmes. He has a lot of respect locally from both medical and managerial staff and executive staff. We’ve been given quite a lot of freedom to get on with it, partly because of the trust and the respect that people have for the director [. . .].

CLAHRC management 1, case D

In the case below, the actor was able to act with relative autonomy because of his position in the region and, also, because there was limited interference from HEI clinical academics.

Having a good strong director makes a big difference, someone with gravitas and breadth, someone who can broker relations and so I particularly enjoy working with the director.

Clinical science academic 4, HEI-facing, case C

Under such conditions, a small number of CLAHRC directors were able to lead the bid formation process in a less collective manner.

I mean generally it was me and the director saying about decisions being made and stuff, I think at the beginning no one else quite understood what we were doing. They liked the sound of it or they liked bits of it, there were bits of it they felt comfortable with but no one got the whole picture.

CLAHRC management, case D

As a result, and as we will develop in the next chapter, the resulting envisaged model of CLAHRCs was significantly different to that seen in other CLAHRCs.

Conclusion

In terms of the founding conditions, we have highlighted the importance of (1) the social positions of the main IE actors; (2) the local field conditions in terms of the extent to which the CLAHRC was being developed as a brownfield development or was more greenfield in nature, and the existing relationships between NHS and HEI organisations in the local region; and (3) the resulting influence of the actors’ social positions and the local field context on the degree to which the bid formation was an autonomous or a collective process.

Our research suggests that actors’ social position shape their relationship with the local region in which they are embedded. 149,150 Actors’ social position is important because it influences both their perception of the local context105 and their ability to influence others. 101 In terms of an actor’s social position, we concluded the following. First, HEI-facing clinical academics were generally more likely to view the CLAHRC initiative as another opportunity to gain income to fund their research activities. Given that HEIs often privileged academic publications and research income over other forms of performance indicators, such as research impact indicators, this approach is logical for many HEI-facing clinical academics. Second, NHS-facing clinical academics were more likely to view CLAHRCs as a means to promote service delivery. For NHS-facing clinical academics, the importance of research stemmed from what it could do to enhance service delivery. And, finally, non-clinical actors, including social science academics located in business schools and health sciences departments, health services researchers and engineering academics, sought to use theories and concepts of KT to bridge the implementation gap. However, this group commonly viewed the CLAHRC as a means of generating and testing of academic theory about KT.

In terms of the local field conditions, the presence of pre-existing relationships that spanned HEI and NHS organisations meant that a greater number of actors could be drawn together to develop the CLAHRC bid in a short space of time. In addition, the nature of the local field conditions also shaped who was involved in the bid formation stage. Both the presence of pre-existing relationships and activity shaped the extent to which the CLAHRC bid was developed in an individualistic or collective manner. Where there were pre-existing relationships and activity, the development of the CLAHRC was carried out in a collective manner, and more actors, with their vested interests, were involved. In contrast, where there were fewer pre-existing relationships and less activity, and particularly where the lead actor occupied a powerful social position, the bid formation process was more autonomous in nature, and the resulting CLAHRC was more of a pure de novo activity.

In examining the founding conditions of each of the nine CLAHRCs, attention was drawn to the extent to which the founding conditions may engender ‘lock-in’ towards distinctive ways of conceiving and mobilising CLAHRCs, as evident in the diagnostic and prognostic framing within the envisaging processes. This is discussed in the next chapter.

Diagnostic framing

Some actors’ diagnosis of the problem that CLAHRCs were required to solve was the closing of the T2 and they shaped their bid accordingly. However, for others, there was limited engagement with diagnostic framing, as they saw the CLAHRC as another programme grant.

From my perspective, what I think CLAHRCs are for is not necessarily what all the other senior academics in this CLAHRC or other CLAHRCs that I have spoken to think they are for. Some people I think, some senior academics I know that are involved with CLAHRC seem to think they are rather like programme grants and they get down to their theme and they think ‘I am just going to do it because it is applied health research and it is good for the NHS’. I think, myself, my reading of the CLAHRC is that the themes ought to all be replaceable because they are vehicles for doing something else, the research is a vehicle for doing something else.

Clinical science academic 2, NHS-facing, case H

It was interesting to observe that there was heterogeneity in terms of the way in which actors constructed the problem. We identified three dimensions of their diagnostic frames, which we will discuss below. It is important to note, however, that the dimensions presented are not mutually exclusive.

Prognostic framing

Prognostic framing involves the articulation of a proposed solution to the problem and the strategies for carrying out the plan152,153 Research suggests that there tends to be a correlation between an issue’s diagnostic and prognostic framings, which means that the identification of specific problems and causes tends to constrain the range of possible ‘reasonable’ solutions and strategies advocated. 152,153 In this way we suggest that there is a generative rather than deterministic relationship between diagnostic and prognostic framing.

Conclusion

In this chapter we have examined the initial diagnostic and prognostic frames employed by actors in envisaging the CLAHRCs. Envisaging is important as it the first stage of any organisational/strategic change project whereby actors form a vision of the change they want to enact, based on the interplay between themselves and the context in which they are situated. 26 In the chapters that follow we will examine how the envisaging process shaped the later stages of engaging, embedding and reflecting as CLAHRCs were mobilised.

In terms of diagnostic framing,152 we witnessed variation across actors located in different social positions as to their view of the problem that CLAHRCs had been established to solve. As outlined in Chapter 4, an actor’s social position is important because it may influence his or her perception of the field. 105 However, it is important to note that not all actors had a clear idea about what they diagnosed the problem to be. In general, we found that HEI-facing clinical science academics were more likely to diagnostically frame the problem as translational in nature, i.e. the problem was one of how to make research more accessible. In contrast, a number of more NHS-facing clinical academics framed the problem away from translation, by focusing on who actually defined the problem.

Finally, actors located in social positions which we defined as ‘other’ were more likely to view the T2 as an organisational- or systems-level problem. The idea of KT has tended to focus on engendering individual-level behaviour change and, as outlined in our review of the KT literature, has often played down the role of context. The more organisational- or system-level view focuses on how individuals’ actions are shaped by their context. Therefore, in order to engender meaningful change, context needs to be reshaped accordingly.

Overall, we view the relationship between diagnostic framing and prognostic framing as generative rather than deterministic in nature. All of the CLAHRC main actors understood the importance of marrying research to local NHS needs; however, important differences emerged in relation to their desire to research practice, the balance and interaction between research and practice, and capacity building. In terms of researching the ‘doing’, a small number of CLAHRCs started with front-line service issues and worked backwards, shaped by the diagnostic frame which identified the importance of who defined the problem. The balance and interaction between research and implementation was a common issue for many CLAHRCs, which played out in different ways according to how the two elements were initially structured in relation to one another. We will discuss this later in the report. Finally, in terms of capacity building, all the main actors in CLAHRCs prognostically framed their understanding around the promotion of capacity building.

Winning the minds and hearts of Collaboration for Leadership in Applied Health Research and Care stakeholders

In engaging key stakeholders, actors drew on their social capital with other actors across the HEI and NHS landscape and across different levels of seniority to secure support for their CLAHRCs, but also to access research ideas during the initial bid formation. By leveraging their social capital to influence others, actors were able to champion the support of close allies and orchestrate collective action from those supporting the CLAHRC initiative. 24 We term this work ‘winning the minds of key CLAHRC stakeholders’. This comprised three mains forms of work: (1) ‘drawing on the support of key stakeholders’, (2) ‘doing the rounds’ and (3) ‘spreading the word’. In addition, we highlight work that was undertaken to ‘win the hearts’ of key stakeholders through alignment and consensus building.

Doing the rounds

‘Doing the rounds’ became a core part of many CLAHRC directors’ activities as the CLAHRCs were being established. Often this activity was a core part of ensuring that NHS organisations signed up to CLAHRCs. ‘Doing the rounds’ was particularly evident in NHS regions where there was an absence of key stakeholders who could help to mobilise other NHS organisations to support the CLAHRC initiative.

It’s a bit one-way street in the sense of CLAHRC coming to the trust as opposed to the trust going to CLAHRC. I think the senior directors of the trust acknowledge CLAHRC, it’s all linked in to sort of the world science situation, but I think the devil is in the detail, and they’re not particularly interested in the detail. I don’t think that’s a conscious decision, I just think they just simply don’t see it on their radar.

CLAHRC management, case C

However, even when key NHS stakeholders were engaged to help mobilise support there was still a considerable amount of work that needed to be done in order to get the NHS organisations fully on board, and signed up to specific projects. As one CLAHRC senior academic commented:

It’s one thing getting people to ‘agree in principle’, but then someone still has to go into each of the NHS organisations and work out how this is going to work in practice. At the moment I feel a bit like a tawdry salesperson. I think I’ve done the same pitch about 30 odd times.

Social science academic 2, case E

‘Doing the rounds’ was a very time intensive activity. The work focused on translating what the ‘in principle’ funding was to be used for in practice. This required a great deal of groundwork to ensure that NHS organisations followed through with their initial promise of support, and that the activity of the CLAHRCs and the needs of the NHS partner organisations were aligned. As described in the previous chapters, both existing and new projects were used in the CLAHRC bid to present projects that would be rolled out over the CLAHRC period. CLAHRC directors looked for projects and ideas that were already ‘on the shelf’, but which also fitted the project brief.

We did a lot of groundwork by going out to see various chief executives and various other medical directors on the patch in both primary and secondary care [. . .] we got 80 to 90 per cent of coverage just by getting out there and talking to people. What we also did is conduct a series of informal interviews with a whole variety of people, clinicians and researchers around the patch.

Clinical science academic, NHS-facing, case D

Across both the ‘high-level pitch’ and ‘doing the rounds’ actors had to demonstrate the value of CLAHRCs to the NHS organisations. In the previous chapter on envisaging we examined how actors ‘married research to local needs’ and/or ‘researched the doing’ of practice, both of which were ways of demonstrating value to NHS organisations. In addition to demonstrating value, a key issue of selling centred on what constituted ‘matched funding’.

We had to really use the term ‘matched funding’, as people in trusts became aware of this [resource] requirement, there has to be conversations about this. It doesn’t necessarily mean that we’re going to be asking you for £100,000 every year or whatever. What we’re really looking for is equivalent resources of that level.

CLAHRC management 4, case I

A number of CLAHRC actors interpreted matched funding as a requirement to mean cash. Others interpreted matched funding more broadly to include ‘resourcing in kind’, including physical resources, staff and workspaces or even the adoption of existing NHS research programmes. For the majority of CLAHRCs, matched funding was in the form of staff seconded from the NHS partners and HEIs, who then worked across projects on the different themes.

It became clear to me early on that people agreeing to provide matched funding was one thing, actually getting the cash was a completely different issue. Trying to get actual money was difficult as people think bottom line: What do I get for this? Given the design of our CLAHRC, what I wanted more than money was the time of NHS staff. I soon realised that asking for ‘people time’ rather than actual cash made the sales pitch much easier. In asking for people time, we were ensuring that the CLAHRC was working to their agenda.

Social science academic 2, case E

The high-level pitch for capital which was carried out by CLAHRC senior actors was much harder sell. One CLAHRC director lamented this issue and was surprised to find out how each CLAHRC had interpreted ‘matched funding’ in significantly different ways.

All of our match funding is actual money from XXXX . . . In fact, I found out from going to the programme managers meeting there was . . . ‘complex accounting’ that went to show that they had matched funding, but actually it is not funding at all, it is not money you can do anything with.

Social science academic 3, case C

However, for some, the resourcing-in-kind model was greatly beneficial as it meant that the resources were fully embedded into the host NHS organisation. As one CLAHRC director commented:

I’d rather have people than money, as you’ll only spend the money on people anyway. The big advantage is that they are embedded in the NHS. Also, if money gets tight it has the additional advantage of being a ‘hidden’ resource, it is not bottom line cash that the partner can take back if they get short.

Social science academic 2, case C

The influence of envisaging and founding conditions on engaging

In attempting to engage the minds and hearts of CLAHRC stakeholders, a number of challenges were identified early on in the process. The challenges were grounded in the institutional differences between the fields of research and practice, but also reflected decisions relating to the envisaged CLAHRC structures and the different hierarchical status and roles of the different actors involved. Consequently, some actors found working across the boundary of research and practice more challenging than others.

Conclusion

In this chapter we have examined work undertaken by CLAHRC actors in engaging CLAHRC stakeholders, both during the bid formation and once CLAHRCs had been funded. The first form of work related to winning the minds of CLAHRC stakeholders about the CLAHRC initiative. Across all of our research sites we found evidence of actors leveraging their existing networks and social capital to bring together collectives of people to support the CLAHRC concept. In particular, senior CLAHRC actors worked to sign up people through (1) ‘drawing on the support of key stakeholders’, (2) ‘doing the rounds’ and (3) ‘spreading the word’. In all cases, work began by signing up the ‘big names’ in a locality, from both HEIs and the NHS. Work was then undertaken to deepen engagement and, thereby, mobilise the social movement with those lower down organisational hierarchies. Interestingly, there was a need to engage more powerful actors, with ‘strong arm’ political skills, to act on the CLAHRCs’ behalf in each locality. 109,156

As we outlined above, all CLAHRC directors and senior players were able to engage key stakeholders and those lower down organisational hierarchies. Engagement, however, was a necessary, but not sufficient, condition for closing the T2. The other form of work related to ‘winning the hearts’, which centred on alignment and consensus building. Actors, in engaging with the CLAHRC initiative, may have done so for a number of reasons as shaped by institutional forces and, in doing so, some may have fully aligned with the espoused ideals CLAHRC. An important role for actors was the work that they did to frame discourse in a manner that resonated with the interests and values of the different stakeholder groups. 27,28,152,157 Actors who worked to align stakeholders’ interests with CLAHRC ideals and build consensus across different stakeholder groups highlighted the inherent difficulties in doing so and the importance of repeated interactions across group boundaries.

The key difficulties associated with ‘winning the minds and hearts’ of CLAHRC actors, to embrace the ideals of CLAHRCs, were influenced by the way in which the CLAHRCs were envisaged and the professional status and roles of the individuals involved. Where CLAHRCs were structured around large existing research projects, the centre of gravity of the CLAHRC was more towards HEIs than the NHS, and a clear separation of research and implementation was more likely to result. In these cases, alignment and consensus building was much more difficult to achieve. We found that the bridging of the research–practice divide was more problematic for junior staff than for senior staff, demonstrating the importance of role and status to the process. Overall, there was a disparity between engaging management to enact CLAHRC ideals with actors on the ground. This may well highlight the distinction between getting the management in CLAHRCs to enact CLAHRC ideals and then getting those on the ground to do so as well. We will discuss these issues further through the SNA in Chapter 8.

Education

All the CLAHRC senior actors understood that, in order for research to be translated into practice, those working in practice needed to be able to access education to promote the ideals of CLAHRC and to provide people with relevant skills. In response to this need, actors developed a number of different educational interventions to try and embed CLAHRCs.

CLAHRCs ran a number of courses and workshops to bridge the research–practice divide. These provided practitioners with knowledge and skills on change management, project management and research methodology. By providing education, those in practice were able to build up a level of competence in order to improve and change services and patient care based on research findings. The development of research-related courses was intended to enable professionals in NHS organisations to better understand and utilise research, and to implement findings in practice. In bridging the divides between the two institutions, the intention was that academics would work with practitioners and educated them on how better to use and implement evidence, and further provided them with the skills to generate new evidence.

You’d tend to get clinicians that are interested in changing some aspect of service delivery and they want to try to pilot a new approach and they want to evaluate that to see whether it works or not, whether the evidence can be found to demonstrate that that is a worthwhile change and something that perhaps the trust should consider rolling out more widely.

CLAHRC management 2, case I

Meetings and workshops were developed by CLAHRCs to educate health professionals on strategies to implement research into practice. As part of this, CLAHRCs contacted NHS partners offering courses on research evidence and service evaluation to suit NHS trusts’ needs.

We gave them a menu and they chose from that the ones that they thought would be suitable for the staff in their trust. It would be things like how to find evidence, how to critically appraise it, specific skills in terms of relating to descriptive statistics or interview and questionnaire design.

CLAHRC management 2, case I

In a number of cases the educational interventions were designed to break down organisational and professional cultures and barriers associated with the T2. In one CLAHRC, for example, there were a series of workshops and events that encouraged collaboration across different professional groups and brought together people from within the CLAHRC as well as those from the local health landscape.

We start with organisational culture, we look at change management, we look at team climates, communities of practice, professions, knowledge exchange. We sort of start at the organisational macro change because of course they have different levels of change that they want to achieve in their projects.

Implementation lead, case B

In addition to raising awareness about the importance of research and understanding of how to interpret research findings, educational interventions were also employed to communicate important tools to translate research into practice.

It’s about rebuilding capacity of clinicians . . . giving them advice tools and approaches for implementing change in their practice.

Social science academic 1, case B

In part, actors’ attempts at capacity building in the CLAHRCs focused on the development of educational programmes, which included postgraduate courses at HEIs and educational courses for mid-level career professionals from clinical practice.

We focus on the person and they do a little project which enables them to learn and grow and develop. We’ve had about 40 of these and these people have gone on and done various things. These people who are mid-levels in their careers, so we’ve got a number who’ve gone off because of being involved with CLAHRC, have gone off and done PhDs, they’ve gone to improved, more senior positions.

CLAHRC management 2, case D

As we discussed in Chapter 5, some of the actors central to CLAHRCs diagnostically framed CLAHRCs as an individual-level problem rather than an organisational- and systems-level problem. Accordingly, attempts to develop internal capabilities were commonly focused on the individual, and centred on changing individual-level behaviour, through specific educational interventions. The primary focus of much of the educational work was to inform and develop the skills of front-line staff who worked on CLAHRC projects; the primary focus of much of the educational work was to inform and develop the skills of the front-line staff who worked on CLAHRC, with the intention of helping the projects function more effectively.

Creating new roles

A number of CLAHRC actors developed new roles to build capabilities and enable clinicians and management in practice to gain a deeper understanding of research and its role in implementation, service design, innovation and improvement. Of particular note was the creation of the ‘knowledge broker’, a role which was operationalised under a number of different titles by different CLAHRC actors [e.g. ‘knowledge transfer associate’ (KTA), ‘boundary spanner’, ‘co-ordinator’ and ‘diffusion fellow’].

The knowledge broker roles are those that span and link different organisations and/or organisational fields. In the case of CLAHRCs, the knowledge broker roles were developed to provide a link between HEIs and NHS organisations to encourage collaborative work. The concept of the knowledge broker was first employed by one CLAHRC, led by a social scientist, who wanted to embed CLAHRC ways of working through the diffusion of knowledge in a situated manner. Here, the actor had diagnostically framed the problem facing CLAHRCs as an organisational/systems-level problem. The knowledge broker role was designed to address this need to engender organisational/systems-level change. The role was designed so that knowledge brokers would be able to act beyond the scope of any specific project, be located in the NHS partner organisation, but be co-opted into the CLAHRC on a part-time basis, thereby diffusing CLAHRC practice to NHS partner organisations and, in doing so, help to build capacity.

Through a process of mimetic isomorphism, the knowledge broker roles diffused to other CLAHRCs in a number of different incarnations. The roles included fellowships and secondments of nurses and clinicians to engage in research. CLAHRCs employed knowledge brokers to act as translators across epistemic boundaries and help bridge divides between professional groups. The process of knowledge brokerage had the potential to engender understanding and appreciation of the value of others’ perspectives of the translational problem. Such knowledge brokering had to extend beyond the research–practice boundary to encompass epistemic boundaries within the academic research domain.

We work with secondees who come in from their own organisations to work with CLAHRC on particular projects and then lead those projects. We are talking about doing, they are more interactive than training, but we are doing workshop sessions with groups and they are with us doing things like the evaluations of these projects so that it is not us doing it to them.

Social science academic 2, case C

The creation of such roles built capacity across HEIs and NHS organisations, which drew the two institutions closer together while providing actors from the NHS with research skills which they were then able to apply in their clinical work.

I think there is capacity building in the research group as well, but I think what we are not doing enough of is trying to work out whether there is capacity building that could be done and used in the service by bringing these sides together more closely.

Social science academic 2, case C

In addition, knowledge brokers were used as boundary spanners who crossed the divide between research and practice and established links between partners. They built capacity through the development of new relationships.

Their job is to know what the CLAHRC is doing in their trust and help identify the key priorities and set up a team, what we might call a translation team, which is where we try to get trusts engaging with a really important topic for their trust to try to bring about this thinking of ‘oh right, research is actually quite a useful thing then and it can help us [. . .].’ It was absolutely fundamental I think in trying to bring the researchers and the NHS together.

Clinical science academic 2, HEI-facing, case I

Knowledge brokers who worked between practice and academia benefited from the skills and knowledge gained through the role. In one CLAHRC the knowledge broker role was designed to second health professionals from practice into the CLAHRC to better understand challenges around research methods, implementation and KT.

I think what we decided to do is we try to second people into the CLAHRC much more so they work 1 or 2 days a week with us and are much more involved with running the projects and learning very much from working with the knowledge transfer associates [KTAs] how you do knowledge transfer.

Knowledge broker 1, case C

Knowledge brokers were then able to apply their new skills and knowledge to embed new ways of working back into their own work. The knowledge brokers from clinical settings benefited from the acquisition of research skills that were valued in clinical work.

[. . .] it is a little bit of career progression because they move a little bit away from just being clinically focused, but also develop a career through quality improvement and work within the health economy [. . .].

Knowledge broker 1, case C

The model of employing knowledge brokers also helped to mediate potential problems that arose within CLAHRCs which had structured research and implementation to operate as separate themes. In such cases the role of the knowledge broker was to work closely with practice to develop educational programmes and tools for the local NHS organisations. These were later embedded into practice.

Linked to the SNA results in Chapter 8, we highlight the importance of knowledge brokers in CLAHRCs and their role in fostering relationships between the HEI and NHS, and the translation and implementation of research into clinical practice.

Embedding tools and routines in practice

The third form of IW around embedding related to tools and routines in practice. A number of CLAHRCs either employed existing, well-developed tools and routines or sought to develop new ones that could be embedded into HEI and NHS organisations.

In terms of the use of the existing tools and routines, one CLAHRC developed a distinctive model that employed well-tested service improvement methodologies. The director, a NHS-facing clinical academic, organised his CLAHRC around a portfolio of ‘bid and deliver’ projects. Actors were required to apply for funding from the CLAHRC based on proposals for improving services and/or propose new implementation processes using evidence from existing research. As part of this model, the CLAHRC central team provided a range of tools to practice-facing teams to help manage the service improvement process to enhance patient outcomes, and then to monitor the efficacy of the process.

We apply a standardised method or suite of tools to enable all of those projects to implement evidence into practice. So the precondition is that they apply to us for funding and say ‘we’ve got a piece of evidence, we‘ve got an intervention, which evidence shows to be effective, and what we need to be able to roll that out in our local context’. And the point of the model for improvement, and the point of this suite of tools, is to enable them to apply that within their own context.

CLAHRC management 3, case D

From the start of the projects, tools were embedded into the host NHS organisation. The aim was then to diffuse the tools across the local landscape. Afterwards CLAHRC management monitored these projects and the use of tools to ensure that they were being integrated into daily practice, and that the use of tools translated through into improved patient outcomes. The CLAHRC provided the toolkit and framework to close the T2.

You’re not telling people how to do it, you’re saying this is the idea, you implement it the most effective way for your community hospital and we will support you using our methods. So for the COPD [chronic obstructive pulmonary disease] bundle, that started here XXX and now every single acute trust in our sector use that [. . .] So for the [local hospitals] they are doing that and that is completely embedded and they are still monitoring now, 18 months after the project’s finished [. . .].

CLAHRC management 3, case D

To ensure that there was a cycle of continuous improvement, and that the tools implemented in practice were used effectively, the clinicians were required to update the data from the projects using a web-based reporting tool. CLAHRC management was then able to monitor any issues arising in clinical practice and work with the NHS organisations to ensure that issues, including leadership, research methods and how best to implement research, were addressed.

We’ve set up a web reporting tool, and teams would use that, the suite of improving methods and planning doing study-out cycles and process and outcome measures. But the sustainability tool is one of those. So the individual departments have got a login, they’ll put their score in, the scores for the project are put together and then a composite score is produced and then the charts are produced. And the idea is that the team will look at what their risks are and come up with a strategy to address them.

CLAHRC management 3, Case D

The model of employing standardised service improvement methodologies and tools was directly related to the manner in which the director, who was a NHS-facing clinical academic, had envisaged the CLAHRC. Here, the director viewed CLAHRCs as a vehicle to improve patient care through the implementation of existing research and through addressing the needs of practice and how to support them. The role of CLAHRCs was to close the implementation gap through system/organisation-level change rather than focusing on individuals and the different institutions as separate entities.

In contrast, many other CLAHRCs conducted research first and then developed tools, or found appropriate existing tools, which they then could implement. Here, the emphasis was that research needed to be developed before it could be implemented. Or, in cases where the implementation theme was run in parallel, the implementation team often waited for the research to be conducted first. In a number of cases, implementation teams merely generated their own projects independent of the research themes.

Where the research had to generate new insights, tools and routines before they could be implemented, a slower process of transferring the new tools and routines into practice occurred. However, a number of CLAHRC actors did successfully develop useful tools through formal research-based collaborations, which were then adopted by local NHS organisations. For example, the researcher documented below collaborated with practice in the initial stages of the research project to identify how patient care could be improved with the development of educational tools. Collaborations with the local university enabled the translation of research into new systems and interventions that were then adopted and made routine even after projects had ended.

A policy simulator which lets you answer ‘what if’ questions about where you put resources into the health service. And it will tell you what happens, well it would predict what happens to the population over time. So you can change the interventions you apply, the resources you apply, it will simulate that population. Some of that work goes on in existing collaborations that we already have with the University XXX and epidemiologists there, who have basically delivered for us the sets of requirements that ultimately got translated into systems.

Researcher, case C

A number of other educational tools were developed by CLAHRCs, which later became embedded in practice and enabled evidence to be collated to identify the impact the new care pathway analysis tool had on patient outcomes over time.

What the purpose of this work is to do is to develop a software tool whereby you can define what a standardised care pathway is, you can go into a database containing historical medical data for patients and then you can compare what actually happened to those patients and the trajectory of their disease with what should have happened [. . .] Then you can then use the care pathway analysis tool to see what impact this had on their care and in fact you can then use that as evidence that you feed back into the policy simulator to refine them all.

Researcher, case C

In addition to developing new tools, and in response to the NHS needs, CLAHRC actors also identified existing tools that were documented in research but which had not been translated into practice.

There is research that says that you should be looking after these patients in these particular ways but unless they actually know who these patients are, we can’t actually do that. So the actual finding of people and actually making sure that right ones are on the register has been one aspect of enabling the sort of research about medications to actually be taken forward.

Social science academic 1, case C

An example of the development of a tool in response to NHS needs was:

[. . .] [W]e have actually brought in a tool that XXX [another CLAHRC] developed for running searches on registers to identify patients with chronic kidney disease. Actually it is interesting because in the first project we didn’t give them like a toolkit of how do you increase the number of people on your register, but the PDSA [plan, do, study, act] cycles virtually every practice that was one of the first PDSA cycles they had to do, run searches on their register, find where they were missing identification of patients.

Implementation lead, case C

The development of new evidence-based tools by CLAHRCs in collaboration with practice and the local HEI were embedded in practice and gained interest from the local health community.

And then as a result of going into these practices and learning more about the practice of the practitioners, we’ve then run education which has been very specific to the practices and as a result of that GPs [general practitioners] have said to us ‘Oh this has been so helpful, I feel far more confident now about managing patients’.

Social science academic 1, case C

This approach was also evident in other CLAHRCs that engaged with practitioners to equip them with the skills to be able to manage patient care. Clinical academics and knowledge brokers sought to bring research to practitioners and provided training for them to make services more patient focused.

Training is about patient-centred assessments, negotiation skills with patients, some of it is about actually delivering a new treatment, so a psychological therapy. Some of it’s about cultural competence, delivering care to people from ethnic groups and working together, part of our intervention is training people in primary care to work more closely together in a collaborative sense, so that care is integrated.

Social science academic 4, case C

Other CLAHRCs provided change management advice and new ways of working to practitioners. These were then embedded into the local health landscape to ensure that the tools and methods were used after CLAHRC had ended.

I mean we have very much taken an improvement collaborative approach and we’ve tweaked it and we’re in phase 3 now. I think we have managed to leave something behind in very practical skills, ways of working that they will keep using.

Implementation lead, case C

The institutionalisation of new ways of working and values to improve patient outcomes through the education of those in practice was central to CLAHRCs.

We are providing education to GPs and practice nurses around care, how to treat heart failure care, how to conduct systematic reviews, how to do data searches these kinds of things.

Researcher, case I

However, how successful actors were at embedding differed across the four CLAHRCs we studied. The IW around the creation of roles, tools and routines in practice helped to reinforce change across the NHS organisations and create linkages between the different institutions. In doing so, CLAHRC actors sought to embed the CLAHRC way of working into their partner organisations to build capacity.

Constructing a Collaboration for Leadership in Applied Health Research and Care identity

Identity construction as a form of IW has traditionally been associated with the development of new, and the transformation of existing, professional identities. 158,159 In highlighting the work that was undertaken to promote the development of a CLAHRC identity, we acknowledge the importance of IW around embedding – education, creating new roles, tools and routines – which helped develop a receptive context for such work. As such, identity work was not evident at the inception of CLAHRCs, rather it gathered momentum over time. We suggest that the development of a CLAHRC identity is important as it provided legitimacy for the roles and work that spanned the fields of research and practice.

A lot of the tools we use, whilst they have specific aims, such as process mapping, model for improvement or whatever, they have specific aims in relation to helping the project deliver, but the major side effects or benefits . . . are that first of all they allowed people to start communicating together and secondly they act as team-building tools.

CLAHRC management 1, case D

The construction of a CLAHRC identity was central to the promotion of CLAHRC ideals and in enabling greater stakeholder engagement with the CLAHRC initiative. To help develop a CLAHRC identity, one CLAHRC ran collaborative events to bring together practice and research, which stimulated a culture of ideas sharing and teamwork.

We have a mixture of people coming to events; it’s academics, patients, clinicians, health professionals and NHS managers. And that has helped to develop the ethos of bringing NHS management, clinicians, patients and academia together for the common purpose of closing the second translational gap. I think that has had the desired effect of creating that CLAHRC identity but also bringing people together to understand by working together they’re more likely to actually deliver the outcomes that they’ll want, which is essentially improve services for patients. So that’s worked quite well.

CLAHRC management 3, case D

Identity-building work was also centrally enabled by the NIHR and through numerous SDO learning events. CLAHRC directors, as a unit, saw the need for this higher-level branding as a way to develop and build a CLAHRC identity and secure the call for CLAHRC II funding.

There are learning events across all the CLAHRCs, we have a very strong learning culture. We have a very strong ethos, our principles are around capacity development and they are around public patient engagement, so we have a strategy that crosses over, so they are very cross cutting.

Clinical science academic, HEI-facing, case F

Alongside the encouragement of engagement with the ideals of CLAHRC, the development of a CLAHRC identity provided researchers and those working in the CLAHRCs with enhanced legitimacy within practice, which fostered better engagement and collaboration. The CLAHRC identity acted as a form of ‘brand’, which signalled that the researcher was more likely to be open to engaging fully with practice, which, in turn, meant that NHS staff were more willing to collaborate with them.

Clearly having a 5-year programme that’s dedicated to a specific aim, does give you an identity which then I think probably does help when you reach out to collaborate because you can say ‘Hi, I’m from the XXX CLAHRC, this is what we do’. And they might go ‘Oh yeah, okay, I get CLAHRCs’. So they carry some weight and there is some salience in using the CLAHRC name as a means to collaborate.

Social science academic 4, case C

We found, however, that the development of a strong CLAHRC identity was not prevalent in all CLAHRCs we examined. Where identity work was not as prevalent, we suggest that the cause was a number of more senior actors maintaining their pre-existing professional identities as their dominant identity. In CLAHRCs where there was a clear separation between research and implementation, actors commonly reverted back to their normal ways of working, which reinforced existing professional identities. This was particularly evident from senior academics and clinicians who were already highly embedded in their institutions, and so were less receptive to adopting the emerging CLAHRC identity.

I don’t know how much people will identify themselves with CLAHRC or its aims, I think very loosely. They see themselves as doing research in diabetes; the fact that that study is funded by CLAHRC, they might have been funded by Diabetes UK you know, it’s just a different funder. I personally think that it hasn’t been possible to get people focused on all of the aims of CLAHRC and to work towards them. I think people have used the money that have in their themes to do largely what they wanted to do and that largely meets one of the aims of CLAHRC.

CLAHRC management 2, Case I

Although CLAHRC identity was seen as important, a number of actors stressed that this was merely a means to an end, and that it was more important to focus on the development of a CLAHRC ‘way of thinking and doing’ through the creation of institutional norms and values to support CLAHRC activities. This then would enable the continuation of CLAHRC ways of working even after CLAHRCs ended.

When they’re no longer CLAHRC they can still take those ideas and use them for other things. So the next time they develop a project, even if it’s not CLAHRC funded, well a lot of them will know next time there’s no more money but in the past if they’ve done one successful project they’ve applied for the next round. So that’s how it’s worked. [. . .] Does it really matter if they’re saying ‘We’re CLAHRC, we’re CLAHRC’, what it’s about is it’s about the ethos and the values. If they are using our techniques and applying that, that’s what they want. Whether they call themselves CLAHRC is irrelevant; they are CLAHRC because they’re following the ethos which wasn’t there before.

CLAHRC management 3, Case D

Conclusion

The embedding of CLAHRCs centred on four inter-related areas of work: education, the creation of new roles, embedding tools and routines, and the construction of a CLAHRC identity. Across the four CLAHRCs we witnessed significant differences in how CLAHRC actors sought to embed the CLAHRC. We also noted a significant degree of isomorphism over time, whereby CLAHRCs looked to learn lessons from other CLAHRCs. Here, we draw attention to the archetypes of models for organising knowledge transfer and highlight that no one CLAHRC conformed to any specific archetype because of the process of isomorphism.

In terms of the IW, we saw evidence of education across all our in-depth cases, but educational programmes were conducted in different ways. In line with the study of Hargadon and Douglas,82 we found that the institutionalisation of the CLAHRC was supported by education. However, much of the educational work focused on enhancing the efficiency of existing CLAHRC projects, as opposed to capacity building in general.

The creation of new roles was most evident in the creation of the knowledge broker role, which emerged in one CLAHRC and then diffused to other CLAHRCs. An important reason for the diffusion of knowledge brokers was that NHS staff who had been seconded into such roles for only a fraction of their working week could then be counted as matched funding. The knowledge broker role is a form a hybrid role, which is based around the ideals of situated learning and the diffusion of practice, both of which influence capacity building for organisational- and systems-level change. 160

The two remaining forms of IW for embedding were more varied across the four CLAHRCs. In terms of tools and routines,32 while we witnessed evidence that CLAHRCs had been able to gain some traction in shaping NHS decision-making on a local scale, the reciprocal influence back into HEIs was more inconsistent. In addition, where tools and routines had been embedded in NHS partner organisations, this was largely done on a project basis. Similarly, the work to develop a strong CLAHRC identity varied, and was influenced by the extent to which senior CLAHRC actors had been willing to take on a CLAHRC identity. Where senior actors were unwilling to take on a CLAHRC identity, then this provides an interesting insight into how such actors view themselves, and their relationship to the field, which will orient their thoughts and actions accordingly. 104

Finally, in examining the different work undertaken to embed CLAHRCs, it is interesting to note the extent to which the different forms of work are inter-related and mutually reinforcing. We suggest that the CLAHRCs that have been the most successful in embedding their activity have sought to engage in multiple forms of embedding work. When asked about whether or not CLAHRCs had been able to engender institutional change, one senior-level actor replied:

Give us a chance. We’re now at the position where the local NHS organisations fully trust us, and that’s taken 5 years. We’ve made some changes at a local level, but an institutional level? All I can say is give us another 5 years and hopefully we’ll have scratched the surface.

Social science academic 3, case C

The issue of embedding is important as it relates to how the CLAHRCs were able to reshape existing institutions to close the T2. At present, the CLAHRCs have made significant progress in embedding the principles of CLAHRCs at a very local level, but arguably the macro-level institutions remain untouched.

Findings of cross-sectional data analyses

In this first part of this chapter we report the results of cross-sectional analyses of data from both survey waves.

Findings of longitudinal data analyses

In this section we report the results of the longitudinal analyses for the change actors’ networking behaviour between wave I and wave II. As above, we employ the same independent variables, but developed measures of change in the DVs across wave I and wave II, given by DV_change = DV_{wave II} – DV_{wave I}.

Although every attempt was made to secure the involvement of the same participants in the network survey over time, high staff turnover in one of our in-depth case sites resulted in a very low overlap between the samples of participants obtained in the waves I and II. As a result, during the second survey wave we managed to obtain longitudinal data for only three participants out of 15 surveyed in the first wave in one CLAHRC. As a result of the very low response rate, the decision was made to exclude the three respondents from longitudinal analyses. Therefore, the longitudinal analyses reported in this section are based on data from 42 of the 66 participants initially surveyed from three CLAHRCs.

Conclusion

The results of our SNA highlight the enabling role of individuals’ social position in promoting institutional entrepreneurship associated with the development of network ties across actors’ different dominant orientations (academic vs. practitioner) and foci of interest (clinical vs. non-clinical). 106,114 Specifically, our SNA highlighted that there were systematic variations in actors’ ability to bridge the research–practice boundary. First, practitioners were more likely to develop networks that bridged the divide than academics. Second, actors with many existing connections in their own professional field (i.e. are more embedded) were less likely to bridge the divide than those with fewer connections (i.e. were less embedded). Third, junior actors found it more difficult than their more senior counterparts to bridge the divide. However, on a positive note, our longitudinal analysis suggests that the CLAHRC initiative has led to the development of more relationships that span the research–practice divide.

From wave I to wave II practitioners networked more with, and were influenced more by, academics than vice versa. However, our results suggest that between our two waves of analysis, academics experience a notable increase both in the proportion of practitioners in their CLAHRC network and in the extent to which they are influenced by practitioners in CLAHRC related decision-making. The involvement of academics in CLAHRCs appears to have a positive impact on the institutionalisation of their new collaborative working patterns with practitioners.

Underscoring the role of individuals’ social status in the institutionalisation of new work patterns,24,161,162 the bridging of the academic–practitioner networking and decision-making gaps is found to be more pronounced among the CLAHRC actors of higher professional status. There was no significant change in the effect of participants’ professional status over time. Since higher-status CLAHRC members are more secure in their professional roles, they may be more empowered to exhibit work patterns that deviate from the established jurisdictional standards of their profession. 163 In turn, for lower-status professionals, investing time in work that is not effectively aligned with the reproduction of existing professional standards may compromise their career mobility. Alternatively, but with the same effect, lower-status professionals may have been actively ‘managed’ and directed away from such networking by their superiors (higher-status professionals), who may benefit from this dissuasion through the maintenance of a ‘workforce’ which services their need for academic publications and research completions.

In terms of the enabling role of individuals’ social position, based on the availability and mobilisation of social connections, the findings underscore the role of knowledge brokers in the institutionalisation of KT practices. 164,165 Across our two waves of analyses, CLAHRC members with a higher number of knowledge brokers in their network were more likely to be influenced by the members of the opposition professional domain in CLAHRC-related decision-making. In wave II, the number of knowledge brokers in the network was also found to be positively associated with the formation of networks across academics and practitioners, and members of research and implementation themes. These results suggest that knowledge brokers served to facilitate communication and integration of professional networks among academics and practitioners.

In contrast to the enabling role of individuals’ social position based on professional status and involvement with knowledge brokers, the embeddedness of participants in the network of the same dominant orientation (for example, academics networked with academics) had a restrictive effect on the bridging of the academic–practitioner networking and decision-making gaps. Embeddedness in a network that did not span professional divides appears to have inhibited the involvement of CLAHRC members in the process of institutionalising new collaborative patterns of work. This may be because such patterns undermined the power and autonomy of their professional domain. 166,167

The role of the embeddedness in the prior network of professional connections (irrespective of contacts’ dominant orientations) is more ambivalent. In the initial phase, participants with higher embeddedness in the network of connections formed before joining a CLAHRC are less likely to form networks across academics and practitioners. However, during the 2-year period of involvement in CLAHRCs these members became increasingly involved in the formation of mutually overlapping networks. One interpretation of this finding is that in the initial phase members who were more embedded in their prior network of connections sought to preserve the established power and work standards by resisting the inclusion of new members from the opposite professional domain. However, as these academics and practitioners become more familiar and/or secure with the goals and means of CLAHRCs, they become increasingly open to the formation of networks with the representatives of the opposite professional domain. In doing so, they became involved in the bridging of the academic–practitioner network gap.

We did not hit the ground running

The CLAHRCs were designed around a 5-year programme of activity, and the expectation was that the CLAHRCs would be able to ‘hit the ground running’. However, it soon became apparent to many CLAHRC senior staff that they, and the NIHR, had significantly underestimated the problems of enacting the CLAHRCs.

As outlined in Chapter 6, matched funding had been ‘agreed in principle’, and, although it later proved useful as it was seen to increase the engagement from practice and the partners’ commitment to the projects, there were tensions around what matched funding actually meant and then initially securing and allocating it.

I mean one of the original challenges for CLAHRC is when we used the term ‘matched funding’, that as people in trusts became aware of this requirement, there has to be conversations about well this doesn’t necessarily mean that we’re going to be asking you for £100,000 every year or whatever. What we’re really looking for is equivalent resources of that level.

CLAHRC management 4, case I

Many of the CLAHRC directors and project leaders felt that the NIHR had assumed that there would be no lead time during the CLAHRC set-up and that projects would run from the start of CLAHRCs. However, the initial set-up process was a time-consuming element of enacting the CLAHRCs. Since matched funding included staff, many of the necessary positions were unfilled during the first year of the CLAHRC, which delayed projects.

Well we had the funding, I think we heard about the funding in about the September of 2008 and I think some funding started sort of like in the October. Well there was nobody in place. You can’t spend the money if you haven’t got staff actually in post. And we couldn’t start recruiting until we knew we’d got the money.

Clinical science academic 3, HEI-facing, case I

When you’re putting in grants for something like CLAHRC, you’re forced into a position of assuming that you can hit the ground running, but in fact that doesn’t happen.

Clinical science academic, NHS-facing, case E

The short time between the submission of bids and the beginning of the CLAHRC initiative led to differences between project proposals and their initiation. For example, a number of projects were unable to start because the projects had not been finalised with the partner organisations or had to go through a long ethics process. Other projects had been allocated funding upfront and left with none towards the end of the projects during the stages when implementation of the research in practice was due to take place. These factors led to delays in the use of funding and a lack of planning in the allocation of the funding over the course of CLAHRC – a concern to senior members of the CLAHRC.

I think the money all came in initially in quite a big lump. The way that the funding was done, I don’t think we’d do it the same way again. We had a lot of funding in the first 2 years, there was a lot of pressure to get people employed and get the studies going as soon as possible because otherwise we’d have lost the money. So our last 2 years, the money is much, much smaller.

Clinical science academic 3, HEI-facing, case I

In addition to ensuring the release of resources from partner organisations, a series of additional issues arose related to the practicalities of trying work across the HEI–NHS interface. There was a need to learn how to manage the expectations of both organisations, and to understand how both parties operated.

I think from my point of view there maybe should be at the beginning more emphasis put on the infrastructure set up and because everybody was grappling around because there’s two organisations plus all the others grappling around, they‘ve never been so collaborative before.

CLAHRC management 1, case B

In particular, enabling the release and spending of resources was problematic, especially with regards to recruitment. In many CLAHRCs there were difficulties with getting job specifications and posts approved, and harmonising grades across organisations. These all took a great deal of time to solve. One CLAHRC director commented that:

It’s like walking in treacle. I’ve got all of this money now but I can’t spend it. University HR [human resources] keeps dragging its heels as it informs me that it has not had these types of appointments. It’s a real case of ‘the computer says no’, and then it’s just left on someone’s desk gathering dust because it’s not an easy case. The worst thing is, if I’m not careful I’m going to get it in the neck from the NIHR, but it is out of my hands.

Social science academic 2, case E

On reflection, I would say you need to put in at least 6 months where you’re assuming that people are not doing the projects, they’re actually recruiting now and thinking about recruiting and they’re thinking about some of the things they didn’t have time to do before they started.

Clinical science academic, NHS-facing, case E

The race to get the CLAHRCs up and running meant that tensions between CLAHRC partners caused divides among clinicians, academics and managers. For example, conflict occurred between those in clinical practice who sought to improve services and academics who needed to pursue their research agendas with minimal contact with practice.

I’m not sure there was enough clarity around the original brief. I think the turnaround time for establishing a CLAHRC was far too small and if they were really serious about collaboration and partnership working, working with projects of local importance, they would have allowed time to establish those relationships and to put together work packages that could be longer-term aims of a wider range of organisations.

CLAHRC management 4, case I

Overall, there was a general feeling that at the beginning of the CLAHRCs, rather than hitting the ground running, many projects experienced significant delays.

We committed too much resource upfront

As outlined in Chapter 5, during the envisaging process in which the CLAHRC bids were developed, senior actors looked to draw together existing projects that they thought would be attractive to the NIHR on research grounds. Often these existing projects were already running, or were based around failed research grant applications. A number of CLAHRC directors committed significant amounts of funding upfront to specific programmes of activity, which occasionally resulted in HEI-facing clinical academics viewing the funding as being akin to a ‘normal research grant’. This resulted in many clinical academics aligning with dominant institutions, and privileging research publications above implementation.

As director I feel a bit like a teacher who is trying to keep one chapter ahead of the students. I can see where they want to go. Sometimes I really feel like shaking them. They come to me and say ‘I need more money to do this research’ as if it is just another research grant. But this can be a liability as we are being evaluated on how well we can translate the research into practice; we need to focus more energy and money on the transfer to practice.

Clinical science academic 1, HEI-facing, case C

A number of CLAHRC directors and senior staff committed resources early in the process to convince the NIHR of the quality of their CLAHRC’s research base, and used this commitment of resources to encourage academics to sign up to the CLAHRC. Where the founding conditions led to a more collective process, many clinical academics actively negotiated for ‘their own share’ of the potential CLAHRC resources. However, the commitment of resources upfront to specific programmes of research removed an important performance management lever. On reflection, a number of directors felt that they had no choice but to hand over the control of resources too early.

That was an interesting lesson. We committed much of the money upfront on project in good faith. I wish, with hindsight, that we had drip-fed the resource on a more bid and deliver basis to ensure that some of the usual suspects to not merely revert back to type. The irritating thing is that some of these people looked me in the eye and signed up to the ideals of CLAHRC, but once they got the money it was business as usual.

Social science academic 3, case C

Most CLAHRCs followed a similar pattern of allocating the funding at the start of the project. However, one CLAHRC, directed by a NHS-facing clinical academic, released the funding in stages to different projects and over several project rounds. In doing so, this particular CLAHRC was able to monitor the progress of projects to ensure that they were completed with demonstrable and measurable outputs. The particular founding conditions of this CLAHRC, with its relatively autonomous envisaging process, meant that the director and his team were able to pursue a different internal management model.

Well you could do staged release of funds but again, as I said, the problem is more in the perception of what a good bid looks like. I’m sure everybody thought that’s probably a good idea but we don’t want to jeopardise this money by saying if you’re going to suggest that you’re going to hold money back, then you’re not telling people what you’re going to do with that money and you’re implying that it might not be needed at all.

CLAHRC management 4, case I

Interestingly, a number of other CLAHRC directors viewed the model of ‘bid and deliver’ as a possible alternative approach if CLAHRCs were refinanced.

We would be more responsive, so we’d set aside resource for including funds for as yet unknown projects or priorities. And we would probably rather than just give all our resources to people internal to CLAHRC, we’d set aside some resources that people could bid to as well. And getting a wider set of people involved in the CLAHRC and getting buy-in from a wider community. We would probably encourage a wider variety of project types within the CLAHRC, we would encourage people to not just to do research projects but all sorts of projects, projects on service development and implementation of the existing evidence would be fine for things for us to be funding.

CLAHRC management 4, case I

The loss of control over resources was a significant issue that a number of CLAHRC directors had sought to address during the 5 years of the initiative. In two CLAHRCs, we saw significant work to regain control over resources through reallocating funding from projects that were underperforming, driving work focused on implementation and enforcing stricter performance measures to monitor project outputs.

I think it’s very difficult when you’ve given large sums of money upfront, distributed all of the budget upfront to people, you’ve got no levers. They are independent people, they have got other work they are doing, they are not entirely CLAHRC employees, so there are other things that they’re doing. You have no control. The only control you would have had would have been to retain significant sections of the budget and pass it out for work that met CLAHRC aims. So I think that’s been the biggest mistake really was allocating all the money upfront.

CLAHRC management 2, case I

We had to search for the right balance between research and implementation

The need to rebalance research and implementation activities was caused by the lack of clear envisaging around what CLAHRCs were set up to achieve. As part of this, lack of clarity was the problem that actors were unclear about the emerging agenda and its impact. However, in a number of cases, the lack of clear envisaging around diagnostic framing meant that the resulting prognostic framing led to the promotion of research at the expense of implementation.

I think that overall people had very little understanding of what impact actually meant in the beginning. I think in the beginning there wasn’t any clear picture at all, so people generally worked with their initial understanding of impact which was how well setup is the research trial, is the methodology accurate and are the findings publishable? Ideally in a top tier journal, so that kind of assessment of impact. I think was kind of pervasive in the CLAHRC as a whole.

Social science academic 2, case B

Consequently, an ongoing debate within many CLAHRCs focused on understanding the appropriate balance between research and implementation activities. Across CLAHRCs we saw significant variation in gravity points, and within many CLAHRCs there were debates to decide where their own gravity point should be. Over time, a clear pattern emerged where a number of CLAHRC directors actively worked to rebalance their CLAHRCs to shift the gravity point towards implementation.

There are the ongoing negotiations about where the gravity of the CLAHRC lies, is it primarily about research with a bit of implementation, is it primarily about implementation with the research on the side, and I think there are a number of parallel things going on with this CLAHRC to try and balance that out, so rather than having one centre of gravity you have lots of little points of interest.

Social science academic, case I

Research and implementation were often carried out in parallel, along different timelines and with different outputs. The possibility of future CLAHRC refinancing drove the reallocation of research and implementation activities. External advisory reviews, which emphasised implementation, also influenced some CLAHRCs’ attempts to address the gravity point. In others rebalancing was seen as a response to the needs of local services and partner NHS organisations, who had provided matched funding to CLAHRCs and wanted evidence of translational work and improvements in health services.

The issue for our CLAHRC is we are still 80% core funded for applied research and 20% for implementation, but actually that is not the right balance if you want to achieve the kind of change that we are actually looking for, so we have got to use every little bit of extra resource that we can to beef up the knowledge translation activities which include education about how they do that in trusts, or education about this, that and the other in trusts.

Clinical science academic 2, HEI-facing, case I

Shifting the gravity point was easier in CLAHRCs that were set up with a large number of research projects led by clinical academics and where research for practice was carried out in collaboration with NHS organisations, in comparison with CLAHRCs which had structured research and implementation as separate themes.

We started by being very science driven because academic researchers, they know how to do academic research and it’s changed to the focus being much more on listening to services, responding to services, making services change and to me as a clinician, of course, that’s been a very welcome, kind of, development.

Clinical science academic 5, HEI-facing, case B

A complete change in the design of research projects would have been required to enable the rebalancing of the gravity point in CLAHRCs that had separated research and implementation.

Everyone I think you would speak to would say that the structural split, and I quite understand why it occurred, was there in the beginning . . . Although we have talked endlessly about how we need to draw those [themes] together, we have done very little about that because it’s very difficult to do so.

Social science academic 2, case C

In such cases, the implementation leads and knowledge brokers working in the research themes were left frustrated, as they felt that the partner NHS organisations were expecting results from the research much earlier than the projects were able to deliver.

[. . .] because there are these separate research themes they are still driven by conventional academic goals, which is publication, getting their papers out . . . I think our researcher colleagues just couldn’t get their heads around what we meant by implementation.

Implementation lead, case C

Conversely, in one CLAHRC that had a greater initial emphasis on implementation, senior actors were increasingly active in promoting the importance of research and publication about service improvement projects. Overall, the structural separation of research and implementation hindered interaction between the two themes, and exacerbated the dominant orientation towards HEI or NHS institutions. These problems became increasingly apparent over time.

We needed to learn to work together (what is implementation?)

Linked to the process of envisaging the CLAHRC, there was ambiguity surrounding the definition of ‘implementation’ from implementation leads, knowledge brokers and NHS-facing clinical academics.

We didn’t create a strong enough vision of what we meant by implementation. I had in my head what I thought it was and other people had their own versions in their own heads, but I think collectively we didn’t sit down and say ‘what are the absolute things’. So the things I am saying to you that it has to be non-linear, it has to be multifaceted, they were maybe there implicitly, but I think it would have really helped if we had made those much more transparent early on.

Implementation lead, case C

There was the assumption from those who set up the CLAHRCs that the HEIs and NHS partners would come together at the start and work immediately in collaboration. However, tensions between the academic and clinical work exacerbated divides between research and implementation activities and prevented collaboration.

I think more traditional health-care academics find it really alien and are quite resistant to engaging whereas frontline staff or people who have been involved with quality improvement before really get it and they really appreciate it a lot more, but even then the frontline staff often get it but struggle with the measures, whereas the more academic staff have got their outcome measures sorted before the project has even started [. . .].

CLAHRC management 1, case D

Differences in expectations caused tensions between the outputs of NHS and HEI organisations. While policy-makers called for interdisciplinary research, on the ground this was often inconsistent with performance management frameworks, such as REF, which were seen to drive out interdisciplinary research.

There’s a tension here between what the service delivery units want which is normally a slightly faster horse and the researchers who want to reinvent the horse. We can either take the approach that we can try and deliver a slightly faster horse or try and work out mechanisms for making sure that innovation can take place and can be spread and can be adopted.

Clinical science academic 4, HEI-facing, case B

The disparities across academic and clinical fields about translational research often led to differences in targets and improving health care. As a result, academics set targets that did not reflect what was required in clinical practice. These misaligned goals, a lack of mutual understanding, cultural tensions and a perceived lack of commitment are institutional in nature as individuals from different settings were pulling in different directions. Rebalancing research and implementation was particularly difficult where clinical academics were employed by the HEI and their success was measured by their academic output.

The NIHR hasn’t got its act together properly, and all CLAHRCs would acknowledge that, on CLAHRC impact. So we have to look at publications and grant income and blah-blah-blah, none of which are anything to do with putting stuff into practice. And then they ask us to do what they call added value examples on the end of the annual report [. . .] now if I’m having to go to our local commissioners and say what’s the value of CLAHRC, I tell a very different story. They’re not interested in how many papers are published or how many research grants we’ve got, they are interested in what’s the impact on our local population and how much has it cost us?

Social science academic 3, case C

Simultaneously, the same clinical academics had committed funding and resources from the NHS partner organisations and were expected to deliver outputs to the services. As a result of these different performance measures, and because of the epistemological divides between the research community and practitioners, research and implementation were often seen to be working separately and in different directions.

I think that the academic has a role and a responsibility in the process to do research in a different way perhaps, so that impact can be held. And I guess also in a business school you’re used to needing to relate to the world of practice. But I think what’s become more difficult is that it seems to me that since the beginning of our CLAHRC, there is less integration across the whole in many ways [. . .].

Social science academic 2, case B

In addition to the tensions across research and practice, an epistemological tension also occurred within the academic community between clinical and social science academics.

I really don’t feel understood by the medical community as to what kind of value we can offer because what we want to do is to conceptualise and generate theory. The problem is that they just want us to tell them how to do it.

Social science academic 2, case B

Social science academics were generally seen to be preoccupied with generating theory around KT and organisational theory rather than research that was practical and relevant to the concerns of CLAHRCs. Furthermore, a number of actors from clinical backgrounds were often hostile to what they viewed as social scientists’ ‘soft’ research skills. Social scientists were viewed as generating unscientific research that fell below the clinical gold standard of RCTs.

It does annoy me how social sciences come along and criticise randomised control trials, which is something they don’t know a lot about. So they come along and say blah, blah, blah about randomised control trials and I just know they are talking rubbish. They don’t understand what randomised control trials do. I feel that the current sway of those [social] sciences is undervaluing clinical science and is likely, if we continue to do that it is likely to drive away and offend an awful lot of clinical researchers.

Clinical science academic 2, HEI-facing, case I

Despite emerging tensions between clinical and social science academics, there was an underlying feeling that CLAHRCs needed to harness the expertise of both sides of the divide. NHS clinical academics were more likely to recognise the value of social scientists, specifically of organisational scientists, in helping them bridge the T2.

There’s a double boundary and people talk about the knowledge boundary and the second translation gap, research into practice, but it’s much more complicated than that. And you really see it when you’re in social science because you’re really in a sense trying to work with both of these sides, clinical academic and clinical practitioner, and both of them have a knowledge gap, as far as you’re concerned.

Social science academic 2, case B

We need to do more to develop Collaboration for Leadership in Applied Health Research and Care career structures

Collaborations for Leadership in Applied Health Research and Care enabled more senior HEI-facing clinical academics to attract resources to fund research projects and, thus, enable them to further their academic careers. In addition to CLAHRCs being attractive to actors leading different research projects, the collaborative work involved was beneficial to knowledge brokers, secondees from practice, and boundary spanners who were able to learn new skills from the local HEIs and NHS partners. Skills and knowledge gained on implementation, service change and improvement enhanced the careers of those working in practice or between the two organisations.

It’s been good for me but I think the clinical areas here have benefited as well, just by me getting out there and selling their story and telling their story from their side to the senior managers and the theme leads and the deputy leads who sometimes can forget what it’s like out there.

Implementation manager, case I

However, many felt that the CLAHRC did not progress their career. In particular, junior and mid-career academics found it more challenging to progress with their academic careers and publication rate through CLAHRC.

So I’m stuck at the top of Grade seven, so from my point of view of my career, it’s not done me any good at all, in terms of moving up the university scale. It’s been interesting in terms of moving from a position where I was conducting research, either as a researcher or as a principal investigator, to the position of managing a range of research related activities, including service evaluation projects and doing some teaching and developing you know, online learning resources and those sorts of things. So it’s provided quite a lot of variety and interest. But from a career point of view, as things stand now, I think it’s probably been detrimental to my career.

CLAHRC management 2, case I

Some actors believed that working in CLAHRCs was a disadvantage to academic careers, particularly for those who carried out implementation or management roles. For those from health management or clinical practice, CLAHRCs provided them with an opportunity to become more familiar with research projects and academic work. This benefited their careers in health organisations where this form of experience and expertise was valued.

Well people who want to go into academic careers, starting in service-based research it [CLAHRC] does not seem to me a good thing. It’s fine for people like me who are clinical science academics, very good in fact, very good, it’s fine for people who are clinicians who want to move into academic work but actually for those people who come from academia, I think it’s a wasteland.

Clinical academic 5, HEI-facing, case B

The difficulty facing HEI academics was that the CLAHRC did not enable them to focus on developing a strong publication record. For example, one CLAHRC that was set up with research and implementation themes running in parallel adopted a problem-based approach in which knowledge brokers fed into practice and identified gaps in translation. They then worked with practice to improve health services through the translation of research and implementation of new tools and practice. CLAHRC actors working in the implementation theme, but located in the HEIs, generally felt that, although there were clear improvements in practice, the processes of implementation to create new institutions were focused more on practice-based solutions and less on the generation of new research and publications. This was seen as detrimental to their academic careers.

[. . .] within our CLAHRC here, there wasn’t a great focus on research in the implementation process and that’s really where you would be able to get some sort of academic payback from it, from being able to study it and write it up. I do not think in terms of the things you’re judged on, it’s not been hugely beneficial to me to being in the CLAHRC. [. . .] Our knowledge [brokers] I actually think that it’s been a great opportunity for them, they’ve developed some really good transferable skills around how you facilitate change, how you work with stakeholders.

Implementation lead, case C

There were concerns that junior academics on work-based contracts or those who worked across academic disciplines were unable to produce outputs recognised by the performance measures of the HEIs.

Is this person, is this new role going to be a bit of business school or a bit of social science or a bit of clinical research, or is it really going to be a hybrid? And if it’s going to be a hybrid, what on earth is it? Because it’s a risk and actually I think if you look at the people who’ve fulfilled those roles it has by and large damaged their careers because they haven’t been able to focus on the academic research that they probably should have done to secure tenure or to develop their career.

Social science academic 3, case E

Although junior actors in CLAHRCs were seen as central to CLAHRC success, they were often left without a clear career structure.

And equally, there’s nowhere for them to go because the university career structure doesn’t recognise it. So it’s almost like for the people in the roles, I think actually unless you can get in, use it and get out, it’s dangerous. And I think the people who have gone in, taken something from it and then moved on, have probably done better.

Social science academic 3, case E

Career progression and incentives for junior academics were poor across the CLAHRCs often because of the nature of the job contracts. Although fellowships, PhDs, and Master’s courses were integrated into the CLAHRCs, these were seen as another stream of funding for postgraduate studies rather than the development of an academic career pathway.

What they should have done in this CLAHRC, is devised the career model that would have gone through and said to people ‘Right, you can’t do it for 5 years, we’re only going to let you do it for 2 years and then at the end of that you should move on’. I don’t know? But I think that is the single biggest worry and I’m on the record in books for saying I think contract research is really exploitative and I’m really anti-contract research.

Social science academic 3, case E

In general, CLAHRCs were more beneficial to those working in practice who were able to built research skills that were seen as an asset in clinical practice. For academics, however, and especially junior academics, CLAHRCs were generally seen as a temporary contract and organisation that was unable to provide them with a sustainable academic career. Senior academics, however, were able to benefit from CLAHRC funding as it provided them with another funding stream for their research projects and publications.

I don’t think having the name and the identity of the CLAHRC or being part of this wider group has made it for me, as a non-clinical, as a researcher who works in health services research, I still rely on the contacts that I’ve always had and I’ve started to develop through independent research. You work with academic clinicians and they open up doors and it’s a slow, slow process as you develop your career.

Social science academic 4, case C

Conclusion

CLAHRCs were an experiment and the intention, from the first round of funding, was for CLAHRCs to be thought of as ‘learning organisations’. In the beginning, CLAHRCs were ‘new’ organisations and, although existing relationships and research activity were utilised in many, they still had to build infrastructure, which included creating new physical workspaces, filling new posts and building relationships between HEIs and practice.

I think the problem with the first CLAHRC was it was totally new, people were trying to imagine something that had not been there before and make it exciting, interesting and doable enough to get the money and actually be able to go out and do this work. I think what a second CLAHRC might look like, even if the goalposts change, if we were given different direction from NIHR, I think provided we were given sufficient time, would be a slightly different experience and hopefully a better one. But I think obviously there’s been a lot of learning that we can then use.

Clinical manager, case I

With CLAHRCs nearing an end and the potential of CLAHRC refinancing, CLAHRC actors described that, although there had been challenges across all of the CLAHRCs, there were important positive outputs, such as service improvements, the creation of new roles, new research, collaborations between research and practice and an overall increased awareness of the need to translate research into practice more effectively to improve patient care.

I think one of the successes is the attitude and behaviour change of the research community. I think they are a lot more mindful because of the CLAHRC of the challenges that the NHS has in implementing evidence and engaging with research. They’re much more likely to be running research projects that would have a reasonable chance of continued use in the NHS, whereas before, to be honest, they might not have cared, and what they were really working for is a grant and associated publications.

CLAHRC management 4, case I

While there were clear challenges and lessons learnt across all of the CLAHRCs in terms of envisaging, engaging and embedding, all the CLAHRCs demonstrated efforts to shape and create new institutions to foster knowledge exchange and learning and to build capacity across the different institutions in various ways.

Archetype A: enabling a multidisciplinary research process

One way of organising KT activity entails the purposeful integration of multiple stakeholder groups into the research process. This could include researchers from multiple backgrounds and practitioners from diverse organisations participating in designing the research question, collecting data and receiving ongoing feedback about research progress and findings. An important emphasis in this approach is to alter the culture of research from a single disciplinary silo activity to accommodate more diversity in order to improve research relevance. Archetype A is presented in Figure 2.

FIGURE 2.

Archetype A.

The salient knowledge boundaries that are bridged in the model are between researchers and practitioners, and between academic disciplines. This archetype emphasises rigour in the research process, seeks to adapt the potential relevance of the research output, as well as develop stakeholder ownership among potential users of the research output. This model can readily incorporate PPI either by widening the group engaged in the research process, developing involvement as a research concern in its own right. From the perspective of the researchers this model of KT radically alters the research process itself.

In the context of the CLAHRCs, this model can also emphasise research on KT as a process and science of implementation. Rather than focusing explicitly on local implementation of research outputs, implementation groups can draw on a multiple stakeholder perspective to examine the dynamics of implementation itself. Thus, a core output of this model is to generate conceptual and systematic knowledge regarding implementation and KT as a social process.

The strength of this KT model, in which researchers retain high levels of autonomy, is its lack of compromise on the rigour of research as well as its ability to address complex problems in a systematic manner. Allowing high levels of researcher autonomy can enable research teams to adjust and renegotiate research projects to fit with the needs and emergent context of stakeholders involved. However, this level of coproduction is dependent on adequate flexibility in the research design as well as the researchers’ mind set.

A challenge of delivering KT activity is its high dependence on collaboration. The breakdown of stakeholder boundaries is difficult to manage and risks the retreat of existing groups back to their silos and patterns of historical relationships. A continued challenge for IEs in engaging stakeholders with this organisational archetype is generating and sustaining broad engagement across organisational and disciplinary boundaries. Leaders, therefore, need to maintain loose couplings across the diverse agendas, and must not be seen to favour one stakeholder group above another in order to avoid alienation and the return to compartmentalisation.

The institutional challenge in embedding this model of collaboration is the need to fundamentally sustain change to enable the research process to become more inclusive and leverage multiple perspectives. While researchers retain autonomy and rigour over the research process, here they are required to broaden their perspective by engaging with user stakeholder groups. The research breadth is further challenged by the need to accommodate multiple research paradigms, such as between social science and medical world views.

Archetype B: loosely autonomous research streams with designated knowledge brokers

Knowledge transfer activity can also be organised around loosely structured collaborative research projects, which have a number of designated boundary spanners and knowledge brokers attached to each project. In this way, research is envisaged as being efficiently organised and controlled by HEI researchers. The research questions can, however, be negotiated with the designated knowledge brokers who have critical knowledge of provider issues and established relationships with the research team.

One way to implement this model would be to have knowledge brokers with varying levels of time commitment and seniority within NHS organisations to broker relationships with relevant target audiences and, thus, enable IEs to have broader levels of engagement across the stakeholder groups and status levels. Given that each NHS organisation has a unique context, and each research theme has their own particular dynamics, after designated individuals are charged with spanning the boundary across these domains, they can develop locally suitable ways of facilitating KT between the groups. Individuals can work to their strengths and nest activities into their own practices, ensuring that the new boundary dynamics become sustainable through long-term relationships and the promotion of the embedding of KT process to sustain institutional change. Archetype B is presented in Figure 3.

FIGURE 3.

Archetype B.

A key strength of this archetype is the development of a focused and skilled team of knowledge brokers who have the primary responsibility to manage the KT process between researchers and health providers, and who function as a primary means for engaging the work of KT. The knowledge brokers span the boundaries across two distinct stakeholder groups that consist of a number of managers who are familiar with frontline care delivery and, thus, implementation issues. They would be seconded to work within the CLAHRC for a designated portion of their week to enable dialogue between researchers and providers. Training programmes designed to integrate across diverse stakeholder world views could be tailored to suit the profile of provider organisations involved as well as the level and experience of the participants and would support the embedding of institutional change in working towards KT.

An ongoing challenge for leaders of this institutional change process is the tension between sustaining a strong traditional research focus and motivating engagement processes with stakeholders. Current institutional forces within HEIs promote a research process that focuses on the novelty and rigour of knowledge production, which has escalated in the UK context by emphasis on the REF and high impact publications. Consequently, there is pressure to orientate researchers away from an interest in knowledge dissemination and engagement with providers, towards the production of interesting and publishable findings.

The effects can be significant, as performance management systems and careers structures in HEIs tend to privilege academic publication and prevent the embedding of institutional change. Similarly, in the current fiscal climate of health care, it remains a challenge for NHS organisations to continue to release the designated knowledge brokers from their normal roles so that they can engage with researchers and CLAHRC activities. NHS staff face pressing day-to-day matters, which frequently draw them back into their former routines as the urgency of research can pale in the face of a current crisis.

Archetype C: independent (modular) research and implementation activities

Archetype C envisages organising activity through the separation of research and implementation activities, and their maintenance in a parallel modular fashion. Given the distinct temporal dynamics of research and implementation activities, separation enables focus on research activities that will yield clear outputs in the short term by highly trained academic researchers working on topics they know can be delivered and published. The research themes may broaden their concerns to consider the practical relevance of their work, but this is not their key focus. PPI can be incorporated within the research process, but is likely to be more problematic to incorporate this within the implementation themes, as fewer standard mechanisms exist to guide their involvement. Archetype C is presented in Figure 4.

FIGURE 4.

Archetype C.

Focusing on the existing health research available, the implementation themes are explicitly kept separate to engage with appropriate stakeholders regarding their current evidence concerns to influence health service provision to incorporate existing research findings. Given the wealth of well-established research and rigorous best practice protocols, this model of implementation is efficient. The knowledge boundary that challenges leaders and institutional change is the one between the research and implementation themes within the KT organisation, as the two groups have clearly delineated and differentiated practices and goals. Thus, while changes may embed within implementation themes, who now are using more extant research and practice guidelines to inform their practice, there is little need to engage regularly with researchers and influence their research agenda per se.

An important vehicle for engaging clinicians in this organisational archetype is the speed by which implementation activities can be improved, and the benefits noted by clinicians or service providers. Rather than waiting for the end of a lengthy research study, implementation actors can develop local capacity and influence practice more quickly using existing knowledge outputs. The slow temporal rhythm of research, as compared with clinical and management environment, was a consistent cause of strain across all CLAHRCs. While research production and knowledge creation was a slow and meticulous process, NHS clinicians and managers were confronted daily with making decisions in contexts where there was insufficient information.

Though NHS workers were prepared to engage in the coproduction of research questions and content, by the time the outcomes and findings were clear, the questions often lost relevance. Instead there were new issues that needed to be addressed. Consequently, the potential risk of archetype C is that the research and implementation themes run in parallel – by the time the research themes have developed research to be implemented, the implementation theme has already developed a full portfolio of activity.

Archetype D: collaborating through loose networks

Archetype D takes advantage of existing informal structures and builds organically onto existing relationships. While recognising that KT activity occurs in a context of existing relationships and collaborations, this model seeks first and foremost to develop and extend what is already in place. This model might be particularly relevant in a context in which multiple ties between researchers and health providers are strong, which was an important element of the founding conditions of CLAHRCs. Existing relationships of trust and goodwill can provide a basis for building and embedding the new partnership projects and a means for mediating between competing organisational priorities and goals. In this way governance structures can be more informal and can be guided by mutual goodwill. Networked project groups can also incorporate public and patient participation in line with the locally perceived importance or relevance of lay involvement. Similarly, other stakeholders, such as social services, charities or private businesses can also be accommodated within specific project groups, as enabled by project goals and local relationships. Archetype D is presented in Figure 5.

FIGURE 5.

Archetype D.

As such, IEs use a strategy of engaging a broad array of stakeholders in a more informal manner, and draw on areas with least resistance to embedding change. An advantage of this archetype is that genuine engagement is possible between providers and academic researchers, as neither is able to carry out the networked activity without the adequate coparticipation and engagement with the other.

The leaders’ challenge in embedding this model is maintaining an adequate group of knowledge brokers who can span between project groups and build scale beyond the smaller collaboration level. In particular, there is a need to bring in new members from provider organisations to influence practice as widely as possible. Given the less formalised nature of this model, designating and governing the knowledge brokers is challenged by the competing institutional pressures they face. In addition, brokers need to be strategically located in order to maximise their network impact and broker across unconnected groups or network entities.

Archetype E: centrally controlled service improvement projects

The final envisaged archetype is managerially focused and enables the retention of high levels of control over both research and implementation activities through ongoing accountability mechanisms and monitoring of project teams. The key mechanism for exercising control is centralised budget management and formal accountability in accordance with central management priorities. Thus, while the CLAHRCs’ decision-making powers typically addressed the research end in other archetypes, this archetype for organising KT places a higher emphasis on service effectiveness and the efficiency of research uptake through clearly defined projects. Research activity is aligned with service improvement goals of provider organisations rather than theoretic interests of academic departments. The embedding of the institutional change is driven by the responsiveness of projects to current provider needs, with service implementation and improvement initiatives written in to project deliverables. Archetype E is presented in Figure 6.

FIGURE 6.

Archetype E.

A key strength of this archetype is the horizontal and symmetrical approach to KT, such as collaborative research design, evaluation and implementation at the project level, which serves to embed the institutional change. Centralised managerial control structures project findings and enables accountability for levels of service impact. Frequent updates on the status and outcomes can be requested. As these projects necessarily involve highly integrated provider and researcher relationships, learning, knowledge transfer and social relationships among project teams are enabled and may lead to broader engagement. Central management take responsibility for organising events, workshops, and regular cross-boundary activities in order to promote learning and further KT objectives.

Importantly, a high proportion of the CLAHRC project members who envisaged and initially supported this organisational form were not full-time university researchers, but individuals involved in service provision or part-time consultants hired to implement change. As many of those participating in KT activities are from NHS providers, they will be accustomed to the more rigid control and hierarchy culture common in provider organisations and project management teams.

The low extent of researcher autonomy may mean that engaging and embedding top-level researchers is more of a challenge and could compromise rigorous research, leading to less theoretical innovation and lower levels of publication impact. While concern for service improvement is of interest to local providers of that specific service, its highly contextual nature limits the broad applicability of findings and the international interest in the research outputs.

Summary

In this chapter we have presented five different archetypes for organising KT to communicate the breadth of different approaches that have been tried and tested by the different CLAHRCs. Over time there has been significant isomorphism across the CLAHRCs as senior members of CLAHRCs have imported best practice and learning from other CLAHRCs. Of particular note has been the diffusion of the knowledge broker role, devised by a social science academic in one CLAHRC. This has been subsequently imitated by many other CLAHRCs.

We note, however, that while we have presented archetypes, these models are more or less likely to occur under different founding conditions. The founding conditions of CLAHRCs shaped actors’ envisaging of the models of CLAHRCs they implemented. Therefore, the founding conditions will influence which archetypes the different CLAHRC actors drew on. We suggest that both archetypes A and C, or elements of them, are more likely to be promoted by HEI-facing clinical academics. In contrast, archetype B, or elements of archetype B, will be championed more heavily by actors from a social sciences background. Archetype D, or elements of archetype D, is more likely to be enacted in brownfield sites with good existing relationships across research and practice in the local region. Finally, archetype E, or elements of archetype E, are more likely to be enacted under the founding conditions of a CLAHRC being led by a NHS-facing clinical academic, and where there are lower levels of existing activity, such as greenfield sites. Table 12 details the institutional features, strengths, weaknesses and leadership challenges of each proposed archetype model of organising for KT.

Main findings

A central idea that emanates from our work is that the founding conditions of CLAHRCs, in terms of the social positions of the key actors and the local-level field conditions, played a central role in shaping how CLAHRCs were envisaged, how stakeholders were engaged, how CLAHRCs were embedded and the nature of reflection that actors carried out. We note, however, that the effects were particularly pronounced during the actors’ envisaging stage of CLAHRCs, which then subsequently shaped the issues arising from engaging, embedding and reflecting. Overall, our work suggests that actors’ social positions will shape their propensity to engage in institutional entrepreneurship, or conversely institutional maintenance, to promote institutional change or stability respectively.

The interplay between the founding conditions and the social positions of IEs shaped conceptions of, and activities encompassed within, CLAHRCs, and especially within HEIs. In some cases, the CLAHRC initiative was seen as a vehicle for progressing research bids that had failed to be funded. In others, CLAHRCs were seen as a way of ‘wrapping up’ existing research activity akin to a large-scale programme grant. In such cases, CLAHRC activity was more academically oriented than NHS defined. This model, in part, aligned with a view of those leading the CLAHRC bid development: that the NIHR privileged research excellence in its commissioning objectives. CLAHRC funding therefore ran the risk of reinforcing pre-existing research agendas and modes of research. Some CLAHRC bids could be viewed as offering little more than pre-existing activity. Although CLAHRC funding here enabled pre-existing activity to be accelerated, leveraged and potentially institutionalised for a greater gain than previously possible in the absence of support for large-scale activity. Furthermore, the CLAHRC initiative led to a translational focus that was more service oriented.

Although most of the CLAHRC bids were derived from pre-existing research activity, this proved to be advantageous in the mobilisation of CLAHRCs even if their value-added was reduced. Conversely, two of the CLAHRCs characterised their bid as more greenfield than brownfield activity and, therefore, claimed greater innovation around service-user involvement and focus on service problems. Such CLAHRC bids might sidestep translational ‘lock-in’ to established ways of doing things, but may prove more difficult to mobilise in the face of the greenfield context.

Where CLAHRCs were more oriented towards service improvement in the bidding process there was a difference in whether individual-level behavioural change or wide-scale organisational and system change was required. Here antecedent conditions and position of lead actors played a large part in determining this. Where a CLAHRC was more clinical science oriented, the focus was on the need to change individual-level behaviour. In comparison, social scientists, and at least one senior NHS manager, privileged the need for wider-scale organisational- and system-level change. However, a number of actors became increasingly focused on the importance of capacity building, which was in part fuelled by, and reinforced interest in, the diffusion of the knowledge broker role. Overall, the recognition of the type of change needed was dependent on the configuration of social actors within each CLAHRC. The process of envisaging, as shaped by local-level field conditions and key actors’ social positions, influenced the way in which CLAHRCs were designed and enacted. We suggest that the effectiveness of the initiative was fundamentally shaped by the envisaging process which ‘locked in’ CLAHRCs to a path of action.

During the engagement process, we found that senior CLAHRC actors had to work hard to ‘win the minds’ of key stakeholders and that this was a process that was much harder than many people anticipated. In particular, there was a disparity between the need to obtain resources from NHS partner organisations and then engagement of on-the-ground actors. The ‘winning of minds’ was a necessary but not sufficient condition for encouraging stakeholders to sign up to the ideals of CLAHRC. Additional work was undertaken in the form of aligning and consensus building, which helped to develop the normative component of the CLAHRC networks.

Work to embed CLAHRCs was undertaken across all four of our cases through education and the creation of new roles. Education worked to enhance NHS organisations’ capacity to absorb research. However, the focus of much of the educational work was on enhancing the efficacy of existing CLAHRC projects as opposed to capacity building. In terms of the creation of new roles, the dominant approach was the creation of the knowledge broker role, which emerged in one CLAHRC and then diffused through mimetic isomorphism to other CLAHRCs. The two remaining forms of embedding work – the embedding of tools and routines, and the creation of a CLAHRC identity – were more variable across the case studies. Overall, the difficulties associated with enacting institutional change required long time horizons. In terms of engaging and embedding, we highlight that the work has been more difficult than many CLAHRC actors imagined, highlighting the importance of continuity in resource deployment to such initiatives.

The activity of reflection was the final form of work and was particularly prevalent in the run up to CLAHRC refinancing. There were multiple lessons learned by many senior CLAHRC actors as they mobilised their CLAHRCs: (1) CLAHRCs were more difficult to get up and running than the envisaged form at the outset, which led to delays; (2) the commitment of resource to large-scale projects upfront ran the risk of handing over managerial control; (3) the balance (or gravity point) between research and implementation was difficult and required changes in the emphasis of CLAHRC activity over time; (4) actors across organisational and epistemological boundaries needed to learn how to understand one another and work towards a common understanding of what implementation actually was; and, finally, (5) career structures needed to be better developed to promote and reward CLAHRC behaviour. From the case studies, it could be argued that formalised learning events drawing people from outside CLAHRC and the wider health-care landscape, and other translational initiatives, to share learning in establishing and mobilising new initiatives, with those from all of the CLAHRCs.

Our SNA complemented our qualitative case studies, and provided evidence that the systematic variations in actors’ ability to bridge the research–practice divide related to actors’ social positions in terms of dominant orientations, professional status and existing relationships. For example, practitioners were more likely than academics and actors with many existing connections in their own professional field to develop networks that bridged the divide. Furthermore, junior actors found it more difficult than their senior counterparts to bridge the divide. Our longitudinal analysis, however, suggests that the CLAHRC initiative led to the development of more relationships that spanned the research–practice divide and provides evidence that CLAHRCs have enabled actors to more effectively bridge the research–practice divide.

Finally, given the different founding conditions, and the malleability of the CLAHRC mission presented in the original tender document, there was variation in how the CLAHRCs were organised and structured. 171 Based on our analysis we suggest that a number of different archetype models have emerged which CLAHRCs have drawn on. These models, as outlined in Chapter 10, are more or less likely to occur under different founding conditions. We present a detailed summary of the strengths and weaknesses of the different models in Table 12, in the previous chapter which includes institutional features, strengths, weaknesses and leadership challenges.

Implications for practice

Based on the main findings of our study, we contend that there are important lessons for those involved with, and those attempting to promote, institutional change that can support sustainable KT practices.

First, we encourage policy-makers to consider whether they need to set out a more defined template for translational initiatives in the initial calls for such initiatives or if variation is encouraged. We suggest that the less defined the template, the greater the variation will be in what actors envisage. Second, policy-makers need to understand the importance of both antecedent conditions to the development of any funding bids and the social position of the main actors leading bid development. Although established and known clinical academics are likely to be trusted to lead the development of a funding bid around translational research activity, and the presence of pre-existing organisational relationships are important for mobilisation, privileging such dimensions of any bid may constrain more radical change. Our study highlighted that strategic change and outcomes of innovation may be ‘locked-in’ in a way reflecting traditional clinical research at an early stage of bid development. We suggest that this conclusion is germane to all forms of translational initiative, which will fundamentally shape how any initiative plays out over time. To emphasise, strategies for change are not built independently from the structural context in which they are embedded, inclusive of consideration of the social position of the IEs leading translational innovation and antecedent conditions to bid development.

Second, regarding prescriptions for the development of implementation of KT networks, we tentatively suggest the following points. First, thought is given to selection of their leadership. More emphasis might be placed on those who exhibit recognition of system-level issues, and capability to work across organisational and professional boundaries, rather than remain within their academic research silos. At the same time, we need to recognise that leaders of KT networks require legitimacy from powerful individuals (such as clinical academics) to drive change in research and clinical practice. IEs need to be embedded in existing power structures, but willing to change such structures, if evidence-based innovation is to ensue on the ground. Second, any lock-in at early stages of development of KT networks might be mediated through relaxing any requirement to develop a detailed programme of activity in order to drawdown funding. The coproduction of a research agenda, which balances a service- and research-centred model for translation, might be engendered by more ‘open’ funding.

Third, our work pertaining to the different archetypes of the models of organising KT demonstrates that there are a range of different models that IEs may draw on in leading translational initiatives. We suggest, however, that IEs will seldom have a free choice as to the type of model they should pursue. Rather, we suggest that the founding conditions (local context and the social positions of the focal actors) will influence which archetypes the different actors draw on.

Fourth, practitioners need to be aware of how professional role, hierarchical status and embeddedness may shape actors’ willingness and ability to span the research–practice divide. We suggest that in addition to the social position of IEs influencing their orientation towards institutional change, social position can influence the extent to which others help enact that change (by actually bridging the research–practice divide). In essence, policy-makers need to understand that actors’ behaviours are shaped by institutional forces, and that sustainable change necessitates institutional change.

Study limitations

Our study, as with all studies, has a number of limitations. First, the qualitative work initially focused on nine CLAHRCs and then four CLAHRCs were examined in depth. Examining only four CLAHRCs in depth may have influenced the development of our process-based model of institutional entrepreneurship. However, given potential conflicts of interest with other projects and the practicality of being able to examine all nine CLAHRCs in depth, we feel that the four CLAHRCs we focused on provided us with nuanced insights of institutional entrepreneurship in translational initiatives and lessons for future initiatives.

Second, as outlined in Chapter 3, because of the nature of the CLAHRC initiative, our research protocol following ethics approvals, and a need for particular sensitivity given ongoing CLAHRC refinancing, meant that we were not able to present the data in as fine-grained a manner as we would ordinarily have liked to. Furthermore, we do not draw explicitly on our observational data because of the sensitive nature of much of the information. Consequently, we are slightly constrained in terms of ability to communicate the specific nuances of the different CLAHRCs on a case-by-case, and individual IE, basis.

Third, the high churn of staff in a number of the CLAHRCs we studied in depth meant that it was difficult to develop a large sample of common respondents across the two waves of our analysis. As detailed in Chapter 8, in one CLAHRC we were able to obtain longitudinal data for only three participants out of 15 surveyed in the first wave in one CLAHRC. As a result of a very low response rate, the decision was made to exclude the three respondents from longitudinal analyses. Therefore, the longitudinal analyses reported in this section are based on data from 42 of the 66 participants initially surveyed from three CLAHRCs.

Finally, we recognise that our study examines one form of translational initiative, in a particular national context. Research that investigates transferability to other translational initiatives internationally, moving beyond Anglo-(North) American contexts, seems particularly important given how the NHS context, notably system-level incentives, impacts the way that translational initiatives are received. 172 However, we have sought to mediate the influence of the specific empirical context by developing a theoretically informed process-based model of institutional entrepreneurship, and also the archetype models of KT, so as to maximise the generalisable lessons that may be drawn from our research.

Future research

In this report we have examined the CLAHRC initiative as a whole, as an interesting case of a translational research initiative, and have commented on only the broad social position of the key actors. We did so because an internal case analysis with a fine-grained interrogation of each actor’s unique social position would have undermined their anonymity. It would be interesting, however, for future research to explore the issue of actors’ social positions at a micro level. For example, recent work about health care by Lockett et al. 173 has employed the work of Bourdieu,105 to examine the relationship between each individual actor’s unique social position and the way in which the opportunities and problems of change were conceptualised. Evidence of which, in a focused manner, is provided by our SNA work (see Chapter 8) which indicates that an actor’s social position, based on role, hierarchy and existing networks, may have an important influence on their willingness and ability to bridge the worlds of research and practice. In addition, there might be closer consideration of the influence of brownfield compared with greenfield in shaping actors’ behaviour.

Although we have documented important learning by CLAHRCs in Chapter 9, we suggest that the process through which translational initiatives are refinanced may be an important opportunity for the promotion of further learning via the promotion of reflective thinking. The very process of having to critically examine past performance, identify the key lessons learned, and to translate the lessons into the renewed strategy may help the leaders of translational research initiatives to break away from being ‘locked in’ to existing ways of working that were established through the envisaging of the initiative in its formative years.

Associated with learning, we suggest that there is a need to examine how actors are led to reflect on the emerging lessons from their endeavours. We suggest that, consistent with the work of Lockett et al. ,173 research could examine whether or not actors in different social positions are more or less likely to develop reflective skills. Indeed, the work of Lockett et al. 173 suggests that the diversity of an actor’s social capital may be important in this regard. Hence, we argue that it may be revealing to link actors’ ego networks, and particularly the diversity of their networks, to their capacity to reflect.

Given that institutional change commonly requires the sustained efforts of IEs engaged in IW, we suggest that the first round of CLAHRC funding is only the start of the process of institutional change to close the T2. Therefore, there is a real need to undertake more longitudinal work to examine how translational research initiatives continue to promote institutional change and identify the outputs, both in terms of research and in practice.

Furthermore, our work is based on the study of CLAHRCs, which are just one form of translational initiative. We suggest that important lessons may also be gleaned from comparative work across other forms of translational initiatives such as the AHSCs, BRCs, BRUs, HIECs and the NHS Innovation Hubs. For example, the recent launch of AHSNs has raised the issue of how different translational initiatives could work together. According to a DH report,174 Innovation, Health and Wealth, the role of AHSNs will be to work with stakeholders from across the NHS and the scientific community, academia, the third sector, and local authorities to link up regional innovation systems and drive the diffusion of innovation. In doing so, the goal of AHSNs will be to improve patient and population health outcomes through the translation of research into practice and the development and implementation of integrated health-care systems. Rather than treating each translational initiative as a stand-alone entity, we suggest that research could examine the synergies across the initiatives and analyse how institutional change may be brought about in a more collective fashion.

Contributions of authors

Andy Lockett (Professor, strategy and entrepreneurship, University of Warwick) led the study and the writing of the report, conducted some of the fieldwork and data analysis.

Nellie El Enany [Assistant Professor, organisational behaviour, University of Warwick (was a research fellow for a period on the project)] contributed to the writing of the report, fieldwork and analyses of the data.

Graeme Currie (Professor, public management, University of Warwick) contributed to the writing of the report and analyses of the data.

Eivor Oborn (Professor, health care management, University of Warwick) contributed to the writing of the report, conducted the literature review into knowledge transfer, fieldwork and analyses of the data, particularly the KT models.

Michael Barrett (Professor of Information Systems and Innovation Studies, University of Cambridge) led the study from the University of Cambridge, helped with the writing of the report, conducted the literature review into knowledge transfer, fieldwork and analyses of the data, particularly the KT models.

Girts Racko [Assistant Professor, organisational behaviour, University of Warwick [was a research fellow for a period on the project)] helped with the writing of the report, conducted the literature review into knowledge transfer, fieldwork and analyses of the SNA data.

Simon Bishop [Lecturer, organisational behaviour, University of Nottingham [was a research fellow for a period on the project)] conducted the literature review on institutional entrepreneurship and fieldwork.

Justin Waring (Professor, public management, University of Nottingham) conducted fieldwork.

Disclaimers

This report presents independent research funded by the National Institute for Health Research (NIHR). The views and opinions expressed by authors in this publication are those of the authors and do not necessarily reflect those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health. If there are verbatim quotations included in this publication the views and opinions expressed by the interviewees are those of the interviewees and do not necessarily reflect those of the authors, those of the NHS, the NIHR, NETSCC, the HS&DR programme or the Department of Health.

Phase 1 interview schedule: indicative questions

Please could you tell me about your background, and about how you became involved with this CLAHRC.

What is your role in relation to this CLAHRC?

How is your CLAHRC going about addressing the divide between clinical research and the application of research in practice?

What challenges has it encountered in this process?

How has it got around these challenges?

What individuals and groups are most closely involved in the work of the CLAHRC?

What are the roles of these individuals and groups? Who is most important in the process?

Are there any individuals or groups who are not so closely involved, but should be?

Is there anything else you think might be of interest to me, but which I haven’t mentioned?

Phase 2 interview schedule: indicative questions

(If not involved in phase 1.) Please could you tell me about your background, and about how you became involved with this CLAHRC?

(If not involved in phase 1.) What is your role in relation to this CLAHRC?

(If not involved in phase 1.) Please could you tell me about how things have progressed since I last spoke to you? Please could you tell me if there have been any changes to your role or to the CLAHRC as a whole?

Please could you describe to me in detail what your work in making this CLAHRC happen has involved? What have been the challenges? How has it differed from what your role involved before you linked up with the CLAHRC?

What organisations do you work with most closely in this work? Have there been any particular challenges in engaging them? How have you got round these challenges?

What individuals do you work with most closely in this work? Have there been any particular challenges in engaging them? How have you got round these challenges?

Are there any particular aspects of the environment in which your CLAHRC works that are especially challenging to the objectives of the CLAHRC? For example, policy structures, gaps between organisations, expectations of different professional groups? In an ideal world, how would these be different? In the real world, how can you work around these?

Is there anything else you think might be of interest to me, but which I haven’t mentioned?

Observation guide: indicative issues to look for

Who is in the room? What are their roles (differences in terms of status, professional function, age, gender, etc.)?

How do different actors express their views/concerns etc. in different ways?

What is the role of local context, both in terms of history and politics in the locality, play into emerging relationships and CLAHRC activities?

Who are the most powerful actors in the region and how do they interact with one another? And what are people’s views of those actors and how does that vary by actors’ social positions?

How does the CLAHRC director, and his/her senior management team, relate to other CLAHRC members?

How do the different actors interact with one another, in terms of their use of language and their body language? Are certain groups more vocal/dominant?

What is the focus of attention of different actors, and how does it vary by their social positions?

What is the culture and climate within the CLAHRC?

What important debates appear to be stifled, and why?

Social network analysis questionnaire

1. Please enter your first and last name (this will be made anonymous following data collection)

2. [……………….]

3. Please enter your professional/occupational role

4. [……………….]

5. The questions below relate to the people who have influenced your decision-making about the CLAHRC theme or project(s) which you help to manage or lead. Please think about the last 6 months of work on your theme/project(s) (or since you joined if shorter). We would like you to nominate all of the people who have influenced your decision-making about the theme/project(s) during this period. We define ‘influence’ as the capacity to shape ideas, select between different courses of action or in some way substantially affect decisions about one or more aspects of the theme/project(s). Influence may relate to any aspect of the theme/project including the objectives, questions, design, process, methodology, implementation or dissemination activities.

6. In the text boxes below, please enter the names of the people who have influenced your decision-making about the theme/project(s) during this period. When you have added all of the people you wish to add, scroll to the bottom of the page and go to the next question.

8. Please enter the professional/occupational role of the people you have identified. If they hold more than one role, please enter all that apply.

10. Again thinking about the last 6 months of your project(s) or theme (or your first 6 months in post), please indicate the extent to which the people you listed influenced your decisions on your theme/project(s) OBJECTIVES AND/OR RESEARCH QUESTIONS (1 = no influence at all, 5 = the highest level of influence).

12. Again thinking about the last 6 months of your project(s) or theme (or your first 6 months in post), please indicate the extent to which the people you listed influenced your decisions on your theme/project(s) PROCESS, DESIGN AND/OR METHODOLOGY (1 = no influence at all, 5 = the highest level of influence).

14. Again thinking about the last 6 months of your project(s) or theme (or your first 6 months in post), please indicate the extent to which the people you listed influenced your decisions on how your theme/project(s) RESEARCH OR IMPLEMENTATION ACTIVITIES SHOULD BE USED TO CHANGE PRACTICE (1 = no influence at all, 5 = the highest level of influence).

16. For each person you have identified, please indicate whether you had worked with that person prior to your involvement in the CLAHRC.

18. Again thinking about the last 6 months of your project(s) or theme (or your first 6 months in post), please identify UP TO FOUR people who have most strongly influenced your decisions about your project(s) OVERALL.

20. Involvement in CLAHRC has provided me with additional funding or other resources.

22. Involvement in CLAHRC has allowed me to acquire new knowledge or skills.

24. Involvement in CLAHRC has led to a loss of control/autonomy over the decisions I make about my project compared with other projects I have been involved with.

26. Involvement in CLAHRC has led to more efficient or more effective use of resources in the organisation(s) that I work for.

28. Involvement in CLAHRC has allowed me to build new relationships which improve the work I do.

30. Involvement in CLAHRC is very time consuming because the CLAHRC involves collaboration with a range of different stakeholders.

32. Involvement in CLAHRC has led to a heightened public profile for my organisation(s).

34. Involvement in CLAHRC has led to a heightened public profile for my own work.

Thank you for taking our survey. Your response is very important to us.