Collective action for knowledge mobilisation: a realist evaluation of the Collaborations for Leadership in Applied Health Research and Care

Aims

1. To inform the NIHR Health Services and Delivery Research programme about the impact of CLAHRCs in relation to one of their key functions: implementing the findings from research in clinical practice.

2. To make a significant contribution to the national and international evidence base concerning research use and impact, and mechanisms for successful partnerships between universities and health-care providers for facilitating research use.

3. To work in partnership so that the evaluation includes stakeholder perspectives and formative input into participating CLAHRCs.

4. To further develop theory-driven approaches to implementation research and evaluation.

Objectives

1. To identify and track the implementation mechanisms and processes used by CLAHRCs and evaluate intended and unintended consequences (impacts) over time.

2. To determine what influences whether or not and how research is used through CLAHRCs, paying particular attention to contextual factors.

3. To investigate the role played by boundary objects in the success or failure of research implementation through CLAHRCs.

4. To determine if and how CLAHRCs develop and sustain interactions and communities of practice.

5. To identify indicators that could be used for further evaluations of the sustainability of CLAHRC-like approaches.

Realist evaluation

A fundamental assumption of realist evaluation is that ‘programmes are complex interventions introduced into complex social systems’ (p. 33). 85 Programmes are composed of theories, involve the actions of people, are rarely linear, and comprise a series of steps or processes that interact, are prone to modification and exist in open and dynamic systems that change as the result of learning. Realist evaluation is therefore an appropriate approach to exploring knowledge mobilisation within CLAHRCs, which, by their nature, are social systems, involve the actions of groups of people and have the potential to change over time. Observing CLAHRCs over time makes realist evaluation particularly appropriate because it is a cyclical and iterative approach.

Within realism, theories are framed as hypotheses about how mechanisms act in context to produce outcomes. We followed the realist approach promoted specifically by Pawson and Tilley. 86 Thus, programmes (in this study, CLAHRCs’ approaches to implementation) are interrogated to identify what it is about them (mechanisms) and the contextual conditions (context) that triggers these mechanisms to produce particular outcomes – commonly expressed as CMO (C + M → O) configurations. It is the CMOs that are the study hypotheses, which are refined and tested over time.

Contexts

The conditions that are necessary for a programme to trigger a mechanism to activate specific outcomes87 are critical for understanding how it works ‘for whom in what conditions’ (p. 72). 86 Context may be defined as space or place but can also be described as the ‘settings within which programmes are placed or factors outside the control of programme designers – people’s motivations, organisational context or structures’. 88 As such, context is not the backdrop to a site/study/case, as some have intimated,89 but is the condition that fires or triggers certain mechanisms.

Mechanisms

There is a paucity of literature relating to clarity of meaning of mechanisms; however, from the realist evaluator’s perspective, the underlying mechanisms that give rise to an event or outcome are the main focus of study. 90 Pawson and Tilley86 use the analogy of a clock to illustrate the meaning of a mechanism: it is only by examining the inside of the clock that it is possible to understand how it works, not by examining the clock face itself. Likewise with mechanisms, in realist evaluation the programme activity and processes are the mechanisms, which may be more or less hidden from view. Westhorp et al. 91 describe a mechanism in terms of how a programme changes people’s decision-making: what people do in response to the resources (of any kind) that a programme provides.

The other important aspect of mechanisms is that they lead to outcomes, but only when triggered by a particular context, or condition. 91,92 In realist evaluation the question is, therefore, not ‘does it work?’ but ‘how does it work and which mechanisms in which contexts give rise to particular outcomes?’.

Outcomes

In realist evaluation, outcomes ‘reflect, or represent, the responses to different mechanisms in particular contexts’ (p. 77). 93 Outcomes may include the learning from programmes or can be related to impact (e.g. a change in behaviour) or processes (whether or not an intervention worked). 94 In this study we captured a range of different types of impact CLAHRCs’ implementation activity might have, from those that are more direct to those that are more conceptual and processual.

Case studies

Case study was selected in order to undertake an in-depth exploration within three CLAHRCs. As Yin95 states, a case study is an empirical enquiry that investigates a contemporary phenomenon within its real-life context, especially when the boundaries between the phenomenon and the context are not clearly evident.

In this study, implementation was the phenomenon that we wanted to study in the real-life context of the CLAHRC. Case studies are appropriate where one does not need to (or wish to) control events, and when one is interested in answering ‘how’ and ‘why’ questions.

Realist evaluation and case studies are an appropriate ‘fit’ in that both aim to be explanatory in nature,86,95 are about understanding a phenomenon in context, and enable an approach that collects multiple sources of data. 96 For this study a ‘case’ is the implementation team/theme/programme within a CLAHRC.

Tracer issues

Tracer issues were chosen as a way to provide a common focus across CLAHRCs, which were heterogeneous, complicated and multifaceted entities. At the time of proposal writing (before the CLAHRCs had set their agendas and approaches), we had expected that these tracer issues might be clinical issues, for example diabetes or stroke; however, as the CLAHRCs began to establish themselves it was evident that there was huge variability and a lack of cross-cutting themes that could provide a common thread. Therefore, in collaboration with CLAHRC study collaborators it was decided to select tracer issues that reflected processes. These were viewed as a watermark in CLAHRC activities: something that could be seen when specifically looked for in projects and initiatives, but which was not in the foreground or the main point of their attention.

The tracer issues were discussed with the CLAHRCs at a stakeholder meeting (in January 2011) where members of all nine CLAHRCs were present, and a consensus was reached. This was then finalised through follow-up telephone calls with the CLAHRCs participating in this study, and included:

1. Change agency: the focus of this was on the people in change agent/boundary-spanning/facilitation roles (each CLAHRC had given these different job titles). Roles were a useful focus in the first instance, but the processes of change agency became an increasing focus in terms of facilitating implementation and the impact arising from this. It was what these people did that became the focus of the tracer issue.

2. Collaboration and partnership: one of the issues that came over strongly from stakeholders was the difficulty in identifying and separating the research and implementation functions of the CLAHRCs. As a tracer issue it provided scope to look into a variety of formal and informal collaborations and the processes of collaborating at different levels within the CLAHRCs. Again, it enabled the individual CLAHRCs to select the projects and initiatives that they felt would be able to focus on collaboration and partnership.

3. Sustainability, adaptability and spread: this tracer issue arose from the concern of the CLAHRCs that change and knowledge use needed to be sustainable beyond the end of individual projects, in a turbulent context and shared across the individual CLAHRCs and beyond where appropriate.

These issues mapped well onto the study’s evaluation framework (see Figure 4) and so were embedded in the questions asked at each round of data collection and in data analysis processes.

Sites

Given the collaborative nature of the CLAHRCs’ mission and realist evaluation’s emphasis on stakeholder engagement, we worked closely with those involved in CLAHRCs to develop the proposal and subsequently deliver the project. This included involving CLAHRC participants as coapplicants. We studied three CLAHRCs in depth (Ashgrove, Hazeldean and Oakdown) while providing opportunities for engagement with the wider CLAHRC community during stakeholder meetings and through an interpretive forum.

Patient and public involvement

As it was a stakeholder-driven project, patient and public involvement (PPI) was an important aspect of the study. Furthermore, we had been asked by the funder to ensure an explicit focus on PPI within implementation, as the other external evaluation projects were not funded to focus on this. Questions about how PPI happens within implementation are important and under-researched, and therefore warranted targeted attention in this project.

We also established a PPI group to help inform this aspect of the research and the work more generally. The group comprised five members: four from our case study CLAHRCs and one person from a non-CLAHRC area. Participants were nominated by the CLAHRCs themselves and as a group had experience of involvement as patients, as a lay member on a CLAHRC board and through participation in INVOLVE. An inaugural face-to-face meeting of the group was held on 12 December 2011. As part of agreeing ways of working, the preference was to engage with individual members of the group at points where their input would be most useful. Subsequently, they participated in the project by reading and commenting on, for example, draft reports, and through physical presence at research team meetings.

Development of the conceptual framework

The conceptual framework was developed through the following steps:

1. Concept mining: a number of sources of information such as the CLAHRC’s original commissioning brief, discussions with the participating CLAHRC’s directors, interviews with members of the commissioning panel and concepts from the explicit theory (K2A and PARIHS frameworks) underpinning the study were mined for key concepts. 17,84,98 The findings from the rapid realist review were also taken into consideration in that they provided an organising framework for exploring the implementation literature. This process resulted in a sizeable list of concepts relevant to the overarching research question and underlying intention of CLAHRCs to undertake research implementation.

2. Concept mapping: the list of concepts provided a focus for reviewing the implementation literature, which resulted in more detailed knowledge about the concepts and their potential meaning to the research question.

3. Mapping across concepts: a conceptual platform85 was developed by clustering the concepts including underpinning evidence into meaningful units or elements in the framework. The concepts underpinning the programme theory are context, knowledge and knowledge production, facilitation, PPI, knowledge sharing and exchange, geography, actors and agents, temporality, architecture and impact. These theory areas and the evidence underpinning them are described further by Rycroft-Malone et al. 39

4. Building the framework: considering the content in each dimension and revisiting the hypothesised purpose of the CLAHRCs implementation function, a framework that visually represents the potential interconnectedness between the dimensions was constructed.

This development process and the evidence underpinning the areas in the framework has been more fully described by Rycroft-Malone et al. 39

Consistent with the focus of realist evaluation on engaging with stakeholders, the framework was presented for comment at meetings with each of the three CLAHRC ‘cases’ and the wider evaluation research team. As a result a few minor modifications were made to the framework. The framework is shown in Figure 4.

FIGURE 4.

Conceptual framework. Source: Rycroft-Malone et al. 39 Reproduced with permission. CoP, Community of Practice.

It was hypothesised that the elements in the framework would be more or less facilitative of a CLAHRC’s ability to deliver on its implementation function; however, at the outset we did not make any links or contingencies across them. Therefore, the framework provided a template upon which we focused data collection in round 1. Following round 1 data collection the realist task was to draw interferences and contingencies across the domains in the framework to provide explanations about CLAHRCs’ approach to implementation. These explanations or CMOs (see Chapter 6) were then refined and tested over the remaining three rounds of data collection.

Sampling

For each round of data analysis the sampling framework was based on a stakeholder analysis99 and used both theoretical and criterion sampling, which determined which stakeholders were essential, important and/or necessary to involve. 100 Details of potential participants were provided by CLAHRC directors or programme managers. Each potential participant was approached initially by e-mail invitation and then an information pack including participant information sheets and consent forms was sent by post. On receipt of consent to participate, interviews were arranged at a time to suit the participant. Snowball sampling was used to recruit other participants who met purposive sampling criteria and who were thought to have a perspective on implementation.

This resulted in an overall focus on implementation approach and roles, and the sample varied between CLAHRCs. Table 4 shows the focus of data collection across the four rounds. Tables 4 and 5 show the study participants and data collected.

Interviews

Semistructured, audio-recorded interviews were undertaken with individual participants by telephone and face to face (as convenient) and were guided by an interview guide. As we were developing explanations over time, the focus and schedule for interviews reflected this development, so we used four different interview schedules (see Appendix 5). The first round of data collection was exploratory and focused explicitly on the elements in the study’s evaluation framework. Following analysis of these data, data collection in rounds 2 and 3 focused on helping us refine the emerging explanations. Interviews in round 4 were focused on testing these explanations. Interviews were audio-recorded and lasted between 30 and 90 minutes. This type of interview process has been described as a realist interview or teacher–learner approach to interviewing. 85

Observation

Non-participant observation of some events and meetings (e.g. board meetings and stakeholder events) was conducted and recorded as field notes using Spradley’s101 nine dimensions of observation: space, actors, activities, objects, acts, events, time, goals and feelings. We asked site collaborators to alert us to observation opportunities. Given this study’s focus, we suggested that these could perhaps be strategic-level meetings about implementation plans, and/or more specific CLAHRC discussions about implementation-related activities. We followed up with CLAHRCs on a regular basis at each round of data collection to check if there were opportunities to which we could be invited.

Documentary data

Documents (see Appendix 6) were gathered from CLAHRCs to support the development of the programme theories and the contextualisation of data collected in the field (Table 6).

Ashgrove case summary

Hazeldean case summary

Oakdown case summary

Summary

In summary, there were both similarities and differences between Ashgrove, Hazeldean and Oakdown.

Starting point

At the time of bid development, Ashgrove, Oakdown and Hazeldean each started at a different point in relation to the nature of the existing organisational relationships between the HEI(s) and local health services through which the collaborations needed to be established. This became an important issue in the context of the relatively short turn-around time between the call and the submission date for CLAHRC, and subsequently at the start of their funding and, therefore, action.

Within Oakdown it was reported that pre-existing relationships had been important at the time of bid development:

We had . . . a very sound framework for the CLAHRC before we started and those key folk contributed hugely to the writing of the application and we managed to put it together very swiftly and in terms of NHS partners because . . . key theme leads . . . were in the NHS and they were in academia so they weren’t full-time university professors . . . so this little group of people were very embedded in the NHS anyway.

Leadership role, CLAHRC core team, Oakdown, R1

Not only had these relationships facilitated the co-development of the bid but they had also created a starting point for the CLAHRC where individuals had not needed to ‘go out and create new relationships, there was already quite an intimate fabric there to build on and for people to engage with’ (leadership role, CLAHRC core team, Oakdown, R1).

In contrast, participants in both Hazeldean and Ashgrove reported a different sort of starting point, in which the relationships needed to be built on a project-by-project basis because these organisational connections had not been well established at bid development stage; for example:

I was told to go out and evaluate the service, first of all I had to find out about the service and this person [name] didn’t know anything about it. So suddenly to have this company called CLAHRC who was not heard of by anybody, because we were very new.

Implementation facilitator, Hazeldean, R1

Similarly, participants in Ashgrove reported that it had taken some time to develop relationships to be able to progress action on CLAHRC activities:

So it’s really taken 12 months, I think to build these clinical relationships with colleagues in primary care . . . get themselves known, to be accepted.

Clinical academic, Ashgrove, R1

The political landscape has changed and we didn’t have the links [with the NHS] there to begin with . . . there wasn’t time to develop the collaborations and although chief executives signed up that is not the same thing as collaboration.

Clinical academic, Ashgrove, R1

Interpretation of the Collaboration for Leadership in Applied Health Research and Care brief

The CLAHRC journey was also shaped by the way in which the call for proposals had been interpreted. The NIHR call set the establishment of the CLAHRC ‘pilots’ within the context of the ‘second gap in translation’ and of improving patient outcomes through the conduct and implementation of applied health research, including evaluating initiatives and strategies to increase the use of evidence in practice. 108 There was significant potential for flexible interpretation of the NIHR call and, therefore, inevitably those leading the bid writing for the CLAHRCs had interpreted the brief variously, particularly in relation to their role in the implementation and application of applied health research and the emphasis they placed on this in their plans.

There had been a trade-off in focus, and, therefore, resources, between conducting research and undertaking implementation-related activity. Overall, the balance tended to be weighted towards activity that focused on conducting, rather than implementing, research. Where the balance was weighted towards the generation of evidence, it was of course possible to conduct research in a more or less collaborative way, leading to the potential development of more or less implementable or implemented research. Oakdown, for example, explicitly set out to avoid the CLAHRC being perceived as ‘some sort of piglet [sic] research programme that has a limited life’ (NHS senior leadership role, Oakdown, R1). Given this, it espoused ‘coproduction’ as its preferred approach and ‘to provide a framework which will make it more systematic to think about how you scope evidence and apply it in practice when you are working on a particular issue’ (academic, Oakdown, R1).

There are also data to suggest that the interpretation of the CLAHRC’s remit may have been influenced by the background and knowledge of those involved in its development, including some political and philosophical tensions: ‘There are huge internal political divisions with the CLAHRC’ (clinical leadership role, Hazeldean, R1).

Some participants also acknowledged the need to learn more about implementation: ‘So this [implementation] is something we are trying to learn’ (clinical academic, Ashgrove, R1).

Once the teams had responded to the brief and received funding, it was perceived that there had been very little flexibility in their plans to make changes later on. One participant also reflected that there had been little dialogue with the funder about the funder’s expectations of the CLAHRC since the decision to fund was made:

The problem with that is that NIHR had done very little to clarify what they are looking for in a CLAHRC. So other than when we put in the original bid, the NIHR have been absolutely silent about what they expect from the CLAHRC.

Leadership role, CLAHRC core team, R1

Setting priorities

Although the broad parameters for CLAHRC activity were set within their proposals, the way in which CLAHRCs went about establishing and agreeing priorities differed. For example, participants in Hazeldean reported a level of pragmatism in their approach to trying to engage with local priorities in that a number of PCTs had funded the CLAHRC and therefore they had to have some work ‘done in them’ (academic, leadership role, Hazeldean, R1):

The minute we got the money and got started . . . you have partners paying, in our case NHS partners, and you have got to get on and do something. So it was much more – ‘we have got four clinical areas, who is interested in doing what?’

Leadership role, CLAHRC core team, R1

In contrast, a number of Ashgrove participants reported a potential disconnect between regional NHS priorities and CLAHRC activity (in the early stages mainly around research priorities):

the potential disconnect between the priorities of the NHS and the work that is being done, that is not to say our projects weren’t important, they were the priorities of some senior people in the NHS . . . but those things were defined possibly as much or even more by those people with their academic hat than the health priorities of the NHS they were serving.

Leadership role, CLAHRC core team, Ashgrove, R1

Over time, and in relation to their implementation remit, both these CLAHRCs shifted their approach to identifying priorities in a more service-orientated way, although still reliant on either party making an approach. It was reported that ‘alignment’ with a service’s priorities had made it easier to ‘implement things and achieve things’ (management role, Hazeldean, R1).

In contrast, participants in Oakdown reported that at bid development stage they had collaboratively identified priorities of relevance to the NHS. This, they stated, had facilitated continued engagement of the NHS ‘because of the implementation side that this wasn’t just about doing blue sky research, it was about embedding it in practice’ (leadership role, CLAHRC core team, Oakdown, R1). This CLAHRC had also developed a mechanism for identifying the ongoing prioritisation of projects through consensus development events/meetings.

However, participants in all three of these CLAHRCs reported the challenges of working to develop priorities with NHS partners in a continually changing landscape, including in their resources and boundaries.

Summary

At the conception of the CLAHRCs these antecedents established some of the conditions that played out in various ways in the subsequent life of the CLAHRCs we studied. The starting position for each CLARHC is mapped in Figure 8. For example, it was evident that the initial position of those developing the CLAHRC proposal on issues, such as the balance between implementation and research, determined the relative attention that was paid to these agendas in their plans. Additionally, a divide between higher education and service, and therefore the potential for different agendas and competing priorities, emerged early on in the life of the CLAHRC depending on the nature and quality of historical and existing organisational relationships. This set the tone for people’s motivation to engage with the CLAHRC and its activities. These starting points or positions set the direction of travel in an enduring way.

FIGURE 8.

Starting positions of CLAHRCs.

Engineered architecture: structure and space

As a distributed model for the conduct and application of applied health research across a health community and wide geographical area, the structures, roles and lines of accountability that were established within a CLAHRC provided a more or less supportive scaffold for communication, collaboration and implementation activity within and across its functions.

The activity within the CLAHRCs had been organised into themes. It was reported that this had been as a result of responding to the way the call had been constructed. The call for proposals had asked for detail about the specific research and implementation themes that would be pursued, including an overview of how they would relate to each other. The allocation of finances within the proposals was also distributed to themes and therefore, on balance, the majority of the financial allocation within CLAHRCs was to the generation of research, rather than its implementation.

Setting up the CLAHRCs as a collection of themes had resulted in the creation of boundaries between them as they operated in parallel and with limited connection between them and their functions:

it doesn’t work in parallel because the implementation teams started at the same time as the researchers and they had to get on implementing something and so they . . . went off and did their own thing . . . but it meant the strands went in different directions. I think that bridge [between research and implementation] has been difficult to properly bridge if people are honest with you.

Researcher, Hazeldean, R1

The consequences of the way in which the CLAHRCs had been engineered included challenges with communication, knowledge flow and sharing.

There were definitely problems with interaction, sometimes information did not flow easily.

Academic, Hazeldean, R1

There is not a shared understanding of what we are all working for because we do have these very separate applied themes who are lost in their research.

Implementation facilitator/boundary spanner, Ashgrove, R1

It was also reported that the issue of sharing across themes was compounded by an element of competition within the CLAHRC:

there was competition there so very often people were not keen to discuss things. They wouldn’t tell you what they were doing because there was some level of competition.

Academic, Hazeldean, R1

Participants suggested that the structural divides served to emphasise existing epistemic and professional differences:

I think the structures . . . have extenuated maybe ideological differences or philosophical differences in how research is done and how the research is gotten into practice. There has been a very big divide on that.

Clinical leadership role, Hazeldean, R1

Given the distributed nature of the CLAHRCs – ‘CLAHRC isn’t an organisation’, as one participant observed – and the challenges that had arisen from compartmentalised structures, their approach to governance became more important. There was evidence within Oakdown that, although the overall themed structure of the CLAHRC had created separation, its approach to governance, including reporting structures and processes, had facilitated some integration and knowledge sharing:

a lot of things around the governance and reporting structures actually helps to build that culture of what is expected and to consolidate that transfer . . . Individual projects without that organisation would be lost.

Leadership role, CLAHRC core team, Oakdown, R1

Although each CLAHRC had taken a similar approach to how it was engineered, there had been a recognition relatively early on that perhaps theme-type structures were not helpful; however, leaders in all three CLAHRCs perceived that there were limited possibilities to make changes partway through. The perception of inflexibility was particularly linked to the way that funding had been structured at the outset:

This CLAHRC as with most of the others, as it was putting itself together obviously came up with a budgetary split across the five themes . . . and that was allocated at that stage and pretty much committed . . . there was relatively little flexibility in the budget to make changes later on.

Leadership role, CLAHRC core team, Ashgrove, R1

Physical proximity between health services and higher education within the CLAHRC entity was a further feature of its engineered architecture. Relative closeness or distance to each other was determined by those setting the original course, related to existing relationships, position and view of a CLAHRC’s mission (e.g. the balance of research and implementation) and approach to doing business (e.g. more or less collaborative versus outreach/consultancy). Oakdown had deliberately decided at the outset to locate ‘CLAHRC central’ within a health service setting; the other two’s main centres remained in higher education settings, although NHS staff employed through CLAHRCs tended to be sited within NHS premises. The concept of colocation was important to Oakdown, as it was perceived to facilitate the development of productive partnerships:

[CLAHRC] brings a lot of likeminded people together in similar kind of areas and bridging that university and service provider divide. A lot of themes have got people from the universities working with service providers all working together and often colocated as well, which is quite important.

Leadership role, CLAHRC core team, Oakdown, R1

. . . so we had a kind of, if I can say, a very sound framework for the CLAHRC before we started and those key folk contributed hugely to the writing of the application . . . in terms of NHS partners because interestingly a lot of those key theme leads . . . they were in the NHS and academia so they weren’t whole-time university professors, so they were gynaecologists who ran clinics, a clinical psychologist who ran clinics, a speech and language therapist who was very involved with the trust speech and language department, myself, who always had a trust appointment as well as a university appointment, so it was this little group of people who were very embedded in the NHS anyway.

Leadership role, CLAHRC core team, Oakdown, R1

In Ashgrove and Hazeldean, those involved in project-level or boundary-spanning activity also recognised the value of sharing physical space as a way of providing opportunities for facilitating local buy-in to projects, building relationships, collaborative working, cross-fertilisation, sharing of ideas and an understanding about what a CLAHRC did; for example:

We are based in a hospital and some of the other themes are not . . . they are scattered and I think the fact that we are sitting together as a theme in one hospital with links with the clinicians and the managers . . . I think that is why actually we have got local enhanced knowledge of what CLAHRC does.

Management role, Ashgrove, R4

Aesthetic architecture: building an identity

Participants described CLAHRCs in various ways, including using the terms ‘consortium’, ‘network’, ‘movement’, ‘confederation’, ‘virtual’, ‘research organisation’, ‘consultancy’ and ‘umbrella organisation’. ‘CLAHRC’ was not a well-understood concept and the acronym itself was felt to be a barrier because it lacked meaning; this was particularly the case for service providers and those not closely aligned to a CLAHRC:

Ha ha, it is obscure . . . no one knows what CLAHRC stands for and those who are engaged with particular parts of CLAHRC do, they know about those parts of CLAHRC but I’m not sure anybody really, outside of the close CLAHRC community, knows what the purpose of a CLAHRC is.

Academic, Oakdown, R1

Both those in the CLAHRC executive and those working more locally in projects and/or in facilitation and boundary-spanning roles described ways in which they had either obscured or explained CLAHRC:

Well . . . number 1, you don’t really mention CLAHRC because nobody understands it.

Implementation facilitator/boundary spanner, Oakdown, R3

. . . also my job is about translation so . . . you know it’s important that our board and our executive team understand what CLAHRC is . . . it’s our job to translate that, make it meaningful to people who are at the bedside or in the clinic or in people’s homes . . . you might say it’s under this heading called CLAHRC but you can see people glaze over sometimes . . . if you use acronyms . . . we have a great role in translation, so they [practitioners] would know it was a project . . . they might not use the term ‘CLAHRC’.

NHS senior leadership role, Oakdown, R2

The challenges with the branding of CLAHRC were recognised as participants reflected on the need for a more active approach to marketing and publicity to raise their profile:

I don’t think a lot of people are aware . . . I think the CLAHRC themselves need to . . . advertise . . . some people have heard of it but they were very much in the minority.

Implementation facilitator/boundary spanner, Oakdown, R3

There was also evidence of an effort to sell CLAHRC to get buy-in and involvement through promoting its potential benefits including those for individuals and for services. The individual benefits of accessing education and training opportunities were made evident by, for example, ensuring certification for professional development portfolios and producing practical tools for practitioners to use. For services, useful ‘carrots that you can dangle in front of them’ (boundary spanner, Ashgrove, R3) had proved to be the potential benefits and incentives of engaging with projects and initiatives that would help them meet targets and gain points in the QOF and/or CQUIN Framework. It was also recognised that the benefits of being involved in CLAHRC activity needed to be realised quickly and obviously by both individuals and organisations.

The perception of ‘CLAHRC as other’ was exacerbated by a view that the partnership was aligned with academia rather than service. Within Ashgrove and Hazeldean, CLAHRC was perceived as academic input or an ‘organisation’ that was based in the universities, with the service side being described separately. There was also a pervasive theme in the data about CLAHRCs being a research funding body, a large programme grant. Given that there was more resource (finance) and attention (themes) on research, and NIHR reporting requirements focused on academic-related metrics, this is perhaps an unsurprising perception and is reflected in the data through scepticism, particularly from service providers, about what a CLAHRC was and what it was there to do:

There was a lengthy discussion about CLAHRC 2 and it was felt that it was going to be important to demonstrate strong partnerships and that ‘money won’t be forthcoming just to do interesting projects, like in CLAHRC 1’. The discussion continued with various academics suggesting that they didn’t do enough as researchers to find out what the priorities of the NHS were, with others feeling that they need to be talking to the NHS now [2011] to find out what their priorities are. This brought a mixed response from others, with the opinion expressed that the NHS changes its priorities so it was pointless asking them. There was concern expressed that by involving the NHS, that they would be seen by others, such as the local AHSC as doing ‘dustbin category’ research rather than pure academic research.

Hazeldean fieldnotes, board meeting 2 December 2011

The perception of CLAHRC as an ‘academic machine’ was perpetuated in cases where there was a higher proportion of ‘pure academics’, who, it was reported, were:

pretty much untouched by the implementation agenda and not that interested and didn’t want to have a dialogue with that half of the CLAHRC.

Clinical leadership role, Hazeldean, R1

The separateness or isolation of the CLAHRC from service providers was also evident in the discourse of participants describing both the design and the execution of project work:

I think we [CLAHRC name] have just been completely in the driving seat as project managers and I guess in an ideal world we would have liked to have someone in the trust . . . on the project management side.

Management role, Hazeldean, R2

Given this, in this example the CLAHRC had taken on more of a consultancy or supplier of services role in supporting trusts to deliver on their priorities. The cofunding arrangements set up an expectation that NHS bodies were going to get a free service. Although that term was used to describe their approach, it was also acknowledged that this approach needed to be balanced by joint working:

it is different with this kind of consultancy with the CLAHRC and it is certainly a balancing act to make sure that you not only have the buy-in but you have people commit to you and work jointly together.

Implementation facilitator, Hazeldean, R1

The identity, role and visibility of CLAHRCs remained a challenge, and participants continued to make observations about this across rounds of data collection, particularly in the context of other, related, policy initiatives such as Academic Health Science Networks. However, as one participant stated and as our data show, the perception of the CLAHRC brand or identity is completely context dependent and therefore patchy. For an academic and/or senior person in the organisation it was more likely that the CLAHRC was visible and that one could have been a beneficiary (e.g. in receipt of financial resources to undertake a project). In contrast ‘in the clinical front line it depends on if the experience was good and the relationships were good and sometimes they weren’t’ (clinical leadership role, Hazeldean, R4). Thus, some people felt part of something called CLAHRC, while others were on the periphery or not involved. These findings probably reflect the distributed nature of a CLAHRC and that it was separate from existing structures in the NHS landscape:

The fact is that although we are a co-operative, a collaborative, in many ways we are not . . . I think it is likely that CLAHRC will be seen as an external organisation in which the trust and CCG deal. It won’t be ‘this is an organisation we are part of’, it won’t be ‘this is a club I am part of’, it will be ‘this is an organisation I am aware of who does things for us because we give them money’.

Leadership role, CLAHRC core team, Ashgrove, R4

In contrast to some of the more negatively framed challenges of ‘CLAHRC’ described above, the CLAHRC label/brand also had the potential to be a boundary object. Organically and over time, which included opportunities for sense making and increasing familiarity, CLAHRCs’ capability in bringing people together to work on common goals developed: ‘well I think it’s the name of the CLAHRC that has enabled this to happen’ (facilitator, Oakdown, R2).

Social architecture: leadership, collaboration and boundaries

Although there were mixed views about what a CLAHRC was, and describing it as an ‘organisation’ in a traditional sense is potentially misleading given its distributed nature, CLAHRCs did directly employ people to deliver work and created environments and spaces for activity and action. Each CLAHRC was strategically and operationally led by some form of executive team, who by virtue of their role and function were the social architects of their CLAHRC, in that they were responsible for creating the milieu to encourage desired action and behaviour. There were a number of features of the social environment that created the conditions in which CLAHRCs approached collaboration and therefore the context through which any implementation activity was mediated.

Summary

The CLAHRCs’ engineered, aesthetic and social architectures shaped the conditions and space for collective action around implementation whereby their governance arrangements prompted varying opportunities for connectivity and engagement. Furthermore, organising activities in themes, which all CLAHRCs had done, emphasised the epistemic and professional differences within and between higher education and practice. The architectures were a consequence of the interpretation of the CLAHRC call, in particular the positioning of implementation and associated resources relative to other functions such as research. Leaders and executives were the social architects of CLAHRCs in that they set the course and the tone for their particular CLAHRC and for delivering the plan. More distributed leadership within a CLAHRC was associated with the social architects being ‘open’ and ‘collaborative’. There were dominant perceptions across all three CLAHRCs, particularly earlier on in their life cycle, that they were academic entities; as a consequence the nature and quality of interaction varied along a co-operation–collaboration continuum. The CLAHRC identity was constructed over time through activities (e.g. project meetings, training sessions) and roles that brought researchers and practitioners together, and thus started to become a known ‘brand’. As each CLAHRC was a distributed and mainly virtual entity, and as a result of the way it had been engineered, multiple types of boundaries were evident. These boundaries then hindered the potential for productive interaction and engagement, and required extra work to overcome them. The negotiation of these boundaries was entrusted to those in boundary-spanning roles, which, as described below, were a CLAHRC’s main investment in knowledge mobilisation.

Motivation to engage with implementation

Motivations to engage emerged over time in the narrative of participants. The motivation or incentive to engage with the implementation function of CLAHRCs was dependent on constituency – the ‘what’s in it for me’ factor. Those that did engage were incentivised by seeing something in it for them. For health services this was expressed in terms of some form of pay-back on their financial investment:

NHS side that we have invested a good deal of money and we want to see ourselves getting something out of it . . . something that will benefit patients and so we should really try very hard to make sure that we hold the CLAHRC to that.

Leadership role, core team, Ashgrove, R4

Services also saw CLAHRCs as an opportunity for support with service priorities and in the improvement of patient care, with the benefit of doing that based on an academic evidence base:

I think the project management support elements of it . . . the academic input side of things, so thinking that they are actually going to get some academic input in how to manage change in their organisation or change a particular culture or context or whatever it might be so that was a big motivator.

Leadership role, Hazeldean, R4

What the CLAHRC did really well was pick up on real service priorities. So it wasn’t a piece of research that was sort of sitting on its own in glorious isolation, it was picking up on real priorities . . . and to have an evidence-based approach to addressing them and getting them into practice was a real motivation for clinical staff . . . we could use CLAHRC as a vehicle to carry out work that enabled us to address those real tricky, wicked problems.

NHS senior leadership role, Oakdown, R4

As described earlier, and reinforced throughout the rounds of data collection, responding and improving on service priorities also had a knock-on effect of meeting targets such as QOF and CQUIN:

The nutrition project and the VTE project were identified by the organisation because they were CQUINs targets and if they didn’t meet the CQUINs targets they would lose a percentage of their income.

Leadership role, Oakdown, R2

For academics, the motivation and incentive to engage presented opposing stances. On the one hand the idea of having the opportunity to be more closely aligned with services and other providers was viewed positively:

From a university’s point of view what we do is public service and public health research . . . so the CLAHRC is just a vehicle for doing the sort of research that we do with the added bonus of close engagement with other providers, the NHS and indeed some industry groups as well so it enabled a much clearer model of coproduction.

Academic, Oakdown, R4

However, for some, the applied research and implementation focus of CLAHRCs did not meet the perceived academic standards that the Research Excellence Framework (REF) demands.

The differences of opinion between the communities explained why there were differences in whether or not they engaged in collective action. This serves to highlight the importance of mutual benefit. It was observed that that benefit tends to arise from the quality of relationships, which, as described earlier, were in varying stages of development even later on in the life cycle of CLAHRC 1:

I think that getting people engaged in it is about them seeing there’s some mutual benefit and where there wasn’t seen as any mutual benefit it doesn’t happen. But seeing there’s mutual benefit has come from relationship building, and there are plenty of times, and I know other CLAHRC directors feel a bit the same, that you feel like you’re a salesperson going round trying to sell things.

Leadership role, core team, Hazeldean, R4

Theory and its application

Both Oakdown and Hazeldean had articulated the use of a particular framework to guide their implementation activity. Hazeldean had framed its bid around the use of the PARIHS framework, and Oakdown had based its on the K2A framework. At the outset, Ashgrove had not articulated a particular theoretical position or starting point, but later ‘talked about our approach, which is the K2A cycle’ (leadership role, core team, Ashgrove, R1). How the use of these frameworks played out in practice varied, particularly at the level of the CLAHRC as a whole; however, their use was more easily described at project level.

In Hazeldean the use of PARIHS alongside a Plan, Do, Study, Act approach was mentioned, although more than one participant agreed that their knowledge, experience and application of both had been limited:

looking at the PARIHS framework was something I think we all adhered to but I don’t think it was something which we made an effort towards working with . . . so all the elements regarding evidence, context and facilitation, we knew they were key parts . . . But perhaps we didn’t actually do a formal context assessment of each practice or situation, it would perhaps be more ad hoc and more observational.

Implementation facilitator, Hazeldean, R1

However, in one of the improvement projects conducted within this CLAHRC, an assessment based on the context element of PARIHS had been undertaken. This discrepancy serves to highlight a disconnect between the expectations of the CLAHRC as a whole and what was happening at project level. That is, there was not a consistency of expectation about the use of PARIHS as the framework of choice for implementation activity. This became more visible in the reporting from a different participant, who was using normalisation process theory in her project activity (although it was not clear how this theory was being used either):

We have used the normalisation process model a lot in our interventions and working with clinicians to change their practice as they go along and I suppose it is a bit arrogant but I thought that that model worked and wasn’t prepared really to engage with a different model.

Researcher, Hazeldean, R1

A lack of consistency in expectation about the use of the PARIHS framework meant that:

across the four teams there are four completely different models of implementation that have been enacted.

Implementation facilitator, Hazeldean, R1

Within Oakdown, it was reported that it used the K2A framework to guide its implementation efforts. Although it was not always articulated how the framework was being used at either CLAHRC or project level, it seemed that different stages/phases within this planned action theory were being operationalised. For example, there was evidence that baseline audits had been conducted within projects, and there were reports that action arising from them had been undertaken. This activity corresponds with stages of the cyclical approach of K2A. For example:

We go through exercises based on literature reviews we did around the evidence of what influences the effectiveness of teams . . . then from that day we have actions that we take forward and we have half a day kind of action learning sets . . . there’s quite a lot of evidence gathering that goes on around it as well . . . all make sure we are not doing any harm but also see areas that we might improve as a result of the changes we are making and we can start to feed that back as well to various patients and staff and indicators.

Leadership role, core team, Oakdown, R1

Clear and explicit links between theory and action, that is theoretical fidelity, were difficult to find in Oakdown and Hazeldean and were absent from the data we collected from Ashgrove.

Type of knowledge mobilisation

The different views, values, interpretations and visions come together to result in a mixed picture, with varying amounts of implementation taking place within each of the CLAHRCs in this study. Over time we identified six types of activity that capture how knowledge was, or had the potential to be, mobilised and actively used, each with the possibility of being approached in interactive and coproductive ways:

1. Service improvement – the implementation of quality improvement methods within and across sites to improve specific service and/or clinical issues, for example in CKD, helping GP practices to diagnose patients with CKD earlier and helping to raise awareness on how to manage the condition more effectively.

2. Making evidence accessible – taking National Institute for Health and Care Excellence guidance and translating it into easily digestible, practical and potentially useable resources/packages, for example taking blood pressure targets and developing aides-memoire for clinical staff to use in practice.

3. Taking national evidence and getting it into practice – typically evident through a focus on prioritising the implementation of guidance (local or national) in local services, for example in improving care for people with VTE based on national guidance and quality standards through helping local implementation of a VTE assessment tool.

4. Mobilising local evidence – examples of intelligence gathering around implementation projects and potential sharing of local evidence about effective practice within and across CLAHRCs, for example using knowledge from one service improvement project to inform a different initiative, and as a result tinkering with the model/approach.

5. Using home-grown research – there was an aspiration, linked to funder expectations, that CLAHRCs should be implementing the research they generate within the 3- to 5-year period of funding. This aspiration was achieved in Ashgrove, which implemented its own research from CKD and COPD projects and an online cardiac rehabilitation tool.

6. Paying attention to implementation in the conduct of research – breaking down the divide between research and its use by considering implementation at the beginning of the research process, and/or adopting an approach to conducting research that could be described as coproductive.

In reality we observed a mixture of these different types of implementation within and across CLAHRCs. However, each CLAHRC tended to coalesce around certain types; for example, Hazeldean’s approach focused on service improvement and Oakdown’s on implementing guidance. Across the three CLAHRCs there was a greater balance towards knowledge transfer approaches than towards those that were more coproduced.

Additionally, each CLAHRC came from a different starting point with respect to both its view and its experience of knowledge mobilisation, and all were going through some form of journey in figuring it out. For example, participants from Oakdown were very clear that at the outset their approach would be one of ‘coproduction’. This then played out in their approach to working with partners in the way they conducted their research, and their implementation work was led by a practitioner-researcher experienced in evidence-based practice. Individuals in Ashgrove gave a very honest account of their contrasting starting point with respect to their implementation remit:

I think where I have found it difficult is understanding this second part of the CLAHRC, this implementation translation, and I think it has come across, we just don’t know how to do this.

Leadership role, core team, Ashgrove, R1

In this case, it was recognised that this issue was not helped by the fact that ‘the lines of communication between academics and the health trust are not well formed and so there isn’t an obvious route for implementation’ (leadership role, Ashgrove, core team, R1), and that implementation had not been clearly articulated in early plans because ‘a lot of us . . . weren’t up to speed with this agenda and how that would work’ (leadership role, core team, Ashgrove, R1).

Privileging of evidence

Different types of implementation privileged different types of evidence from different sources of knowledge. Perhaps unsurprisingly, in contexts where the research function of a CLAHRC was more prominent, research and academic knowledge tended to be privileged. In contexts where there was a broader appreciation of the CLAHRC remit, and evidence of implementation, such as service improvement activity, the value of incorporating different sources of knowledge was recognised; for example:

I think in our CLAHRC there is quite a lot of service improvement going on and service evaluation where different knowledge is used to inform and measure it over time . . . there is a move towards knowledge as practice or research as practice . . . if you don’t adopt all the different knowledges including research knowledge . . . practitioner knowledge, policy knowledge, user knowledge, if you don’t use those to interpret it [research] and put it into practice you are into a losing game really.

Leadership role, Oakdown, R1

Types of patient and public involvement

Even where research themes within CLAHRCs had a history of PPI, and some infrastructure to support it, they found it difficult to augment the focus of PPI in research to include implementation. The data demonstrate a lack of conceptual clarity about PPI, with cited examples including:

• patients as research study participants

• consultation activity across all CLAHRCs, but including qualitative research into the patient experience in Ashgrove

• using PPI as a focus for learning at improvement events, either directly or through patient stories

• using PPI as a source of knowledge/expertise to be represented in improvement work

• collaborating in product and service development

• dissemination, including the design and content of websites.

Hazeldean’s work on the development of a framework for assessment at 6 months after stroke was held up as an example of coproduction, and specifically its focus groups with patients ‘looking at what they considered to be the problems they had after their stroke’ (implementation facilitator, Hazeldean, R1). Indeed, in other CLAHRCs, although coproduction was usually couched in terms of ‘events’, there was a desire for future CLAHRCs to pay more attention to coproduction as an approach to meaningful PPI. Although participants across all CLAHRCs felt that progress had been made in embedding PPI in implementation projects, and clear instances of impact on activity and products were evident, PPI was viewed as a work in progress requiring sustained and strategic action in subsequent CLAHRC-type initiatives.

Influences and mediators of patient and public involvement

How the CLAHRCs had organised their research and implementation functions inevitably influenced how PPI was conceptualised. For example, where an initial approach to implementation focused predominantly on the (future) use of home-grown evidence in Ashgrove, then participants reported difficulty in contemplating the interplay between evidence from research and the patient voice: ‘asking patients what they want from services isn’t the same as injecting research evidence into those services’ (leadership role, core team, Ashgrove, R1). Further on, the development of ‘project groups’, with PPI representatives adopting an advisory role, was reported by both Hazeldean and Oakdown as helpful in providing a structure for melding different types of information for implementation.

In a context where there was a lack of early strategic intent around PPI, projects relied on efforts to engage patients in feedback on ‘redesign rather than design’ (secondee to CLAHRC, Hazeldean, R1) implementation initiatives. This led to a perception that PPI efforts were mostly around ‘catch-up’ (implementation facilitator, Hazeldean, R1), even in the context of a strong push from leadership around PPI. This was particularly evident in Ashgrove, where, after an external review, the appointment of a PPI champion led to the development of a PPI forum to cover both research and implementation CLAHRC functions. This led to input into all applied research projects. Attention to leadership was also mirrored by investment of resources in the training PPI. These changes led to the construction of a framework for PPI across the knowledge production and utilisation cycle, which aimed to enhance the implementability of research: ‘if everybody is being consulted at the right points throughout the process, you’re not going to have those barriers to implementation’ (implementation facilitator/boundary spanner, Ashgrove, R3).

Within the context of a programme of work to improve CKD services, there was a disconnect between research and implementation which meant that PPI fed into implementation/service improvement activity rather than the research upon which products were produced.

The data demonstrate that participants were persuaded of the importance of PPI: ‘everyone knows they should be doing it and most of them do it, and some of them do it outstandingly well. Others need to be monitored and encouraged’ (leadership role, core team, Hazeldean, R1). This view was mirrored in Ashgrove, where gaps between intention and action were crystallised: ‘no one seems to be very sure about how to set it up’ and there was ‘a problem in understanding what it is and what it consists of’ (implementation facilitator/boundary spanner, Ashgrove, R1). Intentions to engage patients in service improvement activities were sometimes thwarted through limited capacity for patient engagement within the service side: ‘most practices have underdeveloped systems for consulting their patients’ (leadership role, core team, Hazeldean, R1). However, there was a contrary perspective around positive intention in the data, where PPI was not always seen as essential, for example where ‘you are spreading proven innovation’ (leadership role, core team, Hazeldean, R1). PPI was often perceived as a NHS responsibility, although there was a recognition that capacity and capability were limited (leadership role, core team, Hazeldean, R1). Where the focus of implementation activities was principally conceived as generating a change in clinician behaviour, there also appeared to be little interest in PPI, other than in the production of patient information resources as in the case of HF work in Hazeldean. However, a sense of a moral dimension to PPI emerged in the narratives, specifically about PPI being the ‘right thing to do’. This was echoed by leaders, who reported that staff should ‘feel at least guilty for not doing it’ (leadership role, core team, Hazeldean, R1).

Patient and public involvement seemed to work well where there was a clear clinical focus around which patients and professionals could collaborate, as in the case of Oakdown’s work on diabetes research, as this provided a ‘shared interest’ to motivate engagement (NHS senior leadership role, Oakdown, R1). However, where there was a lack of agreement on the feasibility or appropriateness of the implementation activity, as appears to be the case for Hazeldean’s work around CKD management in primary care, there was little appetite for early patient engagement. The absence of a clear PPI strategy in the early stages of CLAHRC development probably reflects a predominant narrative in the data around PPI being something to be done when projects were up and running. There was no evidence in our data of PPI informing the selection of implementation projects to be conducted at CLAHRC level.

There was a general reliance on tapping into patient groups and networks that were already in existence, and serendipity about whether or not there was the right mix of resources. In Hazeldean, projects tended to ‘work with whoever just happens to be there and not if they aren’t’ (leadership role, core team, Hazeldean, R1). This appeared to reflect concerns about the significant costs associated with the development of infrastructure to support PPI. Oakdown also reported that its PPI activity was mostly through voluntary organisations and advocacy groups. However, Hazeldean’s work around HF, and the associated networking of professional groups and stakeholders, was successful in creating access to a ‘lot of patient of patient groups that existed, but nobody actually knew where they were’ (implementation facilitator, Hazeldean, R1). Data show that the further formation of service user groups or networks in this CLAHRC had been useful in informing the design of aspects of implementation projects, for example in establishing ‘what success would look like’ (management role, Hazeldean, R2), and was considered a key PPI success for the CLAHRC. Sustaining these was highlighted by both Hazeldean and Oakdown as a strategic challenge for the next round of CLAHRCs, given the considerable amounts of time and resources associated with group or network development. Continuing investment in PPI leadership was seen as key to the future in Ashgrove.

The strongest perspective in the data that emerged around PPI was the view of patients as holding a knowledge resource which could be tapped. The use of this resource appeared to be the most significant early impact of PPI, specifically in the capture and use of this knowledge to design patient information materials. Within Ashgrove, for example, concerns about the uptake of cardiac rehabilitation services, which were described as ‘really poor’ (implementation facilitator, Ashgrove, R2), were addressed through the coconstruction of a web-based support programme. Other more obvious impacts reported were around increasing access to hard-to-reach or ‘marginalised’ (leadership role, core team, Hazeldean, R1) groups such as ‘men with coronary heart disease in isolated circumstances’ (researcher, Hazeldean, R1).

Reflecting on their approaches to patient and public involvement

Strategic uncertainty about PPI within the CLAHRC appeared to be associated with reported challenges about scaling up, or learning about PPI, which both Hazeldean and Ashgrove recognised as requiring improvement, although progress with this appeared slow. This was also reinforced during the interpretive forum in which participants reiterated their challenges with operationalising PPI, particularly in the absence of an evidence base for PPI within implementation. Despite a learning event to reflect on PPI, Hazeldean had not developed any guidance on PPI. This left feelings of tokenism, with ‘little visibility’ (leadership role, Hazeldean, R4) of any achievement of PPI, and a concern that future efforts might not be ‘progressive and meaningful’ (clinical leadership role, Hazeldean, R4). In this CLAHRC, and despite processes for reporting progress with PPI, the board was reported to lack any ‘systematic view of how integral PPI is across the research theme or implementation theme. They get snapshots . . . they don’t get any real feeling of actual engagement’ (leadership role, Hazeldean, core team, R1). It appears that, in this case, board lay members were particularly exercised about this.

As time went on, there was evidence of a recognition that there was a lack of guidance around PPI. As a result, Ashgrove undertook a review of the literature on PPI in implementation, and engaged in other networking activity across CLAHRCs to further this aspect of their mission.

Although most CLAHRCs had made progress in the establishment or consolidation of PPI networks around projects, concerns emerged in later data collection rounds around the democratic nature of representation. Specifically, concerns were addressed around what agenda PPI representatives were bringing to programmes, and that the ‘same people were popping up all the time’ (management role, Hazeldean, R4). Despite these concerns, the development of more infrastructure for PPI was associated with a ‘less reactive’ (management role, Hazeldean, R4) approach, reflecting greater knowledge and confidence of PPI issues.

Perspectives from a different Collaboration for Leadership in Applied Health Research and Care

The configuration and range of experiences were checked out in one additional CLAHRC, which had adopted a more embedded approach to PPI from the outset. As with Ashgrove, leadership was key to driving PPI forward, although in this CLAHRC the leadership was part of a long-standing programme of public engagement around health issues within the CLAHRC footprint, including a ’10-year programme of doing user-led research’ (leadership role, PPI CLAHRC, R4). Additionally, leadership was sustained through dedicated funding for PPI staffing and related activities such as patient costs. The embedded approach to PPI was made explicit with a clear strategy for PPI at the inception of the CLAHRC, defined as ‘Engagement by Design’, and covered research priority setting and design issues such as the selection of outcome domains and measures. This reflected a recognition of the need to attend to implementation issues in the earliest phases of the knowledge production cycle. There was an assumption that, in this way, ‘the knowledge we’ve produced is actually much more likely to be taken up into practice’ (leadership role, PPI CLAHRC, R4). Whereas in our partner CLAHRCs PPI had been associated with surfacing patients’ experiential knowledge as a resource for improvement, and was ‘the right thing to do’, the ambitions of PPI in this CLAHRC were broader. Here there was an emphasis on changing the discourse of health through involvement at a regional level, increasing collaborative and collective capacity for implementation as ‘patients and professionals are learning about the evidence base together’ (PPI lead). Extending PPI beyond CLAHRC projects in this way appeared to reflect a regional tradition of activism around health, which provided the foundation for this CLAHRC’s approach to PPI. While other CLAHRCs worried about the professionalisation of PPI through the ‘usual suspects’ (PPI lead), this CLAHRC paid less attention to representation and more to the ‘authenticity of the experiences round the table’ (leadership role, PPI CLAHRC, R4) being brought to bear through PPI.

Role in knowledge mobilisation

Individuals in these roles generally said that they had vague job descriptions, particularly at the outset. However, in all three CLAHRCs those appointed to these roles were expected to engage in activity that ranged from training in research and evaluation to being focused on facilitating knowledge mobilisation. In contrast to the training and education function of individuals in Ashgrove, the implementation facilitators in Oakdown were more focused on knowledge mobilisation. Here, they were involved in the development of tools and procedures in three projects to support the use of knowledge in practice. This involved providing e-learning resources, training staff and working with steering groups to develop tools and procedures for implementing evidence. In addition, they had a supporting role for the ward-based champions, who had been identified as another means of knowledge mobilisation. In this sense there was the enactment of an external–internal facilitator-type approach:

One [approach] was to introduce ward-based nutritional champions so members of the ward team would help facilitate that change in practice with support of what we would call [implementation facilitators], who come from CLAHRC.

Leadership role, core team, Oakdown, R2

Oakdown facilitators were also expected to spread evidence-based improvements across the hospitals in which they were working:

there’s been spread through our [implementation facilitators] that we appointed to work across the wards and help disseminate so there’s been, I suppose, formal approaches like the workshops and the newsletter and there have been less formal ones where there’s been spread through people meeting informally.

Leadership role, core team, Oakdown, R3

There was also some clarity about the role of the facilitators in Hazeldean, where they were expected to implement evidence into practice:

I think it started off that they employed like seven [implementation facilitators] and our job was to facilitate the implementation of evidence, whatever evidence into practice.

Implementation facilitator, Hazeldean, R1

Boundary spanning

In all three CLAHRCs these individuals also served as boundary spanners; this was most obvious in Oakdown, where, in descriptions of the implementation facilitators and their role, ‘boundary spanning’ or ‘boundary spanners’ was the dominant discourse. Here, there was a recognition that it was necessary to have boundary spanners functioning at different levels within the health-care organisation:

I think what has become evident for us is the importance of boundary spanning at different levels . . . it is about the importance of boundary spanning at executive and board level going down to middle managers and steering committee members, key clinicians in the trust as well as middle managers and then importantly boundary spanning with frontline staff, the people whose practice we are trying to change.

Leadership role, core team, Oakdown, R2

Likewise in Ashgrove, the skills and qualities of the boundary spanner were identified in outlining their role:

we needed somebody in the trust to bring the organisations and the researchers together . . . a good [boundary spanner] is someone who is basically a great people person, brings people together, communicates, organises, networks, you know, speaks their minds . . . It’s not necessarily about the evidence, but it is about the people skills . . . we see them as sort of boundary spanners really, getting people across the boundaries and letting things happen that way.

Leadership role, core team, Ashgrove, R1

The critical feature of success for people in these roles was their credibility. Therefore, over time, Hazeldean augmented the work of its boundary spanners by employing clinical staff on secondment, because the people they had employed lacked clinical credibility, which had been a problem. In clinically embedded projects (CKD and HF), these roles were seen as important because the people had knowledge of the health-care context, including clinical knowledge:

So across the CLAHRC as a whole now we’ve got as least as many seconded people in knowledge transfer-type roles as we have people we originally recruited because that does bring that much more informal knowledge of people, networks and the clinical knowledge you know, and although there’s a few of those who we recruited who are good facilitators, in view of credibility and particularly the confidence that goes with those abilities are very important I think.

Leadership role, Hazeldean, R3

In contrast, Oakdown had employed only staff with a clinical background in its implementation facilitator roles, so they brought with them the clinical and contextual knowledge (i.e. local knowledge) that was seen as important for implementation success. In Ashgrove, boundary spanners were based in PCT R&D departments. In addition to the implementation facilitators in the PCTs, one of the research themes in Ashgrove had employed a full-time senior nurse as an implementation manager. This was seen as bringing clinical credibility to the role along with a sound knowledge of the health-care context, including barriers and enablers to implementation.

Overall, it was perceived that individuals in these roles were pivotal to knowledge mobilisation within CLAHRCs through facilitation and boundary spanning. They were also the most visible presence of the CLAHRC within health services. The focus of their function was allied to the particular position the CLAHRC had taken around research versus implementation, and in relation to the use of particular frameworks/models to underpin its activities. These individuals were perceived to be credible messengers – credible in the sense that they could interface with individuals at various levels of organisations and in that they brought clinical and contextual savvy to the implementation situation. The investment in them also provided the potential to build capability and capacity for implementation and research within health services.

General overview of the types of things that can be classified as boundary objects in theory

Those objects listed in the columns labelled ‘Standardised methods and forms’ and ‘Objects, models and maps’ suggest a considerable overlap between classes (many of these listed items can occupy both classes). However, multiple classification is a feature of many boundary objects, and a single boundary object may reside in several classes simultaneously.

During interviews with participants who were operating as boundary spanners, conceptual (e.g. CLAHRC concept) entities also emerged that appeared to operate as boundary objects, and it became evident that whether or not the boundary objects in theory operated as boundary objects, in practice was a function of the way in which they evolved and the meaning that was attached to them. Interviews with participants verified if and how boundary objects in theory (i.e. those that were evident in documents; Table 9) played out in practice as boundary objects in use.

Concrete to conceptual boundary objects

A range of what could be described as concrete boundary objects was evident in the discourse of the boundary-spanner interviewees. The nature and properties of some of these are outlined in Table 10. These objects had the potential to share meaning and knowledge and to catalyse action among those who coalesced around them.

In addition to the tangible objects that were identified as potential boundary objects, less tangible entities, conceptual or symbolic, emerged that could also have boundary object properties attached. CLAHRCs as a concept served as a boundary object, in that they possessed some cohesive property (which varied across them) in catalysing the potential to cultivate collaboration. There were varying perceptions about what a CLAHRC is, which were related to the type of stakeholder expressing the opinion: those in CLAHRC leadership roles were clearer about it than those in the front line of the health service. Over time, and through a process of collective sense making, CLAHRCs as a concept became clearer for some:

we really sort of got our heads together about what CLAHRC was, and actually what we should be doing . . . yeah, we kind of just worked something out ourselves and just created a job and created work for ourselves, based on our interpretations of . . . of what it is . . . it’s a programme of work to promote collaborative . . . collaborative work between academia and health care to . . . ensure research evidence is used quickly, and it is . . . is . . . worthwhile, it’s wanted, and it’s used.

Implementation facilitator/boundary spanner, Ashgrove, R3

However, CLAHRCs’ catalytic potential to bring about collaboration was hindered by their architectures.

There were also examples of language being used to create a shared meaning around issues and topics, and thereby acting as a symbolic boundary object. In this example a facilitator had been using what she described as a slogan to engage practitioners’ attention:

I’m tending to use a slogan that I suppose is about patient safety . . . Everybody’s business. So those are sort of catchphrases that capture people’s interest.

Implementation facilitator/boundary spanner, Oakdown, R3

Clinical issues also had the potential to have cohesive properties. For example, in Oakdown shared clinical topics such as nutrition and dysphagia were boundary-spanning concepts, which were meaningful to a range of stakeholders including practitioners and patients.

I think the thing with nutrition is it’s not a hard sell . . . I really don’t think anybody thinks it’s not important . . . everybody thinks it is important . . . And most people, and I can’t think . . . as I say, most people believe nutrition is important . . . So it’s not a hard sell. What’s the hard sell is how to do it.

Implementation facilitator/boundary spanner, R3

In this example, nutrition was a useful symbolic boundary object that resonated across contexts and was perceived to be universally important, providing a focus around which to catalyse engagement and potential action for improvement.

The evolution of boundary objects: collective action

The potential of boundary objects to have cohesive properties appeared to be partly a function of the way in which they evolved. Those objects that transformed from objects in theory to object in use had similarities in terms of their collective generation. Collective generation occurred through discussion and collaborative activity in developing, amending and tailoring objects for use. There are a number of examples in the data where particular tools had emerged from collective endeavours, which had involved the engagement of relevant stakeholders and resulted in their use in practice [e.g. CKD audit tool at Ashgrove and Hazeldean, Malnutrition Universal Screening Tool (MUST)+ and VTE assessment tools at Oakdown and HF alert card at Hazeldean]. In this way they mobilised knowledge between communities because the process involved the integrating of local evidence and experience with external evidence from guidance and thereby became meaningful to stakeholders.

Box 5 provides an example of how collective action around a shared symbolic object was transformed into a concrete boundary object, something that was relevant and had resonance with its end-users, which was then used in practice.

Within Oakdown there were also reports of collective tailoring of standardised generic objects that had originated externally from the CLAHRC organisations, including the MUST and VTE assessment tools. These tools underwent a process of tailoring and contextualisation, including the incorporation of local knowledge:

things like the MUST screening tool or the Department of Health VTE assessment form and the idea that those are then adapted to the local context so MUST was developed to what we called MUST+ because it had an extra question that we felt was appropriate.

Clinical academic, core team, Oakdown, R3

. . . without us . . . without doing enough tailoring . . . I think what we learnt was you have to do a lot more tailoring than you think.

Implementation facilitator/boundary spanner, Oakdown, R3

If there was not enough collective action involving relevant stakeholders in either development or tailoring, the result was that a concrete boundary object in theory potentially operated in an inhibitory rather than catalytic way in practice; for example:

they decided, because . . . South Asian communities have a higher incidence of diabetes at a lower BMI [body mass index] . . . this was a real . . . it was important, and obviously Ashgrove has a very high South Asian population; it was really important that this tool worked for that group . . . They’d done a literal translation, which was in places quite offensive . . . and the . . . the . . . as a visual aid, it’s like a traffic light . . . you know, red, two ambers and a green, and they couldn’t get why you would have two ambers. It really . . . you know, it stopped the purpose of the tool, it . . . you know, they were saying ‘Oh why . . .’ you know, ‘How do I know which amber I am?’ and things like this. So those discussions, if they hadn’t have taken place that tool would have gone out, I mean it is out, Diabetes UK host it, it is a really valuable tool . . . But it would not have worked for that group if they hadn’t had that conversation.

Leadership role, Ashgrove, R3

Our data show that meaningful collaboration provided a condition in which the potential of boundary objects may be released, because this provided a receptive context and opportunity for attaching meaning, resonance and value, which enabled knowledge mobilisation. Therefore it could be predicted that, in environments in which there is more and good-quality collaboration, the power and potential of boundary objects might be greater.

Summary: knowledge and its mobilisation

Different levels of attention were focused on CLAHRCs’ implementation function. These levels linked back to how the CLAHRC initially interpreted the brief (i.e. its position about what CLAHRC was for), and the positioning of resources to enact its plans. However, we identified a number of different types of activity that mobilised knowledge or had the potential to mobilise it, and around which each CLAHRC tended to coalesce. On balance these approaches were concerned more with knowledge transfer than with coproduction; that reflected an emphasis on CLARHCs as producers rather than users of applied health research. CLAHRCs were figuring out PPI within knowledge mobilisation and articulated their challenges with this remit. Generally, they had conflated PPI in research and PPI in implementation, which demonstrated a lack of conceptual clarity around this issue and their challenge in operationalising it in a CLAHRC context. Engaging with the CLAHRC agenda and around knowledge mobilisation was an enactment of ‘what’s in it for me’; different stakeholder motivations provided a loop of reinforcement for engagement. Motivations to engage also differed between health services and academia; those in practice perceived CLAHRCs to be dominated by an academic agenda.

The CLAHRCs positioned financial investment in implementation through the creation of boundary-spanning roles. Individuals who were credible and visible in these roles played a significant role in mobilising knowledge (and in making a CLAHRC real). They developed and had at their disposal a number of ‘things’ that were, or became, boundary objects. Potentially meaningful collaboration (e.g. in the creation of objects) provided the conditions in which the potential of boundary objects was released.

Direct, processual and conceptual impacts

Throughout the rounds of data collection there was a consistent narrative about needing to demonstrate impact. This was particularly acute in the early stages of the life cycle of the CLAHRCS: ‘high expectations from the trust and the funding, there is a lot we need to achieve in a quite short space of time and I think that is quite difficult or I personally found quite difficult, quite a lot of pressure in a sense to achieve results quickly’ (implementation facilitator, Hazeldean, R2). Given the time that it takes to generate impact, particularly in relation to changes in practice, service delivery and patient outcomes, it was perhaps unsurprising that evidence of more direct impacts accumulated over time and was, therefore, more obvious at the point of transition between CLAHRC 1 and CLAHRC 2, when data collection in this project was finishing. Appendix 8 provides a list of evidence extracted from a variety of documents about the direct impacts that CLAHRC’s had generated and reported. Some of these impacts are illustrated in Table 11. The most prominent source of these more direct types of impacts from implementation activity appears to be service/quality improvement-type projects. Discussions between CLAHRC participants at the interpretive forum acknowledged that the (regional) public health impacts expected in the original CLAHRC bid had not been realised as intended, and that perhaps this was partly a result of the types of metrics they were being asked to deliver and report on.

In addition to an increasing accumulation of direct impacts, we also heard about different sorts of impacts arising from the implementation of specific projects and from being involved in a CLAHRC. For example, respondents reported impacts on the processes of care through the implementation of particular tools, which, in the case of the illustration below, if assessment led to appropriate action, had the potential to impact on outcomes:

So it was huge . . . when we got that in [VTE assessment into documentation] I mean I did an audit when it had been in about 2 or 3 months and the . . . compliance you could see had just gone up. It’s not by any means perfectly completed, but they are risk-assessing and, you know, it’s much better.

Implementation facilitator/boundary spanner, Oakdown, R3

There were also other processual impacts on service delivery processes. For example, a care pathway to co-ordinate the physical health of people with enduring mental health problems between primary, community and inpatient services was implemented, and that had impacts on communication:

Communication had improved between GPs and the trust . . . but also communication within the trust had improved with greater numbers of referrals of patients to lifestyle services who were able to offer advice about smoking cessation and weight loss for service users.

NHS partner, Hazeldean, R2

Further, partly as a function of the closeness of relationships between a CLAHRC’s constituent services and HEIs, including joint appointment, there was also evidence that learning through a CLAHRC had an impact on curriculum development: ‘we can influence the curriculum and how the curriculum can respond more quickly to the learning from CLAHRC’ (implementation facilitator/boundary spanner, Oakdown, R3).

Additionally, there were numerous reports of changes to thinking, knowledge, skills and attitudes as a result of project-related activity. However, the gap between conceptual and direct impacts was also noted:

We did get some nice changes in attitude and knowledge using the questionnaire but . . . it was much more difficult to see what had actually changed . . . so it was more of a conceptual use of knowledge rather than the instrumental use of knowledge.

Implementation facilitator/boundary spanner, Oakdown, R2

The challenge of spreading impacts beyond the projects from which they originated and beyond the boundaries of the CLAHRC was an issue that was articulated consistently by those in leadership positions within CLAHRCs:

It has got to be about the impact and the scale of it and the spread of it so you know it is something that not just a handful of people are benefiting from because there is so many pockets of good practice and things being done well but then if you are the unfortunate person who doesn’t fit into that pocket then you don’t get the benefit and I think it has got to be the scale of it.

Management role, Hazeldean, R4

However, there were examples of particular tools developed through CLAHRCs (e.g. an online cardiac rehabilitation programme) that had proved to be popular (i.e. useful and relevant) and spread across the UK, and their translation/extension into other disease groups had been initiated. Tools such as these had been developed collaboratively and had been driven by a service-identified need.

Personal impacts

Data show that different sort of impacts were important for different stakeholders. Academics valued publications and the provision of opportunities to increase grant capture. CLAHRCs had concentrated or focused expertise and academic talent within England, which has resulted in increased activity around grant applications and awards. However, the applied nature of the CLAHRC work has caused a tension for some, particularly in relation to career framework expectations and REF 2014:

I think some of it [CLAHRC activity] is considered subscience and I think they like the fact that it is going on and I wonder if people are glad that it is happening but not them doing it . . . the so-called hard core scientists actually like to leave it to others and now I understand why, because these things, however good, and PPI and all that sort of stuff, it doesn’t impact on REF or is more difficult to impact on REF-type activities . . . I am not sure it is of hard core value in the world of academia, certainly not yet.

Academic, Ashgrove, R4

Although it was noted by participants at the interpretive forum that, in the context of the (then) forthcoming outcome of REF 2014, impact stories, for which CLAHRC activity provides a natural pipeline, may contribute to the survival of the CLAHRC concept and a shift in thinking by academics to value engagement with more applied research and its implementation as a rewarding activity.

It is clear that CLAHRCs have provided opportunities for capability building and for individuals to develop personally and professionally. Involvement in activities and projects has provided job satisfaction to those who have felt that they have contributed to making a difference, and it has given others the chance to develop their curriculum vitae, while in parallel developing implementation capability within the system:

I think importantly what it has also done for a lot of people is develop their own knowledge and skills around implementation, so my core team had varying knowledge about implementation when they started but through projects that we have done, the reading that we have done through their engagement in KU [knowledge utilisation] events . . . people have been exposed to a different environment . . . in the NHS . . . working in partnership with academics in universities that often they don’t do that, so I think they have learnt more about the process of research of the process of rigorous evaluation through that process . . . they have developed their CV [curriculum vitae] so we had people promoted through readership to personal chairs . . . through the NHS from Band 6s to Band 7s and taking on more leadership responsibility.

Leadership role, core team, Oakdown, R4

Development and personal growth impacts were very particular to those individuals who took on boundary-spanning and facilitator-type roles. However, there was also evidence from others that being involved in a CLAHRC had provided a platform for career development and an opportunity for personal profiling:

I am the director of [NHS organisation] – how did that happen?! That was a direct result of [CLAHRC]; there is absolutely no way that I would have the kind of experience I needed . . . I wouldn’t have had that experience to go to the trust board if it hadn’t have been for [CLAHRC] . . . it would have taken me another 10 years to get where I am if it hadn’t been for [CLAHRC].

NHS partner, Oakdown, R4

You know they’ve [facilitators] all . . . you know, become experts in their fields over the years, and some of them did that very quickly and were then able to transfer knowledge very quickly. I think the lady who runs the . . . post-stroke assessment . . . dare I say probably . . . at a national level known quite well as an expert in stroke . . . she would be seen probably as an opinion leader in her own right.

Academic leadership role, Hazeldean, R3

Collaboration for Leadership in Applied Health Research and Care ‘footprint’

As the above examples begin to illustrate, there were many and varying types of impacts that could be attributed to the existence of a CLAHRC. However, one issue that was discussed within the interpretive forum and was thought to be either missing or not yet articulated was the ‘footprint’ left by CLAHRC. This means the impact that CLAHRC had had on an area and the NHS as a whole, and cultural change: the ‘way we do research’ or the ‘way we do implementation’. The ability to see the footprint was potentially impeded by changes to the NHS landscape, including frequent changes in relationships and health service boundaries. However, the ability to identify the footprint might also be linked to the absence or presence of mechanisms and processes for meta-learning within and across CLAHRCs.

Summary: impacts

We observed many different types of impact from CLAHRC activity. These could be considered to be positioned on a continuum, in that direct impacts (on practice and service delivery) took time to realise and were preceded by other types of impacts, which were less instrumental, including those that were more personal to individuals engaged in CLAHRC roles. Participants stressed their desire and need to make an impact, and the funder’s monitoring focused attention on particular metrics, for example number of publications and amount of research funding. External reporting requirements fuelled an emphasis on particular types of metrics and on a need to demonstrate volume of activity. Locally generated reports also included case studies and stories of impact. The impact of the CLAHRC was an accumulation of project-level impacts rather than a demonstration of cultural change in a region or in the NHS, and therefore the imprint left by the CLAHRC footprint as a whole was still faint when we stopped collecting data.

Information sharing

When asked to reflect on the processes and mechanisms for learning within CLAHRCs, most participants talked about sharing information between projects and themes through, for example, reports, meetings and knowledge-sharing events. However, a common perception that emerged from participants across all three CLAHRCs was that sharing of information tended to be focused on metrics, at the level of individual projects, and for the purpose of feeding into 6-monthly returns for the NIHR:

There was a process, there was some really dysfunctional research and implementation meetings but nothing got done. They tended to be focused around things like the 6-monthly NIHR reports and the annual report.

Leadership role, Hazeldean, R4

Information sharing within a CLAHRC was hindered by the structures that had been established (engineered architecture), the leadership approach and style (more or less transparent and open to critique and learning) and the communication mechanisms that had been developed and sustained. In contrast, where there were strong relationships and connections between individuals, teams and services, this created openness, which facilitated information sharing. However, most participants felt that sharing for learning within and across CLAHRCs could have been better. The prevalent reason for sharing was, as one participant put it, provision of information rather than sharing for learning by bringing challenges to the table and learning from each other. It was noted, however, that the potential to learn would require a different sort of forum from that which currently existed:

There is a difference between going to a meeting where there is an agenda, one to six different projects, and a meeting where we are beginning to think . . . about what is the same, what is different, what have we learned, is any of it generalisable, can it be used in theory. Those are different kinds of meetings. Most of the meetings have been A rather than B.

NHS partner, Ashgrove, R4

Scaling up

Given this, although there were information sharing and feedback mechanisms in place within CLAHRCs, it was unclear how this information was being used to learn or scale up from individual projects. This finding was corroborated at the interpretive forum, at which participants reflected that not formally evaluating the question ‘what have we learnt?’ was a missed opportunity. However, it was reported by CLAHRC directors that there had been some ‘organisational’ learning in CLAHRC 1 that was being taken forward in revisions to structures (fewer divisions between structures) and some processes (considering more opportunities for learning) for CLAHRC 2. Furthermore, it was felt that the externally funded evaluations were not universally helpful because in reality it had been a challenge for them to provide timely formative information, and because some of the projects had not been designed in an interactive way. These problems were not perceived positively by some CLAHRC directors.

Responses

The CLAHRCs within this study responded in different ways to different (mainly externally located) stimuli prompting changes to the way things were being done. There were considerable changes to the NHS landscape during the life cycle of CLAHRC 1; these significantly affected Hazeldean, which had set up a funding structure that was reliant on actual (rather than in-kind) resource from primary care partners. During this time, health service partners left the collaboration, withdrawing their money, which necessitated the CLAHRC’s cutting its cloth accordingly: prioritising activities with the resources they were left with and doing less. In the first 2 years of its existence, the board of Ashgrove (the body the CLAHRC was accountable to) instigated a formal external review, which in itself signalled a need and openness to receive feedback. The review team critiqued its approach, specifically the balance of activity, which was felt to be too weighted towards research and not enough towards its application, and building capacity and capability. The external review resulted in a course correction for this CLAHRC, through which it began to pay more attention to implementation:

Yes definitely, that it [implementation] had to be incorporated and I think it was a difficult concept really because we were doing clinical trials and we thought, actually you are doing this trial because you don’t know the answer, so it is difficult to think about implementation . . . but now [after the evaluation] if you are embarking on a clinical trial then we do appreciate that you have to talk to patients, you have to talk to commissioners and you have to think about implementation . . . so I think gradually you know the penny had dropped and so it has changed, will change our view over the longer term.

Management role, Ashgrove, R4

In contrast, Oakdown took an ongoing approach to reviewing its activity and approach through reflection and negotiation with internal and external stakeholders. This seemed to have insulated the CLAHRC from changes in the primary care landscape and enabled it to be responsive to partners without compromising its ongoing activity and future plans.

Summary: evaluation and learning

Learning within and across Ashgrove, Oakdown and Hazeldean was patchy, with varying levels of receptiveness and therefore varying levels of attention being given to evaluation and to structures and processes that could mediate feedback and sharing. Learning at a project level was more evident than learning from the CLAHRC as a whole; however, from our data it was not clear how project learning was being incorporated into doing things differently in the future. Equally, their potential to learn from the externally funded evaluations had been varied, with issues raised about the timing and format of the feedback provided. However, there had been different externally driven prompts in Ashgrove and Hazeldean that had necessitated review and resulted in adaption. Oakdown took a more ongoing approach to reflection and subsequent refinement. It was also evident that learning from CLAHRC 1, or the ‘pilot’, had been taken forward into proposals for CLAHRC 2.

Positioning and interpretation

Conceptual, cognitive and physical positioning of stakeholders at micro, meso and macro levels led to individual, group and CLAHRC interpretations of collaborative action, which resulted in setting and sustaining a particular direction of travel or path dependency, including approach to implementation.

The figuring out, mainly organically, of their specific purpose and approach to implementation was set within a broader context of the way in which the CLAHRCs had interpreted their purpose, related activity and way of working. This varied interpretation appeared to be a function of a mixture of conditions including:

• how they had made sense of the brief, that is where they started from and their ‘cognitive positioning’

• what they individually and collectively brought to the issue, that is their ‘conceptual positioning’

• how constituencies and stakeholders positioned themselves geographically, that is their ‘physical positioning’.

The course or direction of the CLAHRCs appeared to be fairly fixed at the time of bid development and subsequent award of funding because their proposals became part of the contract on which they were held to account. Therefore, their starting point and where they came from on a number of issues played out in a pervasive and persistent way. That is, the contingent relationship between the context or condition of positioning and the mechanism of interpretation was one of reinforcement during CLAHRC 1.

Interpretation of the ‘brief’ created a path dependency. Given this, fulfilling a role and function around what the NIHR call described as the application of research findings (i.e. implementation) was contextualised within a broader view or position about a CLAHRC’s overall remit. Specifically, their resultant approaches to implementation were a function of:

• how much attention was paid to implementation by CLAHRCs per se

• their existing knowledge about implementation

• how they had interpreted collaboration between services and academia, and whether implementation was perceived to be a more or less collaborative act.

Data show that views about collaboration varied from viewing it as a challenge and something that was not well understood – ‘the nature of the call is collaboration, that is the key word, and the nature of collaboration with the NHS is not terribly well founded in my view’ (Clinical academic, Ashgrove, R1) – to a perception that ‘the CLAHRC as a whole is a very collaborative approach and joint appointments were integrated and demonstrated . . . the synergy between the organisations’ (NHS partner, Oakdown, R4).

A CLAHRC’s decisions about the balance between research and implementation were critical to the allocation of resources (financial and human) and consequently the relative attention afforded to each area of activity. Each of the CLAHRCs in this study had traded research activity and implementation activity in a similar way and our findings show that, in response to the perceived terms of the call, greater emphasis was placed on the generation of research than its mobilisation in practice:

We have, I suppose 80% more or less for applied health research themes and one implementation theme, broadly the money’s been distributed 20% each . . . I think if I were bidding again we could certainly change that distribution.

Leadership role, CLAHRC core team, Ashgrove, R1

However, within Oakdown there was a commonly expressed aspiration that both the creation and use of knowledge in practice could be achieved through coproductive and integrated ways of working: ‘but again see it more as a shared endeavour to get more research embedded in what they are doing’ (leadership role, Oakdown, R1). Accordingly, the purpose of the CLAHRC, which incorporated its role and function for knowledge mobilisation, was conceived differently across the CLAHRCs involved in this study. There were also some honest accounts from some participants that they were being challenged by the concept of implementation and were on a journey of ‘figuring out’ the implementation function and role of their CLAHRCs’ remit: ‘we just don’t know how to do it . . . a lot of us aren’t up to speed with this [implementation] agenda’ (leadership role, Ashgrove, R1). However, fundamentally, their interpretation seemed to be dependent upon how they had interpreted the first ‘C’ of CLAHRC in combination with their experience and expertise in knowledge mobilisation.

Physical proximity was both a condition for, and a function of, their view of implementation as a collaborative act/process, for example whether the CLAHRC leadership team was situated within health services or HEI(s). Oakdown had purposively positioned its senior/core team within the health service, and the other two were based within universities, although they posted secondees and boundary spanners out to the service setting. Being physically embedded within the service setting was symbolic in the context of the raison d’être of a CLAHRC, but was also a function of a history of closer working relationships between services and higher education. Where this history did not exist, collaborative and trusting working relationships took time to establish, particularly ‘that getting to know time . . . as to how people work’ (implementation facilitator, Oakdown, R3). Building up the collaborations was further compounded by the issue of time early in the life cycle, when there was a pressure to do something: ‘The minute we got the money and got started . . . you have partners paying, in our case NHS partners, and you have got to get on and do something’ (leadership role, CLAHRC core team, Hazeldean, R1). Therefore, more established relationships catalysed collaborative contexts in a shorter time.

The different views, values, interpretations and visions came together to result in a mixed picture, with more or less implementation (i.e. explicit activity concerned with the actual use of evidence, in its broadest sense, in practice and service delivery) taking place. During the course of this study, we distilled the approaches to mobilising knowledge into the following categories:

• service improvement, that is implementation of quality improvement methods

• making evidence accessible, that is converting evidence/guidance into more practical products

• implementing national and/or local guidance into practice

• mobilising local evidence, that is sharing intelligence about local evidence of effective practice

• implementing home grown evidence – a stated, but minimally realised, aspiration

• paying attention to aspects of implementation in the conduct of research, from paying attention to intervention implementation in a trial to conducting research that could be described as coproduced.

As this categorisation makes evident, the different types of knowledge mobilisation could be placed on a continuum from knowledge transfer to coproduction, with the overall balance weighted towards knowledge transfer-type approaches. In Oakdown, there was evidence of historic collaboration and an aspiration for coproduction; in contrast, these conditions were less obvious in the other two CLAHRCs. However, within specific projects in Hazeldean and Ashgrove there was evidence of engagement in the absence of established partnerships. Furthermore, there were different approaches embedded and evident within these knowledge mobilisation categories, such as taking on a consultancy or supplier of services type role to the partnered health care organisations. This makes more visible the particular conceptual, cognitive and physical positioning of a CLAHRC: in this example, as something slightly removed or separate from the service, which reinforced a ‘potential disconnect between the priorities of the NHS and the work that is being done [in the CLAHRC]’ (leadership role, Ashgrove, R1).

Furthermore, conceptual positioning and theoretical fidelity should in theory be conditional upon and aligned with each other. Other than providing a focus for talking about implementation, it was difficult to uncover exactly how the theories and frameworks that CLAHRCs had signed up to were being operationalised in implementation practice and research. However, in Hazeldean and Oakdown, where they had articulated the use of particular frameworks, it was possible to see traces of their use, such that they provided a heuristic for project, group and individual activity and thinking:

Normally often within the NHS people launch straight into a project and they don’t necessarily look at barriers and enablers . . . they don’t necessarily think about evaluation or feedback loops and mechanisms. They don’t always think about the KT strategy the facilitation approach that they’re going to be using. So we’ve used the K2A cycle to help people to understand that as we’ve gone through . . . The facilitators at times have occasionally referred to PARIHS framework . . . At a very superficial level on the basis of the concepts of evidence facilitation and context to help people understand the different dimensions that we’re bringing the evidence, that we need to take account of the change of context at different levels.

Leadership role, Oakdown, R3

The interpretation of implementation within these two CLAHRCs, including their use of theory, came from greater attention to implementation within their plans, and the existence of implementation research and practice expertise within their senior teams (i.e. their cognitive and conceptual positioning).

There also appeared to be a link between a CLAHRC’s interpretation of the brief and its attention to different types of evidence. A cognitive position where there was more attention to the production of research (e.g. Ashgrove) led to (perhaps unsurprisingly) the privileging of research and less attention to other sources of evidence. In contrast, within the service improvement efforts in both Hazeldean and Oakdown and in the facilitation of guidance into practice projects in Oakdown, there were accounts of seeking and incorporating evidence from propositional and non-propositional sources of knowledge into practice and research.

The reinforcing contingency between positioning and interpretation had determined CLAHRCs’ approach to implementation, which was evident early in their life cycle. Over time it became more apparent that the CLAHRCs’ starting point in relation to their mission more generally (i.e. their view about the purpose of CLAHRC and how collaboration should operate) provided an additional explanation of why they did what they did, and why they then persisted with that direction of travel. The CMO about learning and review provides evidence of how a direction of travel could be disrupted, if not completely redirected.

Governance and connectivity

The CLAHRCs’ governance arrangements, including both structures and processes between people, places, ideology and activity, prompted different opportunities for connectivity, which affected the potential to have productive relationships and interactions for collaborative action around implementation.

The engineered, aesthetic and social architectures, including leadership approaches in CLAHRCs, provided a physical and aesthetic scaffold with which individuals, teams and organisations could potentially connect. In reality there were varying levels of connectivity within and to CLAHRCs that affected the type and quality of collaboration, and therefore how productive relationships for collaborative action around implementation were.

As a distributed model across a large geography containing many individuals, teams and health-care organisations, the way in which the CLAHRCs organised themselves became critical to their potential for collaboration and action. Their architectures provided a more or less supportive scaffold for communication, collaboration and therefore any implementation activity that was to result. The degree of fit and integration across different activities and constituencies varied, with some being more integrated and networked than others. Organising the work of the CLAHRCs within themes or strands appeared to be counterproductive to working in an integrated way because ‘it meant strands went in different directions’ (academic, Hazeldean, R1). In all three CLAHRCs the structures were not obviously connected. Organising themselves in themes also inhibited sharing information, enacting the vision for the CLAHRC and embedding PPI. However, in Oakdown, for example, where there appeared to be supplementary mechanisms for integration, accountability (i.e. reporting structure) and communication, in combination with an internal evaluation, connections between projects, activities and people were facilitated. Additionally, in Oakdown, Hazeldean and Ashgrove, the decision to resource roles such as boundary spanners and facilitators had provided opportunities for connectivity, and therefore the potential for more action around implementation.

In these contexts, boundaries of varying types were created and/or emphasised rather than bridged. Such boundaries mediated the potential for connections to be made, requiring greater effort to overcome them. Of particular note is that the structure of CLAHRCs had in some cases emphasised the professional and epistemic differences between higher education and practice because they had reinforced both the metaphorical and the physical distance between them:

There was quite a lot of siloed behaviour of that being research and that being implementation and I think that a lot of those people didn’t really budge position at the end of 5 years, so from that sense it wasn’t a roaring success.

Clinical leadership role, Hazeldean, R4

This also played out in behaviour through tribalism between groups, such that ‘if you helicoptered over this room . . . it had all the implementation theme down one end of the room in a big circle . . . and then there was one research team up one end, another two wandered in and another two somewhere else’ (leadership role, Hazeldean, R4). This feature links to the path dependency described above, in that the conceptualisation of CLAHRC had played out in features of its engineered architecture; relative closeness or distance was a feature of the operationalisation of collaboration.

Less integrated structures were overcome by creating opportunities, and therefore resources, for connections to be catalysed and for connectivity to be enacted through specific activities and project work. Opportunities that created ‘space’ for connections between services and higher education to be made, for ideas and knowledge to be shared among different communities and for cross-fertilisation and learning had resulted in some productive relationship building around specific CLAHRC activities. This led to collective action around research and/or implementation. Over time all three CLAHRCs had managed successfully to create these spaces. The added value of these activities was that they also made the CLAHRC itself visible and increased the likelihood that individuals would feel connected to it as a concept.

In contrast to CLAHRC creating or reinforcing a distance between services and academia, the CLAHRC ‘brand’ had also provided a potential catalyst for many different opportunities, including as a vehicle to stimulate exchange. The resources of the CLAHRC had prompted activities, from formal events to creating the space to enable projects and ideas to happen serendipitously. It had also provided opportunities that might otherwise not have occurred, including providing a space for testing out ideas and new ways of working before rolling them out. In this sense the CLAHRCs were perceived to be a legitimate test bed, such that, if ideas failed, the cost was accepted as part of the natural CLAHRC experiment. Furthermore, over time, the CLAHRC itself began to act as a boundary object: as something that encouraged and facilitated communication across different individuals, groups and organisations. Additionally, for some, the brand became trusted and had established a reputation and some kudos:

I think universities align themselves with the brand because it is prestigious and it gives them access to money . . . it allows universities to do their jobs.

Academic, Oakdown, R4

I think we have got a good one [CLAHRC brand] . . . When you first start out and nobody knows you and you are not quite sure what you are doing it was much more difficult . . . But once you have done things and some group has worked with you, we found it much easier to recruit practices and in fact with the CCGs we had a very good reputation.

Clinical leadership role, Hazeldean, R4

. . . it was heavily dominated by the University of [place] and that was where the kudos was going to sit.

Clinical leadership role, Hazeldean, R4

Connectivity was a response that operated variously across the layers or levels of CLAHRCs. Projects, for example, provided another potential for engagement, which may not have been mirrored at the organisational level of a CLAHRC. There were a number of examples, for example within Hazeldean, of service improvement projects having provided an opportunity to successfully engage relevant stakeholders from both health-care organisations and academia to work on relevant issues to positive effect. These effects were realised in terms of bringing about positive health benefits (e.g. in the assessment and detection of CKD) through the use of evidence, and doing so in a way that facilitated the sharing of expertise among stakeholders, and in building capacity and capability in improvement approaches. In this sense, the CLAHRC programme had catalysed collective action around particular implementation challenges by providing the space, conditions and resources for these projects to happen. The question remains how CLAHRCs then become greater than their constituent activities and projects, particularly in conditions where the CLAHRC network is less integrated and established.

The social architects of CLAHRCs were their leaders. Social architects shaped the environment that encouraged certain types of behaviour towards particular goals, which made them powerful agents within their CLAHRCs: ‘the leads very much feel they have influenced the thinking behind the CLAHRC and how that CLAHRC has evolved over time’ (leadership role, core team, Oakdown, R4). Given this, the leadership approaches and styles of CLAHRCs’ leaders were critical to creating a more or less facilitative milieu and in providing the conditions for internal and external stakeholders to engage and connect with a CLAHRC and its activity. A more centralised leadership approach, which was obvious in one CLAHRC participating in our study, led to closer and tighter networks that were more difficult for people to penetrate. This contrasted with more distributed leadership, which provided opportunities for engagement at various levels and intersections. Further, more centralised versus distributed leadership approaches were linked to descriptions of leadership style; those who were more centralised were described as command and control, or divide and rule, in contrast to those encouraging a more distributed approach, which were described as open and facilitative. These different styles provoked responses that were both practical (‘keep people in their clearly defined boxes and manage in a vertical way’) and emotional (‘I found the whole thing to be challenging’) (leadership role, core team, Hazeldean, R4). This led to variable feelings of connectivity with and within a CLAHRC, and therefore potential opportunities for collective action.

The concomitant contingency between governance and connectivity in CLAHRCs had provided opportunities for joining up people, teams and organisations working across different boundaries, disciplines and mind-sets, and in different places and spaces. More integrated structures and processes of governance provided greater resources for connectivity. Opportunities for meeting, communicating and interacting provided occasions for catalysing collaborative action on knowledge mobilisation.

Given the critical role that leadership styles, roles and approaches appeared to play in practice and in the minds of participants, leaders (at all levels in a model of distributed leadership), in their capacity as social architects, could be considered the oil that lubricated the CLAHRC system.

Resources and facilitation

Positioning and availability of resources, including funding for implementation, roles, opportunities and tools, prompted facilitation, resulting in a range of impacts including engagement, capability and capacity building, improved care processes and patient outcomes, and personal benefits.

Facilitative capacity and capability was released in the context of CLAHRCs’ position and approach to implementation, and the associated resources that were made available for this function, thus reinforcing the path dependency described in Positioning and interpretation. There was a catalytic contingency between resources and facilitation in that their interaction stimulated the potential for action and thus different types of impacts, including, in the later stages of our study, direct impacts on outcomes. In this context, the mechanism of facilitation encompassed enabling, freeing up, helping and making things easier, and had potential impact on individuals, teams and services.

Investment in formal roles was an obvious and visible investment in knowledge mobilisation in the CLAHRCs. Individuals in these jointly appointed roles served a boundary-spanning and/or facilitation-type function. Their functions related to a CLAHRC’s stance on knowledge mobilisation, including what they perceived it to be and where it was on the continuum between collaborative action around implementation and knowledge transfer. These roles were also loosely linked or aligned to the frameworks CLAHRCs had chosen to adopt and/or adapt, for example an investment in roles called ‘facilitators’ in the context of using the PARIHS framework in Hazeldean. Those in boundary-spanning roles (linking service and academia) were most evident in contexts where the balance was weighted towards research production and knowledge transfer was the dominant model of knowledge mobilisation:

I’ve been involved in an introductory training package . . . which was all around trying to develop a sort of an introduction to research and evaluation techniques for NHS staff. But also to have it led and taught by NHS staff so the idea was for it to be a sustainable thing to sort of increase research . . . to sort of build up research capacity.

Implementation facilitator/boundary spanner, Ashgrove, R3

In contrast, facilitators (those enabling implementation processes) were visible within contexts where there was more of a focus on projects and activities ‘to help facilitate that change in practice’ (leadership role, Oakdown, R2), for example in guideline/guidance implementation and service improvement projects. Clearly, these functions were not mutually exclusive – that is, those in facilitator-type roles could also act as boundary spanners. However, it was less likely that those in boundary-spanning roles were undertaking facilitation because of their defined remit in training and education in, for example, research skills and awareness.

Individuals in these roles were important ambassadors of the CLAHRCs. Through enacting the CLAHRC’s position on knowledge production and knowledge mobilisation they were the visible face of the CLAHRC and made it more tangible. This was an important function, particularly in the early days of the CLAHRCs, when there was a lack of clarity in participating communities and constituencies about what the CLAHRC was. Their ability to communicate, make connections and network across the various service and academic boundaries was critical in establishing engagement with the CLAHRC generally and in its activities (e.g. training events and projects) specifically. They did this in a variety of ways, including through ‘informal’ techniques such as coining and using appropriate language and phrases to encourage ward staff to become involved in the quality improvement initiatives, for example seeing patients’ safety as ‘everyone’s business’ (boundary spanner, Oakdown, R3).

Therefore, the personal qualities and skills were an important condition of the success of individuals in these roles being both the credible messengers and the public face of a CLAHRC. The clinical credibility of these individuals was particularly important. This had not been foreseen when the CLAHRCs were first set up, which was part of what Hazeldean and Ashgrove in particular learned. This is a further illustration of how the starting position of the clinical–academic partnerships supported by CLAHRC funding affected on the success of their plans. In contexts where the relationships were not established and required time to be developed, creating credible links to a CLAHRC, which at this point was perceived by some to be an ‘academic machine’ (NHS clinician, Ashgrove, R4), was partly dependent on people in these linking roles being able to influence others about the value of CLAHRC. For those in health-care organisations, their response to the presence and work of these individuals was enhanced by perceptions of clinical credibility, which resulted in bridging to those in health-care organisations: ‘I think the [facilitators] have done a really good job of bridging the boundaries between the university and the NHS, not perfectly, but at a relationship level, they have, I think’ (leadership role, Hazeldean, R3).

The availability and targeting of resources in, for example, implementation and improvement projects and the development of tools released facilitative potential in that they created opportunities for engagement and collaboration. The collective generation of, for example, clinically relevant tools (e.g. VTE assessment form or CKD improvement guide) resulted in the mobilisation of knowledge, which had an impact on care processes and outcomes. These tools acted as boundary objects; that is, they had the potential to facilitate communication and common understanding between individuals and/or groups.

These tools and resources developed as boundary objects because of the way in which they evolved. The transition from boundary objects in theory to boundary objects in use was a function of their collective generation, amendment and tailoring for contexts and practical use through collaborative activity. This established their catalytic properties. Collective generation provided opportunities for end-users to attach meaning and resonance to these tools, which increased the likelihood of their being valued and used. Those that did not go through such processes operated in an inhibitory rather than catalytic way. In Hazeldean and Oakdown, where there had been greater attention and commitment of resources to implementation tools, activities and facilitator roles, there was more evidence of these types of generative processes resulting in tools with catalytic properties.

Over time, positioning and availability of resources and facilitative capacity and capability led to an accumulation of impacts. This was the foundation upon which further impacts were catalysed and accrued. Accruing impacts was a function of the time needed to establish relationships, priorities and work plans and then to commence activity. There was evidence of a shift from evidence of what could be described as conceptual and processual impacts, including building capability and capacity in the system for ‘doing’ implementation, to those were more direct or instrumental: actual changes to practice and service outcomes. Actual changes to practice were particularly evident in relation to the conduct of improvement projects. Both Hazeldean and Oakdown had used this approach as part of their implementation activity, and they accumulated a number of direct impacts within the funding period. Across all three CLAHRCs, their investment in boundary-spanning type roles had resulted in personal impacts, such as career development and opportunities for building individuals’ personal profiles.

Agendas and competing drivers: motivations to engage

Stakeholder agendas and competing drivers prompted different motivations to engage, resulting in a variety of understandings about CLAHRC goals and outcomes.

The CLAHRC was an amalgam of many different individual, group and organisational stakeholders, agendas and therefore potentially competing drivers. This context triggered different motivations to engage with the CLAHRC in the first place, and on a more sustained basis. This was evident across all three CLAHRCs and in the different motivations between stakeholder groups (e.g. practitioners and academics). These motivations were made visible through the views and opinions of stakeholders about the purpose of CLAHRCs, whom they were serving and what their expected outcomes would be. One manifestation of the mechanism of motivation was how ‘what’s in it for me’ was enacted through the incentives and rewards that were perceived to be available through engagement in a CLAHRC’s activities. Sustaining a CLAHRC may therefore be a function of how successfully they worked with different agendas, drivers and motivations while realising planned goals, in parallel to being responsive to issues that arose through continued interaction.

The service–academic divide had played out in a number of ways in the CLAHRCs that we studied and was foundational at the stage of bid development. This division was evident in the different reasoning of people and their motivations to engage, particularly where the CLAHRC was perceived as something separate. This separateness had created different degrees of belonging or buy-in to it as a concept and therefore as something people should or would want to engage with. The sceptics were mainly those working within health-care organisations, because they perceived the CLAHRC to be dominated by an academic agenda:

It was clear from the trusts that they were . . . a bit frustrated in what CLAHRC was doing in that it just seemed to have a pre-set agenda, a research agenda that it was pursuing . . . they had been expecting something significantly different from the CLAHRC . . . so they were a bit frustrated . . . they didn’t have a great deal of enthusiasm.

Leadership role, CLAHRC core team, Ashgrove, R1

This view was perpetuated by those researchers within CLAHRCs who, because they perceived they would be unable to conduct research that would be of an appropriate academic standard, did not show an interest in the implementation or more service-orientated agenda:

I don’t think it worked from a REF perspective . . . I would be interested to know how many people who have been involved in CLAHRC have been producing international-style papers with T2-style research.

Academic, Ashgrove, R4

These different agendas were evident in the discourse and behaviour of stakeholders because there was a lack of a shared value base, language and understanding. Where they (CLAHRCs and individuals within CLAHRCs) positioned themselves (conceptually and cognitively) fundamentally affected their level of engagement and therefore what they expected to get out of it:

it will be seen as an external organisation . . . It won’t be ‘this is an organisation we are part of’, it won’t be ‘this is a club I am part of’, it will be ‘this is an organisation I am aware of who does things for us because we give them money’.

Leadership role, Ashgrove, R4

Therefore, there were questions about what the CLAHRC is, and who ‘belongs’ to it, which did provoke some strong feelings and reactions. These issues also related to the conception of CLAHRC as a distributed model for the conduct and application of health research across a health community, and how its architecture and branding was managed to facilitate connectivity and potential engagement. In contexts where there was no history of collaboration, where there had been less activity around jointly setting priorities either at the bid development stage (e.g. Ashgrove) or through ongoing prioritisation mechanisms (e.g. Ashgrove and Hazeldean), the need to sell the benefits of CLAHRC to encourage or incentivise engagement was evident.

Tapping into the different motivations of stakeholders was a particularly useful mechanism; for example, selling the message to health-care organisations that ‘this is what we [the CLAHRC] can do for you to help you meet your CQUINs targets or your service improvement challenges’ (leadership role, CLAHRC core team, Oakdown, R4) did incentivise engagement. However, motivations were different between constituencies. For example, some academics did not engage because they believed there would be no benefits to them in terms of the requirements for the REF. However, others valued the opportunity to engage more closely with practice and practitioners, and take advantage of the roles and opportunities that were afforded by the additional resource of the CLAHRCs.

These findings provide further explanation of what we observed to be involvement along a co-operation to collaboration continuum, highlighting that stakeholders will have different agendas and therefore different motivations (‘what’s in it for me’), which need to be accessed if engagement is going to be both meaningful and sustained. This included the motivation to work across CLAHRCs, which was eroded by the call for CLAHRC 2, which set up an agenda of competition and resulted in a gradual withdrawal from each other:

Going into the second round of funding applications there was an organisational decision that we wouldn’t share very much about what we had learned and what we were doing and what we were planning . . . we were in a competitive environment . . . I think it potentially had a negative effect on the national programme as a whole . . . it wasn’t an environment that was very conducive to collaboration and sharing, it was more an environment which was very competitive.

Leadership role, Oakdown, R4

Fundamentally, these findings show that any exchange, including engagement, needs to result in mutual benefit because this acts as a reinforcing loop.

The mainly professional (whether that be related to academia or practice) agenda as a context for motivating engagement was particularly evident in CLAHRCs’ approach to PPI, which had been poorly conceptualised and therefore challenging to operationalise within the three CLAHRCs in this study. PPI in research and PPI in implementation had been conflated. Honest accounts were provided of the challenges in knowing how to engage patients and the public in their implementation activity: ‘we were a bit off the mark, I would say . . . we are stronger in research than implementation in PPI’ (academic, Oakdown, R4). These accounts showed that PPI tended to be conceived as an add-on rather than an embedded activity, and therefore it was operationalised on a project-by-project basis rather than by the CLAHRC as a whole. As a result, and despite representation of service users at a strategic level, PPI remained a mainly professionally led agenda. This was evident, for example, in academics making choices about what sort of projects would be appropriate to engage patients and the public in, the sort of aspects within projects that would benefit from their input and how that input would be made. In this context, PPI appeared to focus on surfacing the patient experience, focusing particularly on information resources for patients and the public, and was seen as the ‘right thing to do’.

Although this was not represented within our partner CLAHRCs, testing out our findings with a CLAHRC that had an early strategic intent around PPI, including dedicated funding, showed more activism and potential success around PPI. Where there was a history of leadership and progress with public engagement around health, it was possible to adopt a more bottom-up approach that linked PPI across knowledge production cycles and aimed to increase capacity and capability for engagement in implementation. While there was a consensus about the importance of PPI and a view that it was ‘work in progress’, the approach that had been taken related back to the positioning of PPI in the original plans (e.g. strategic intent and resource allocation) and therefore to the interpretation of the brief, which links naturally to how stakeholders’ agendas also played out.

Receptiveness to evaluation and learning: review and reflection

A CLAHRC’s receptiveness to evaluation and learning led to review and reflection, which resulted in adaption and refinement.

The openness of a CLAHRC’s mind-set and engineered structures (how connected its structures and processes were) to internal and external evaluation and learning prompted the potential for review and reflection, which over time resulted in thinking about and doing things differently. There had been a number of opportunities, occasions and events that had required (e.g. external evaluation), and in some cases forced (e.g. change to funding environment), CLAHRCs to make a response, in contrast to taking an ongoing approach to review, reflection and negotiation. Across all CLAHRCs there was a sense of learning over time and learning by doing, particularly as the funding for CLAHRC 2 was announced and they reflected on what they might learn from, and do differently in a new funding proposal for a refreshed entity.

Their capacity for learning and evaluation was mediated by the importance they attached to it and therefore the attention they gave it. The relative focus on evaluation and learning was a function of:

• the leadership approach (i.e. openness to critique and learning)

• the way that they had organised themselves (i.e. themes without communication mechanisms impeded connections and information sharing)

• the type of evaluation and review information that was valued and therefore collected (i.e. the data that could incentivise review and reflection).

Relationships and connections, which were facilitated or impeded through a CLAHRC’s social and engineered architectures, created the potential for information sharing, but not necessarily learning from information collected and/or shared. While all CLAHRCs had to collect metrics about their progress and achievements for the funder (e.g. grant income, papers published, examples of impact), this had been potentially restrictive and resulted in less attention to process and other types of impact:

but NIHR are one of the stakeholders . . . who put a particular performance management framework on what you do . . . you have to make a decision . . . whether you allow that to drive the design of your CLAHRC, which is what we did . . . I don’t really think, if CLAHRCs are going to achieve what they need to achieve with their partners, you can do that.

Leadership role, Hazeldean, R4

The original direction of travel of two CLAHRCs had been disrupted by events and had prompted a response. For example, the course correction taken by one CLAHRC following an external review demonstrated that openness to evaluation could result in adaptation by reallocation of both resources and attention to (implementation) functions. Another CLAHRC had to cut its cloth through having to review its programme of activities in the context of a reduction in resources, which resulted in radically adapting its original plans. However, there were also examples of CLAHRCs reflecting internally on how they might do things better or differently, particularly the way that they had structured and organised their activities.

There was also some reflection on, and acknowledgement of, their challenges with PPI (as findings show, PPI in research was conflated with PPI in implementation), with some additional activity to figure out how this might be approached differently. However, these efforts did not result in changes that were progressive and meaningful. Additionally, any fundamental changes to their activities and structures seemed to be thwarted by a lack of receptiveness to revising plans partway through the funding cycle within the performance framework that had already been set.

Structures and processes to facilitate review and learning within the various layers and components of CLAHRC were absent: ‘I don’t know that we’ve done enough on evaluating the whole approach’ (leadership role, Hazeldean, R4). This impeded the potential for demonstrating how a CLAHRC was something greater than the sum of its parts, that is a set of activities, projects and roles. The potential for meta-learning by scaling up within and across CLAHRCs was not realised and therefore the footprint left by them was not yet clearly visible.

Structures, positions and resource alignment: release of potential for collective action

Where structures, positions and resources are aligned, this releases the potential for, and unlocks barriers to, purposeful collective action for implementation, the successful delivery of projects and positive impacts on processes and outcomes.

In contexts where there was greater alignment between structures, including the way that the CLAHRC had organised its implementation activity, allocation of appropriate resources including people and expertise in implementation, and their positioning about knowledge mobilisation, greater potential for collective action was released and cognitive and practical barriers were more likely to be overcome. This resulted in positive impacts on processes and outcomes through the successful delivery of projects.

This CMO configuration relates to the need for things to come together to provide the conditions for a more successful outcome to be achieved. Successful outcomes – particularly direct impacts on patient outcomes – were a result of the accrued benefits of things coming together or lining up in a way that increased the effect. This particular explanation for successful project outcomes emerged over time, which highlights how temporality (once again) influences the development of collective action around implementation within collaborative entities, and therefore the realisation of any potential impacts.

The broader context of CLAHRCs determined the specific or more local conditions of the projects nested in them. It is clear from our findings that a number of factors, both tangible and less concrete, came together to create the environment and milieu which catalysed and fuelled the delivery of projects. Specifically, the alignment of vision, values, goals and purpose around both the nature of collaboration and knowledge mobilisation led to more impactful project work because this synergy released opportunities and resources, including social, financial and intellectual capital. Any synergy realised was as a result of a CLAHRC’s starting point (its positioning and therefore interpretation of the brief), its leadership, and its structures and processes, including potential for ongoing reflection and learning. Leadership structures and approaches were particularly critical to enabling alignment: ‘distributed so that is not only directive but shaped by principles . . . You know, there is some co-ordination, cohesion but it’s usually around the way we do things’ (academic lead, Oakdown, R4). Structures and processes which were more integrated between health-care organisations and HEIs, and less centralised within a CLAHRC, together with facilitative leadership, including the development and articulation of a shared vision, added to a facilitative context. Aligning understanding and expertise in implementation with the allocation of appropriate resources had an additive effect, enabling things to happen.

Potential was released in various ways including unblocking channels of communication, overcoming boundaries, providing space (cognitive and physical) and opportunities, adding legitimacy and enabling connectivity. Evidence of this release in potential was observed at project level through implementation projects and improvement initiatives, for example in Oakdown and Hazeldean, which had led successfully to an impact on patient outcomes and care processes. The greater the alignment between features and factors, the greater potential these projects had for successful outcomes. However, we also observed that some projects succeeded in the absence of alignment at a higher level within a CLAHRC, for example where the structure of a CLAHRC was perceived to inhibit collaboration and where leadership was centralised. Therefore, the success of projects at a local level was not always and consistently reliant on complete alignment. Successful outcomes from collective action reinforced synergy.

Summary

The final set of CMO configurations, which were developed, refined and tested over the four rounds of data collection, are summarised in Box 7.

The relationship these CMOs have to each other and in creating the potential for collective action on knowledge mobilisation is represented in Figure 13. This figure also demonstrates development and movement from the conceptual map or framework that we presented at the start of the project (see Figure 4) in that it begins to highlight some contingencies between the elements of the CMOs. This figure shows a path dependency, which starts with the position of stakeholders on key issues on collaboration, knowledge and implementation. These positions influence how knowledge mobilisation within the context of collaboration is both organised and operationalised. The degree of alignment between these positions and features determine outcomes. It is hypothesised that greater alignment leads to impacts that are more relevant and timely for stakeholders and services. The development and progress of implementation through collective action will be influenced by the collaboration’s approach to evaluation and learning and their response to any signals or events.

FIGURE 13.

Representation of contingencies between CMO configurations. –ve, negative; +ve, positive.

To identify and track the implementation mechanisms and processes used by Collaborations for Leadership in Applied Health Research and Care and evaluate intended and unintended consequences (impacts) over time

Undertaking a longitudinal study meant we were able to successfully track the journey of three CLAHRCs over time, including identifying their strategies and approaches to implementation. Being able to study CLAHRCs over time led us to identify the potential of a life cycle or ecology of implementation as they evolved and developed. The temporal thread was evident in their evolution, and in one site more of a revolution, around the implementation agenda. The life cycle of the CLAHRC, and more fundamentally the stage of development of the collaboration itself, provided the conditions for collective action around knowledge mobilisation. Individuals, groups and therefore the CLAHRCs went through a process of sense making. Over time, through engagement and reflection on events, meaning and understandings about CLAHRCs were constructed. In contrast to previous conceptualisations, this sense making did not necessarily result in a consensus about a shared identity or cohesiveness114,115 CLAHRCs were not born within a vacuum, and our findings indicate that CLAHRC-like entities need time to learn and develop,51 particularly in the absence of history50,116 or any pre-formative work. 16,54,73

Their ongoing formation and development, rather than reflecting the stages and phases that others have proposed (e.g. Centers for Disease Control and Prevention117), was more iterative and dynamic. Furthermore, their evolution was influenced by factors that were sometimes not in their sphere of control (e.g. changes to NHS structures and funding arrangements). Their response to such events was a function of their perspective on, and approach to, evaluation and learning, and their perceived capacity to adapt and adjust. More reflection and potential learning could result in greater potential to evolve within a shorter time frame. The 5-year funding period was both enabling (need to get on and do something) and constraining (direct impacts were difficult to realise).

The ebb and flow of the CLAHRC’s life cycle points to the notion of an ecology of implementation. Collaborations as well as implementation projects have lifespans in that they are conceived, live and potentially degenerate and/or transform in response to their particular conditions of existence. The complex relationships and interactions between actors (‘organisms’ in ecological terms) and their environments (including territories) create the dynamic in which both collaboration and implementation evolve.

As reported, a CLAHRC’s specific attention to implementation was in some part shrouded by its focus on fulfilling the remit around the conduct of applied health research. However, as described, we identified a number of different types of knowledge mobilisation operating within CLAHRCs. Overall, however, implementing home-grown research within the initial 5-year funding period remained an unattained aspiration. The predominant focus and most common mechanism for mobilising knowledge were through the use of boundary spanners. These individuals had varied functions, from training, sharing knowledge and linking people and groups together, to engaging in the facilitation of ‘evidence into practice’ activities and projects.

Perhaps unsurprisingly, given what is already known about the gap between implementation activity and direct impact on practice and policy, the direct impacts from CLAHRCs’ activity were slow to be realised. Service improvement activities appeared to be having an impact on service delivery, which was translating into patient outcomes (e.g. early detection). Additionally, we observed a number of different types of other effects of project-related activity, including perceived changes to thinking, knowledge, skills, attitudes and practice, and impacts on the personal and professional development of those involved in CLAHRCs, particularly those in boundary-spanning functions. Scaling up project-related impacts into an effect that was demonstrative of a CLAHRC’s ‘footprint’ was difficult for us to detect and for those in CLAHRCs to articulate. An unexpected consequence we observed was the tension and rivalry within a CLAHRC (e.g. internal competition for resources) and across the interface between CLAHRCs, which was made visible as speculation mounted about the potential of funding for CLAHRC 2. This element of competition resulted in reluctance to share and reduced communication: features that are the antithesis of collaboration.

To determine what influences whether or not and how research is used through Collaborations for Leadership in Applied Health Research and Care, paying particular attention to contextual factors

Our investigation was focused on how context influenced whether or not research was used in CLAHRCs. Specifically, realist inquiry focuses the investigator’s attention on context as a condition rather than a backdrop for action. In this way we were able to gain a detailed understanding and develop an explanation of how particular conditions in the contexts of CLAHRCs affected fulfilling the programme’s remit around the application of research.

Collaboration was expected to provide both the structure and the opportunity for developing a shared space or spaces in and around which knowledge mobilisation could occur. Sharing of both physical space(s) and cognitive space(s) was realised by the three CLAHRCs in this study to varying extents. Approaches to coproduction118 and engaged scholarship26 emphasise a positive link between stakeholder engagement and the production and implementation of knowledge. However, achieving genuinely shared space requires the blurring of epistemological, role and practical boundaries and therefore the relinquishing of power and influence held by individuals, teams and organisations, which is notoriously challenging. 119 As Orr and Bennett point out, politics and other ‘tricky issues’ arise from ‘co-producing research involving cooperative interactions between members of two communities that have distinct interests, expectations and priorities’. 120

Preceding conditions influenced the subsequent course and journey of the CLAHRCs. This included where they started from in their relationships with partners, including the presence or absence of a history of working together. These conditions determined how long it took to engage in meaningful collective action around implementation. Their interpretation of the brief in relation to the specific expectations about knowledge mobilisation in the context of conducting more applied research and building capacity and capability (the vision) played out in the way they engineered their structures and processes and in how resources were allocated.

The context of action was critical in that there was an interconnection and interaction of enabling and restraining forces that interlocked and had an impact on how each CLAHRC delivered on its implementation function. These interactions not only included actors but extended to interactions between the actors and context. Negotiation and renegotiation of a shared space in the development of genuine and collaborative action was explained by multiple contexts including:

• temporal (historical, longitudinal and living history of relationships and working together)

• cognitive (collective and individual differences and similarities about notions of collaboration, evidence, knowledge and implementation)

• emotional (thoughts and feelings of individuals and the collective – what people thought about the CLAHRC, how they enacted ‘what’s in it for me’)

• professional (epistemic, professional)

• physical (structures and processes, geography).

These contexts then acted and reacted so that they became more than a backdrop to action but coalesced to create the conditions and contingencies that explain relationships, activity and subsequent outcomes.

Governance arrangements were a condition or context that linked to different opportunities for connectivity and engagement. Collaborations that pay attention to structures, infrastructures and management are those that have the potential to facilitate the success of centres and people working together. 50,69,70 Additionally we found that distribution and use of resources, including financial as well as social and intellectual capital, was a precursor to a CLAHRC’s attention to implementation. A collaboration’s engineered social and aesthetic architectures provided both a tangible (e.g. organisation of activity/projects, resource management) and a less tangible (e.g. clarity around decision-making, buy-in and belonging) collaborative scaffold for aligning strategy, people and activity.

Given that CLAHRCs are networks of stakeholders, governance arrangements that facilitate connectedness and connectivity, particularly through face-to-face interaction, provided greater scope for creativity and for sustainable activity around implementation. This includes a network of actors who are systematically arranged and managed to pursue a set of activities under a collective goal around implementation. Therefore the flexibility of these arrangements and how they operate across all levels of the collaboration – from the project(s) to the ‘organisation’ or network as a whole – will help explain a collaboration’s ability to ensure appropriately resourced activity and the capacity to respond to wider issues and pressures as they arise. It has been suggested that an organisation’s ambidexterity, that is its ability to be aligned and adapt to demands, has been found to be a prerequisite of organisational survival and success,121 and arguably for its resilience too. The way in which concepts such as these might transfer to a ‘constellation of interconnected practices’122 such as CLAHRCs, is in their potential to explain how these networks evolve and then sustain themselves (or not). Walter et al. 123 observed that sustainable partnerships provide the conditions that allow researchers to better support users to test and implement research findings and encourage collaborative reflection beyond the knowledge production process and on to research use processes.

Leadership (designated and distributed style and approach) were a critical part of a CLAHRC’s governance arrangements and therefore vital to establishing the collaboration, and to determining and then enacting a vision around implementation. Research shows that a blend and alignment of designated leadership with distributed leadership has been shown to provide a necessary condition and mechanism for collective action around implementation. 16,113 It has been suggested that leadership within collaboration is concerned with making things happen – specifically, the formulation of the collaboration’s plan/policy and activity agenda. 76 The importance of leadership for successful change, innovation and implementation is reflected in existing theory and frameworks (e.g. Pettigrew and Whipp,124 Greenhalgh et al. ,16 Rycroft-Malone et al. 15) and was reinforced in this study.

As we observed, leaders contributed to shaping the context of collaboration through structure and agency. 125 A number of principles have been identified that include facilitating interorganisational collaboration demands of leaders, including inspiring commitment and action, leading as a peer problem solver, building broad-based involvement, and sustaining hope and participation. 126 Additionally, leaders need to attend to their personal style and approach, as the practice of leadership for collaboration demands power-sharing, practice-based leadership, systems thinking and being ‘managers of meaning’. 125 This resonates with our findings. In a context where there was more aligning of vision, structures, processes, people and resources through credible, authentic and embedded leadership, the collaboration seemed to be more robust, and there was a greater focus on collective action around implementation. Leadership roles, style and approach are the ‘oil’ that lubricates the system. Furthermore, a life-cycle view of collaboration, including the idea of ecology of implementation, suggests the need for regular renegotiation (e.g. arrangements, relationships, agreements) requiring a flexible approach that is tactical and strategic, and contextually situated.

The potential success of collective action in implementation appears to be at least in part a function of an alignment in organisational structures, processes and the reasoning of those in the collaboration. As Jagosh et al. 127 remind us, collaborations are not de facto synergistic but their success is predicated on some effort to align values, goals and purpose. More successful and impactful attempts at collective action in implementation were determined by the alignment of a number of features, including foundational relationships, vision, values, structures and processes (including the potential for greater learning and meta-learning), purpose and thoughts about the nature of the collaboration and knowledge mobilisation (including theory and approaches). Strategically and structurally the potential for alignment was vested in the leaders of the collaborations, and within projects and activities this was entrusted to individuals in boundary-spanning roles. Therefore the presence of both designated and distributed leadership at all levels appears to be important for alignment. Furthermore, Best et al. 25 suggest that large-system transformation in health care is enabled through alignment between top leadership and distributed leadership because this can reduce cognitive dissonance and facilitate integration between intraorganisational boundaries. Given this, it could be hypothesised that knowledge mobilisation within a collaborative context could be enhanced by creating opportunities for alignment across all the levels and corners of the collaboration in ways that facilitate synergy between structure and agency.

Within an ecological view of implementation, synergy has the potential to develop and build over time where successful outcomes from collaborative knowledge mobilisation activity provide reinforcement. Additionally, alignment has the potential to develop over time where there is attention to learning and evaluation with appropriate adaptation. 127 However, it is unclear if some degree of misalignment or tension within the implementation ‘system’ could potentially act as a form of catalyst for action, which could minimise the potential for entrenchment, habitual thinking and behaviour. 128 It is conceivable, for example, that alignment may stop being a catalytic mechanism if consensus and groupthink develop. Creating opportunities for renewal and refreshment through reflection, evaluation and learning may militate against potential stability versus stagnation.

To investigate the role played by boundary objects in the success or failure of research implementation through Collaborations for Leadership in Applied Health Research and Care

The CLAHRC model was predicated on an assumption that providing resources and an architecture would enable the research and practice community to work more closely together – to close the metaphorical ‘know–do’ gap. Within this networked model of collaboration we observed both the creation and blurring of boundaries. The CLAHRCs’ architectures and different perspectives and positions resulted in the construction of a number of different types of boundaries, including:

• organisational, between different organisations and divisions/departments within institutions

• epistemic, between the different philosophical perspectives about knowledge and its mobilisation

• semantic, between people and groups because of different understandings about meaning and language

• professional, between different groups in different contexts

• geographical, as a result of the physical geography of the CLAHRC, the CLAHRC network and NHS geography.

Collaborations for Leadership in Applied Health Research and Care have been described as an example of an institutionalised ‘constellation of interconnected practices’. 129 They comprise numerous boundaries and therefore territories that need to be negotiated and/or bridged if meaningful action is to take place. Furthermore, demarcated boundaries between the ‘worlds’ of researchers and practitioners, each with their different epistemic cultures, can result in communication challenges and tensions. Co-ordinating and sharing knowledge across boundaries have converged around three primary perspectives,130,131 which also resonate with our findings: information processing – knowledge is viewed as objective and therefore needs to be codified, stored and retrieved across people and contexts; cultural – knowledge is embedded within members of the community and therefore shared through creating a shared language and negotiated through the use of boundary objects and/or through boundary spanners; and political – knowledge is rooted in the accumulated know-how of the community and shared through the use of different types of shared communicative devices. Where boundaries were blurred and knowledge sharing and/or implementation occurred this was as a result of the creation of boundary objects and through the agency of those in boundary-spanning roles, including facilitators.

Van de Ven and Johnson132 describe ‘Arbitrage, dialectical inquiry and constructive conflict management among researchers and practitioners’ as central to engaged scholarship. These processes require active management and skilled facilitation, and therefore investment in a network of actors across the collaboration as linking and bridging agents. If people in boundary-spanning and facilitator roles share an understanding of both collaboration and implementation, they have the potential to manage activity, enable interactions, develop shared spaces and negotiate tensions and conflict. Tools to include in their armoury include their skills, credibility and opportunities to collectively develop ‘artefacts’ that have the potential to become boundary objects, to which people in different territories and across various boundaries can attach meaning, resonance and value. We found that what activated boundary objects in theory to be realised as a boundary objects in use was related to how they evolved. Those objects that transformed from objects in theory to objects in use are similar in terms of their collective generation. The creation of, for example, different practice tools through meaningful collaboration provided an opportunity for different stakeholders to come together and engage in a process that involved integrating local evidence and experience with external evidence from guidance. The process of collective design made the artefacts meaningful to different stakeholders in different groups and increased their potential to be used in practice. Therefore, it could be predicted that the potential of boundary objects to mobilise knowledge would be enhanced if developed in contexts in which there is good-quality collaboration, with planned opportunities for joint creation and design among stakeholders.

To determine if and how Collaborations for Leadership in Applied Health Research and Care develop and sustain interactions and communities of practice

The potential of the CLAHRC context to create opportunities to develop and sustain interactions and communities of practice was fulfilled to varying extents. Communities of practice can analyse practice and solve practice-related problems and encourage mutual learning and the sharing of knowledge. Given this, CLAHRCs had created opportunities for groups and teams to come together for sharing knowledge and expertise, but to a lesser extent for learning. Interactions were facilitated through opportunities to engage in specific projects and by those in boundary-spanning roles who were perceived to be credible and helpful. However, their potential was mediated by some role confusion and by the context in which they were operating. In this way, project communities were created and sustained for the life of the project. We do not know whether or not these interactions will be sustained beyond the life of projects and the initial CLAHRC funding period.

Engagement of stakeholders was contingent upon incentives, benefits and/or rewards individuals and organisations perceived they would reap from CLAHRCs. Therefore, the levers or motivations for engagement varied over time so the success of implementation activity within a shared space was also mixed. Different theoretical perspectives from organisational theory help explain potential motivations, which include, for example, learning and communities of practice. 133

The notion that communities of practice would work together on ‘something’ is a central element of much of the literature. 134,135 However, developing a shared understanding of what that ‘something’ is not a one-off event or exercise; it takes time to develop and involves ongoing negotiation and renegotiation with participating organisations and individuals. 70,76 Working on a shared endeavour helps to build group identity and integrate individuals while still allowing them to retain their identity and links with their organisation of origin. 136 It is the interaction of individuals and active collaboration137 that creates group identity as individuals create meaning through sense making. 138 Within the current study we observed this happening to some extent through specific projects, such as those that employed more interactive methods, for example improvement projects. This supports the idea that the topic or subject area around which a collaboration is focused is also important for its success. 51,72

However, the mediating issues of power and, particularly, competition are neglected in the communities-of-practice literature. The motivation to engage in these shared endeavours may build over time as trust is developed through the development of relationships and ties, which may turn into reciprocity. The need to navigate different types of boundaries, including the geographical boundaries that precluded colocation and close proximity between individuals and groups, limited the potential for interaction and therefore the development of communities of practice. Equally, fundamental epistemic differences between groups were difficult to resolve and were challenged by different motivations to engage in joint enterprise and by differentials in power and authority.

Many of the discussions about interaction and engagement make the assumption that members are getting (or perceive they will get) something from being involved in a community of practice. Further, individuals and organisations may be motivated to engage in collaborative activities that minimise transaction and maximise opportunity costs. Therefore, if researchers and practitioners are going to work together productively over time there needs to be recognition of scope for bidirectionality in benefits and rewards, which need to be made visible for individuals as well as organisations.

Sustaining interactions and communities of practice is, at least in part, likely to be related to the capacity of a collaboration to pay attention to evaluation and learning in an ongoing way. Our findings show that there was evidence of within-project evaluation (and potential learning), but structures and processes that paid attention to systematic evaluation and learning at a higher level and between CLAHRCs was absent. Organisational learning theories suggest that the ability of an organisation to learn is a characteristic of an adaptive organisation, that is one that picks up signals from its internal and external environment and adapts accordingly. 139 The ability to pick up signals requires deliberate attention to the establishment of feedback loops in which evaluation that blends hard and soft metrics at different levels of the system could both incentivise and reward engagement and activity.

Collaborations for Leadership in Applied Health Research and Care were created to catalyse a step change in the conduct and application of high-quality research in the English NHS within regional contexts and health priorities. Their ability to engineer this could be enhanced by greater attention to systems and processes that accumulate and use (reflect on and adapt appropriately) the knowledge from the experience of individuals, teams and organisations that are part of their distributed network. While there was some evidence of this, their own reflections provided an honest account of how they could have ‘done this better’ (leadership role, CLAHRC core team, Oakdown, interpretive forum), particularly in relation to how CLAHRCs could have combined and learned from a collective intelligence. At this stage, therefore, it is difficult to describe how CLAHRCs were greater than the sum of their parts (i.e. projects, activities and people).

It could be hypothesised that implementation within collaboration may be enhanced if a continuous improvement approach to the collaboration and its component activities is adopted. Paying greater attention to both the structures and mechanisms for ongoing reflection and learning would also increase the potential for meta-learning.

To identify indicators that could be used for further evaluations of the sustainability of Collaboration for Leadership in Applied Health Research and Care-like approaches

Our findings provide a reference point for future evaluations of CLAHRC-like approaches to the mobilisation of knowledge.

These contribute to a potential ‘re-usable conceptual platform’ (p. 86)85 about how implementation within collaborations might work. As a middle-range theory it provides a starting point, some co-ordinates and the conceptual ground for any future evaluation and learning that is cumulative. We also provide a starting point for those at the beginning of the journey in creating the conditions for collection action for knowledge mobilisation, including paying attention to:

• surfacing and articulating the different perspectives of all stakeholders around collaboration, knowledge and implementation, including engaging in pre-formative activity and continued dialogue

• the organisation and operationalisation of the collaboration, particularly around the structures and processes that will be needed to bring people together, and how activity will be resourced and managed

• setting up opportunities and mechanisms to facilitate the bridging and brokering of boundaries, the employment of people in facilitator-type roles

• purposefully creating spaces (physical and cognitive) for sharing and learning

• tapping into the motivations that different groups, individuals and organisations will have for engaging, and using these to both incentivise and reward them

• resourcing and mobilising formal and distributed leadership in a way that galvanises and motivates both the collaboration and its activities for knowledge mobilisation.

Implications for implementation practice

Collaboration does not appear out of a vacuum; therefore, attention needs to be given to pre-formative work in which stakeholders have the opportunity to develop relationships and established shared goals. In the absence of pre-formative work, implementation strategies that rely on organisational collaboration should allow time, space and other resources for the creation of partnerships between individuals and teams. Activity around developing relationships and collaboration should be balanced with building in opportunities to achieve some ‘quick wins’ early on in the collaboration’s life cycle. These should be relevant and meaningful to stakeholders, and could therefore be linked to relevant incentives and policy/practice priorities for maximal impact.

Over time, partnerships should use, or allow the creation of, a variety of boundary objects that provide a focus for collective effort around the different interfaces within implementation, for example:

• professional boundaries – patient stories, clinical guidelines

• organisational boundaries – governance and reporting frameworks, learning events and artefacts

• epistemological boundaries – mid-range theories that provide sufficient specification and abstraction for action, and learning across implementation programmes.

Our findings show that the potency and catalytic action of boundary objects is born out of the collective and deliberative processes of their development, which includes involving the right stakeholders.

Reflecting the multiple approaches to implementation observed within our data, organisations contributing to CLAHRC-like programmes/initiatives should provide opportunities for the collaborations to develop a shared vision and common language about implementation. Our findings show that this is best achieved through opportunities for face-to-face interaction between relevant stakeholders, including patients and the public. Implementation models and frameworks may be effective boundary objects in this respect by, for example, providing a useful heuristic around which to begin conversations.

In addition, engaging with multiple stakeholders in the systematic identification of priorities for action on implementation can help enhance the relevance of this vision, and increase organisational buy-in to the collaboration. Ensuring synergy between the vision and the governance arrangements will provide the foundation on which participating organisations’ expectations and commitments, including funding arrangements, can be managed.

Organising implementation activity in cognate themes or programmes provides a focus that has currency with clinicians, managers and other stakeholders. Organising activity within clinical topics was a typical approach used by the CLAHRCs in this study. However, with this approach there is also a danger of working in silos, so a theme-based approach should be balanced with the adoption of strategies that allow cross-theme or cross-programme communication and working to increase access to implementation expertise, and to share learning. The potential for cross-theme working should also be built in to governance, including reporting arrangements. Where this was working well in one of the CLAHRCs, we observed greater opportunities for ongoing review and learning.

Leadership has been identified within the implementation literature as critical for creating the conditions for success. Our findings show that a more distributed approach to leadership within CLAHRC-like programmes appears to be most effective in making strategy around implementation visible. Investing in individuals not in designated leadership roles (such as boundary spanners) can also create some synergy between the different levels and corners of the collaboration.

In this study, implementation was achieved through resource allocation and therefore investment in the establishment of roles to fulfil facilitation and boundary-spanning functions. Generally, people in these roles were successful, although attention needs to be paid to their skills, experience and credibility. We found that credibility was not necessarily related to seniority, but was more about their currency within the context in which they were working. Our findings indicate that, when boundary spanners do not have experience of, and credibility within, a health service setting, their impacts can be dampened. Secondment of clinical staff from service delivery to boundary-spanning roles appears to generate buy-in to the collaboration, and has the potential to increase capability within the system for implementation. Furthermore, clarity about role descriptions, ongoing development and succession planning needs to be built into any organisational investment in facilitation/boundary-spanner programmes.

There is a very limited evidence base for how to involve patients and other lay stakeholders in implementation. Findings from data collected in a CLAHRC that was not one of the three forming the main focus of this evaluation showed that its success in involvement was a result of building on a long history of user-led research. This implies that, where possible, implementation and involvement activity should draw on existing lay involvement initiatives and networks. Furthermore, patient experience should be viewed as a credible form of evidence for implementation.

Individuals and organisations are motivated by different incentives and our findings show that the ‘what’s in it for me’ factor was strongly linked to engagement in CLARHC activities, particularly implementation. Therefore, ensuring that clinicians and academics who are expected to engage in CLAHRC-like initiatives can transparently map their engagement onto relevant professional and career development frameworks will generate buy-in, and ensure that expectations and experiences can be more effectively managed. Engagement in this context should include both project-based activities and more formal capability-building approaches such as embedded doctoral programmes. Similarly, aligning implementation activity where possible around policy and organisational incentives (e.g. QOF) will also increase the relevance and impact of drivers for engagement in implementation.

Minimising any unintended consequences of competition for external funding may be achieved through the sharing of learning about what works in implementation. Virtual repositories of products that could be developed within a CLAHRC as well as ones that are shared across the CLARHC network, such as implementation reports and other artefacts, may provide a platform to facilitate sharing and learning.

A combination of internal and external review has provided some opportunity for learning and a re-evaluation of implementation activity. However, there is still uncertainty about the CLAHRC footprint. Therefore, there are implications about balancing different types of performance metrics, which focus on process as well as outcomes. Learning and research should focus on the core underlying mechanisms of change that are associated with implementation activity. The mechanisms and their contingencies embedded within our programme theory could provide some direction. It would also be important to ensure there is capacity and capability within the system to ensure the potential to scale up from individual project-level metrics to the collaboration, and to the network of collaborations as a whole. Furthermore, our findings imply that it would be useful to identify the different pathways to impact early on in the collaboration’s life cycle. This would provide the platform upon which to develop a prospective evaluation strategy and for tracking impacts as they occur.

In summary, creating the conditions for collection action for implementation requires paying attention to:

• surfacing and articulating the different perspectives of all stakeholders around collaboration, knowledge and implementation, including engaging in pre-formative activity and continued dialogue

• the organisation and operationalisation of the collaboration, particularly around the structures and processes that will be needed to bring people together, and how activity will be resourced and managed

• setting up opportunities and mechanisms to facilitate the bridging and brokering of boundaries, the employment of people in facilitator-type roles

• purposefully creating spaces (physical and cognitive) for sharing and learning

• tapping into the motivations that different groups, individuals and organisations will have for engaging, and using these to both incentivise and reward them

• resourcing and mobilising formal and distributed leadership in a way that galvanises and motivates both the collaboration and its activities for knowledge mobilisation.

Implications for implementation research

Organisational commitment to implementation should be structured to exploit opportunities to advance implementation research by paying attention to two key areas:

1. identifying opportunities for capability building by, for example, embedding doctoral training programmes

2. paying attention to the advancement of theory in the development and evaluation of implementation programmes.

As a relatively young field, implementation science provides space for a number of different epistemological positions, and their associated methodologies and methods. Explanatory, mid-range theory of what works in implementation can provide a potential middle ground around which these different contributions can meld. Paying attention to the role of theory and how this plays out in implementation efforts (theoretical fidelity) could provide some useful insights into how to achieve a balance between practical relevance and rigour.

Our data indicate a variety of drivers for implementation operating in different personal, project, team, programme, professional and organisational contexts. Research that further investigates the importance of alignment between these, such as the balance of collaboration, rivalry and competition, is warranted, including a focus on the expected and unforeseen consequences.

Findings demonstrate that there was limited attention to particularising implementation strategies to circumstances. There is still much to learn about how implementation interventions and approaches are tailored to and in different contexts, including how context is assessed and judgements made about selecting and then implementing different strategies.

Although we found that a distributed approach to leadership for implementation was important, further investigation of the influence of different types of leadership and power in implementation over time, how they are constructed and manifested, and their influence in different implementation contexts would be valuable.

Theory comes in many guises, and this study has shown the potential of combining explicit theory with the inductive development of a middle-range theory in studies about implementation processes and outcomes. We advocate the need to pay greater attention to theory use and development within future implementation research efforts.

Although it is a longitudinal study, we had limited opportunity to observe medium-term consequences of implementation activity within CLAHRCs. Further research could usefully investigate a more extended life cycle of implementation, focusing on the cues for both the creation and the refreshment of organisational collaboration on implementation over a longer time. The second wave of funding for CLAHRC might present some opportunities to do this research.

The research team and CLAHRC participants observed that there had been a lack of attention to scaling up of successful implementation approaches/projects. There is the potential, therefore, to study how best to scale up from individual projects/initiatives, and the facilitators and barriers to this in the context of a distributed network structure.

Element in evaluation framework

Within this project, what are the gaps between knowledge and practice that you are trying to close?

• How were these identified?

• Had anything been tried before – tell me about the history of the project?

• How was it prioritised (who decided) or what made it a priority? Was it influenced by particular organisations and people’s agendas? Was there any PPI involvement in this?

• How does this fit with the CLAHRC implementation strategy?

• How does it link to other initiatives within or outwith CLAHRC?

What activities are planned or undertaken to close the gaps?

• What has influenced the design of the project?

• What has worked and why and has there been any learning from the project? How is this fed back to the CLAHRC? Are there any impacts/outputs that have led to things being done differently?

Who will be/is included in the project and why (who are key stakeholders and why?)

• In what ways have people worked together?

• What has helped/hindered?

How has the Collaboration for Leadership in Applied Health Research and Care contributed to/influenced initiation or progress of the project or activities within it?

• Access to resources (people/money/others).

• Use of different types of knowledge/expertise/evidence – who, what and why privileged and how are they integrated/used?

What from the Collaboration for Leadership in Applied Health Research and Care contribution has worked and why – how do you know/how will you know? What will ‘success’ look like? (Contribution and consequences)

• Has this changed over time and if so in what ways?

• Has there been any shift in barriers and enablers?

On the basis of this project how has/will capacity and capability for implementation changed or how do you anticipate it will change?

• What opportunities has the CLAHRC provided?

• Who has benefited and in what ways?

• What levels of impact have you observed/captured and how do you/will you know? Levels – individual, organisational, public, etc.

Anything else about the project setup that you want to mention?

Your role in Collaboration for Leadership in Applied Health Research and Care

1. Can you describe your role, what sorts of things you do or are involved in?

   1. Tell me about some of the implementation projects that you’ve been involved in . . .

   2. Can you tell me a little bit more about communication and what sorts of things were helpful in opening up a dialogue?

2. Shared understanding

   1. Can you tell me about an implementation project that you’ve been involved in when it became clear that people did not understand each other?

   2. And one when everyone understood each other?

   3. Was there anything that this understanding hinged on? For example was there a specific moment when it became clear that everyone understood each other, or was it a gradual process?

   4. How was this understanding reached?

3. Knowledge exchange

   1. Can you describe an instance when it became clear that knowledge had not been shared been those involved in implementation work (for example a knowledge gap between different stakeholders that had not been identified or met)?

   2. Can you tell me about a time when you’ve shared knowledge with other people during implementation work?

   3. What was the outcome?

   4. How did this help or hinder?

4. Collaboration – working together

   1. Can you describe an example of when you worked in partnership with other people and groups involved in implementation work?

   2. Can you think of any factors that led to the success of this collaboration?

   3. There are different levels of collaboration across different projects, for example the role of patients and the public varies in some projects compared to others. Is there a ‘bottom line’ for working together, for example what degree of collaboration is good enough in terms of implementation?

5. Boundaries and crossing

   1. We are interested in finding out how boundaries are crossed when different groups work together to get evidence into practice through CLAHRCS, such as those between healthcare services and higher education. Can you tell me about some of the boundaries that you have encountered?

   2. What sorts of things have been useful in crossing boundaries? Are there any things, ideas, approaches or strategies you’ve found helpful and why?

   3. How would you describe their role when boundaries are crossed?

6. Cross-boundary relationships

   1. Part of boundary crossing is about being able to establish rapport and develop relationships across different boundaries. How have you gone about establishing rapport across the different boundaries you work across?

   2. How have you maintained these relationships?

Recap and summarise.

Anything else participant would like to add that hasn’t been covered in relation to implementation?

Thanks.

END.

Collaboration to enhance the use of knowledge in practice: a workshop for sharing and learning

Facilitated by Professor Huw Davies and the ECLIPS team.

Held in Radisson Blu Edwardian, Free Trade Hall, Peter Street, Manchester M2 5GP.

This workshop is part of an NIHR funded project (HS&DR 09/1809/1072).

Project details: www.nets.nihr.ac.uk/projects/hsdr/0918091072.

As can be seen, the day took the form of an interactive workshop with a short presentation (below) of the high-level emerging findings (participants had been asked to read a published paper prior to the meeting) and then small-group work to check out the resonance of these with participants. This ended with a plenary session, with small-group feedback to the whole group.

The afternoon session provided participants with a list of potential factors to take into consideration when developing collaborations and asked them to consider in small groups which were the most and least important ingredients in developing a collaboration to enhance and facilitate knowledge use.

Group discussion 2

Here are some of the characteristics of CLAHRCs’ approach and ways of working in facilitating implementation. If you were to start again in building organisational collaborations to facilitate the implementation if evidence, which of these would you give most attention to and why?

• Approach to implementation (e.g. links with research, responsiveness vs. fidelity).

• Vision (e.g. commonly understood, shared, bought into).

• Impacts (what was expected to be important/any shift?).

• Resource flow (e.g. targeted, flexible).

• Leadership (e.g. centralised, distributed).

• Brokering and bridging processes and people (including roles and skills).

• Incentives and incentivisation.

• Learning, evaluation and meta-learning (including capability and capacity building).

• Engagement (e.g. quality and nature of relationships, over time).

• Organisations.

• Teams and people.

• Patient and public involvement (e.g. starting point, purpose and integration).

• Flexible structures/architectures (including governance).

This also ended with a plenary session, with small groups feeding back to the whole group.

Feedback from both sessions was positive and attendees related that the findings presented resonated strongly with their own experience of collaborative working to enhance knowledge use.