Getting the most out of knowledge and innovation transfer agents in health care: a qualitative study

Academic Health Science Collaborations, Partnerships and Networks

Following the Carruthers report,27 Academic Health Science Networks (AHSNs) have brought most NHS organisations in England into collaboration with universities. In England, 15 AHSNs were licensed in March 2013. AHSNs are tasked with aligning ‘education, clinical research, informatics, training and education and healthcare delivery’ and improving ‘patient and population health outcomes by translating research into practice and developing and implementing integrated health care systems’. 28 Like their predecessors, Academic Health Science Collaborations (AHSCs), the central aim of these collaborations is ‘knowledge mobilisation, rather than research production’. 22 As designated in ‘Innovation Health and Wealth’27 and the ‘Strategy for UK Life Sciences’,29 AHSNs are a systematic delivery mechanism for the adoption and spread of innovation at pace and scale through the NHS. The networks are designed to foster collaborations between academia, industry and health service, and shared aims include diffusing innovation, putting research into practice, and promoting economic growth. 30 They are expected to work closely with industry and funders to bring together researchers, managers, patient groups, planners and policy-makers.

Compared with England, infrastructure targeting knowledge mobilisation and innovation is not well funded in Wales. However, the sole AHSC in Wales has identified knowledge transfer as a priority. The AHSC formed three regional hubs – in the north, south-west and south-east of Wales. In their initial period, these hubs attracted small-scale funding from Health and Care Research Wales [formerly the National Institute for Social Care and Health Research (NISCHR)], but this ceased in 2014. The South East Wales Academic Health Science Partnership (SEWAHSP) became independent and continued to operate. SEWAHSP has two key objectives: (1) to increase the speed and quality of ‘translational’ research; and (2) to promote and support innovation in south-east Wales. 31 A national Task and Finish Group also made recommendations to Health and Care Research Wales on knowledge transfer policy. 32

Collaborations for Leadership in Applied Health Research and Care

Descriptive studies focused on how research does make it into practice point to the importance of close interpersonal relationships between researcher and user. 33–35 This has been built into interventions that seek to develop opportunities for both parties to link and engage. In England, these include programmes such as the National Institute for Health Research (NIHR)’s Collaborations for Leadership in Applied Health Research and Care (CLAHRCs), which were designed to address what Cooksey1 termed the ‘second gap in translation’, related to the failure of new ideas and tools to reach practice. CLAHRCs are serviced-led partnerships that aim to contract high-quality applied health research, implement findings and increase NHS capacity to engage in research. 36–39 In 2008, nine CLAHRCs were established and a second wave extended the CLAHRCs reach with tapered funding (from NIHR) for 13 CLAHRCs. This is an indicator of the perceived success of the programme.

The CLAHRCs are the most established and evaluated programmes in the UK. 39–46 The reports to date highlight similarities and differences between structural and content features of the CLAHRCs and point to early successes and challenges. For example, successes include strengthened networks and relationships;39,44,47 new organisational roles that ‘make sense to professionals’; collective action to improve practices;48 and creating a culture of reflection and learning. 47 More specific successes have also been reported. For example, the CLAHRC for Greater Manchester achieved success in improving patient services in chronic kidney disease. 41,49 Although such results demonstrate the impact of CLAHRCs and how the collaborations can change the approach of organisations for the better,39,50 it is very difficult to demonstrate a causal effect given the complexity of what they are and what they are trying to achieve. Walshe and Davies22 are more circumspect and conclude that ‘promising lessons’ can be distilled from the collaborations in England, which, among others, include ‘the development of organizational capacity in knowledge mobilisation’. Currie et al. 43 usefully summarise key areas of uncertainty for CLAHRCs, which include the problem of metrics. They note the following uncertainties:

The balance of activity between research and implementation; whether research should be clinically or implementation focused; appropriate metrics for CLAHRCs; whether CLAHRCs should orientate towards their academic or NHS partners; and whether CLAHRCs should focus upon individual behavioural or organizational/system level change.

They argue that the dominant approach is research focused, fixed on changing individual behaviour rather than ‘wider scale organizational and system level change’, as favoured by those from a social science tradition. 43

Knowledge brokers

Embedded within the concept of knowledge mobilisation are the roles of knowledge broker and boundary spanner. 51–53 Roles vary,42,54 but the essential feature is that they facilitate engagement between research and practice. 55 With the aim of improving the transfer of knowledge and innovation, knowledge brokers seek to close knowledge gaps and foster knowledge-responsive capacity and culture. 5,56–59

To facilitate knowledge mobilisation, many CLAHRCs used knowledge brokers, variously named. 22,60 For example, in the first round of CLAHRCs funding, the Cambridgeshire and Peterborough CLAHRC had a fellowship programme for clinicians, health- and social-care practitioners and managers to work alongside researchers; the Nottinghamshire, Derbyshire and Lincolnshire CLAHRC funded35 ‘diffusion fellows’ attached to their research projects. 61

The NIHR Service Delivery and Organisation (SDO) Management Fellowship programme provided another example, and one aimed exclusively at managers; an evaluation showed benefits from the interactions between the fellows, their NHS colleagues and research teams, but also revealed challenges in maximising those benefits for the workplace. 62 The NIHR SDO scheme was later merged with the NIHR Health Services Research programme to create the NIHR Health Services and Delivery Research (HSDR) programme.

As knowledge broker roles grew in number and type across the UK, an interest group formed in 2014 looking at fellows in the system. Several organisations, including the Health Foundation, NHS Education for Scotland, NHS Improving Quality, NIHR, and Universities UK, were involved in early data-gathering exercises to understand the characteristics of the wide range of fellows and fellowship programmes that exists across the health and care system. This exercise culminated in a 1-day event, ‘Fellows Connect’, bringing together quality improvement (QI) fellows from across the UK to share experiences. 63 At the same time, Berwick’s report on ‘Improving the safety of patients in England’ recommended a ‘national system of NHS Improvement Fellowships, to recognise the talent of staff and improvement capability and enable this to be available to other organisations’. 64 This resulted in the creation of an initiative called ‘Q for Quality’, led by the Health Foundation and supported and cofunded by NHS England, connecting people skilled in improvement across the UK. The Q initiative aims to grow to be a community of thousands of people: patient-facing front-line staff, managers, researchers, ‘patient leaders’, policy-makers and others in order to accelerate improvements to the quality of care. 65 Together, these recent developments illustrate the interest and also the investment by national organisations in the UK in maximising the potential of knowledge brokers to improve the quality and safety of health care for patients.

Notes on the literature search

This review updates and builds on work previously carried out by Bullock et al. ;66 therefore, literature searches for the preparation of the current document were limited to publications post 2010. A broad search was carried out on Web of Science, PubMed, Ovid MEDLINE, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCOhost and Google Scholar^™ (Google Inc., Mountain View, CA, USA) using appropriate forms of the terms, ‘knowledge AND transfer AND healthcare’, ‘knowledge’ AND (transfer OR translation OR mobili*ation) AND healthcare’, ‘innovation AND healthcare AND implementation’, knowledge AND (transfer OR exchange OR mobili*ation OR intermediatr* OR boundary spanners), ‘knowledge AND broker OR intermediary AND healthcare’, and ‘CLAHRC’. In addition, we sourced earlier papers from the citations of relevant papers and were vigilant for notifications of papers/reports as they were published. We complemented the electronic search by hand-searching two key journals (Implementation Science and Journal of Health Services Research and Policy) and searching the NIHR Journals Library of completed projects (www.journalslibrary.nihr.ac.uk). Grey literature relating to KIT policy in England and Wales was also reviewed (see Appendix 1).

Knowing knowledge

Knowledge is perhaps the most easily grasped of our terms, but the most difficult to define. Some authors have classified knowledge according to the degree of analysis or inherent conceptual complexity. 69,70 Furthermore, literature on knowledge transfer is not narrowly limited to the transfer of facts to answer ‘how’ questions. Rather, although knowledge in this context is seen to include facts and information, importantly, it is also recognised as being about understanding. Knowledge in this sense can be both theoretical and practical, derived from education and experience. However, it is useful to illuminate the interpretation of terms, as they embody implicit assumptions about how knowledge may be transferred, exchanged and mobilised. The different terms used are associated with different concerns and values, and these have practical consequences. Conceptualising knowledge as empirical information, facts or data decontextualises and commodifies it as something that can be ‘moved around’. 4,71 Alavi and Leidner,72 writing about the conceptual foundations of knowledge management, describe the relationship between knowledge and values, experience and context. They explain how knowledge ‘originates and is applied in the minds of knowers’ and how in organisations ‘it often becomes embedded not only in documents or repositories but also in organizational routines, processes, practices and norms’. 72 This quotation raises the distinction between explicit knowledge, written and recorded in documents, and the implicit or tacit knowledge held by individuals, often without awareness of it and revealed in organisational customs.

Related to the tacit–explicit dimension of knowledge is whether it is understood as individual or social. 72 The distance between tacit (residing in the individual, difficult to transfer) and explicit knowledge (socially and organisationally located) underscores the challenge of identifying, articulating and transferring individually held knowledge. 73–76 Szulanski77 also describes how the ‘stickiness’ of knowledge can hamper its movement, and distinguishes different points at which stickiness is important, including initiation stickiness (which may be affected by competing priorities, for example) and implementation stickiness.

These issues are relevant to knowledge transfer and innovation, as they define what counts as knowledge, and influence how and if it can be transferred. A study of knowledge transfer necessarily gives greatest focus to explicit knowledge, and academic research in particular.

Knowledge and evidence

One issue that is particularly important in the health-care context is the relationship between knowledge and evidence. Knowledge and evidence are contested concepts. In health-care literature, knowledge is often synonymous with evidence and aligned with the principles of evidence-based medicine. Innvaer78 notes that a ‘call for evidence-based [decision-making] is also a call for the use of scientific methods in data collection and in the validation of information’. However, in health care, as well as evidence of effectiveness derived from traditional randomised controlled trials, evidence also needs to encompass feasibility, acceptability and appropriateness. 79

The implicit position of the NIHR,80 in relation to this field of inquiry, is complex. In the commissioning brief for this study, they noted the use of various terms and chose to adopt the term ‘innovation and knowledge transfer’. However, this did not appear to be associated with limited positivistic interpretation of research evidence, and, earlier, they recognised that ‘engagement with research is socially and organisationally situated and heavily dependent on local context’. In this interpretation, knowledge is socially situated, generated by a number of participants and methods81 and intertwined with practice. 82 It allows for the idea that knowledge can be coproduced and co-owned, and recognises the importance of tacit knowledge associated with organisational norms and customs. 72 Likewise, in the Promoting Action on Research Implementation in Health Services (PARiHS) framework,3 in addition to research, evidence includes ‘professional craft knowledge, patient preferences and experiences, and local information’. Harvey and Kitson83 have recently introduced the i-PARiHS (integrated PARiHS) framework. The ‘i’ stands for integrated and reflects how ‘evidence is incorporated within the broader concept of innovation to reflect the dynamic and iterative way in which knowledge to inform practice is generated and applied’. Neither of these definitions fit well with more formal definitions of evidence.

For clarity, we would prefer to hold the two terms as conceptually distinct, although connected, using the term ‘evidence’ to relate to a sort of knowledge defined by the way it was generated. Yet it is imperative that we use both terms as they are applied by the participants in the study in order to understand the terms and their significance from their perspective. Therefore, knowledge transfer will include forms of knowledge as relevant to participants, not simply the transfer of research findings from the positivist tradition.

The Research Supporting Practice in Education84 group at the Institute for Studies in Education, University of Toronto, has devised a potentially useful set of questions that help to clarify different aspects of knowledge and knowledge use. These questions are:

• What knowledge (e.g. tacit, research, evidence, best practice)?

• In whose interests (e.g. organisations, researchers, practitioners, knowledge brokers)?

• For what purposes (e.g. change, influence, practice, decisions, empowerment)?

• In what context (e.g. communities, workplaces, universities, boards)?

• What techniques (e.g. guidelines, training and workshops, facilitation, communities of practice)?

• With what impact (e.g. instrumental, conceptual, changing practice)?

Innovation

This study is interested in the transfer of innovation and knowledge. Therefore, we also need to give attention to ‘innovation’, a term that has increased in usage since publication of the Carruthers report,27 concerned with the adoption and diffusion of innovation in the NHS. This report places innovation at the top of the service agenda and sets out recommendations to encourage quicker transfer of new practice. 27

Carruthers’ definition of innovation built on Rogers’85 interpretation of innovation as a new idea, practice, or object but requiring that it is applied. According to Carruthers,27 innovation is ‘an idea, service or product, new to the NHS or applied in a way that is new to the NHS, which significantly improves the quality of health and care wherever it is applied’. Given the focus of our study on the benefits of innovation to patient care, this explicit inclusion of application in the definition seems helpful.

Alongside policy runs a literature looking at aspects of innovation in more detail. For example, Terwiesch and Ulrich52 have drawn a distinction between innovation that is ‘conceptual’ (new to a field) and innovation that is ‘contextual’ (new to an organisation). This is a potentially helpful distinction, allowing the term innovation to cover a range of ideas, services and products.

Implicit in the application of new ideas, services and products is a change in organisation and or individual behaviour. Birken et al. 86 explain that innovation implementation is a process in which organisational members become proficient in their use of a new practice. Walshe and Davies22 adopt a broad interpretation of innovation that encompasses both ‘clinical practice and service design’ and they explain that ‘service innovation means people at the front-line finding better ways of caring for patients’. Innovation in this sense may not involve formal and explicit knowledge transfer, unless these better ways are transferred outward to other colleagues and organisations. Walshe and Davies’22 perspective serves as a reminder that the focus of our study is anywhere in the health-care system that is relevant to managers’ ultimate role of improved care for patients within public service constraints, but with particular attention paid to the application of new ideas, services and products that are transferred into an organisation rather than those that emerge in an organic manner from within. It is also worth noting that while innovation can ‘go either way’ in terms of impact on care, most literature and policy appears to start from the assumption that innovation is good.

In terms of the application of innovation, Brockman and Morgan87 argue that knowledge transfer facilitates innovation, and Strach and Everett88 write that the ability to seek and maintain knowledge transfer capability facilitates a higher level of innovation. Radaelli et al. 89 found that individuals who share knowledge are also more likely to be engaged in creating and implementing innovations. This reflects a prevalent assumption that knowledge transfer is (or should be) a means to innovation. Knowledge is something you have; innovation is something you do. Innovation does not transfer, but knowledge about it does.

Transfer

The final element of KIT relates to transfer. This is a well-developed area of literature; in its commissioning brief, NIHR noted the multiplicity of terms. Prefaced by ‘knowledge’, ‘transfer’ is just one option of many. Others include ‘exchange’, ‘mobilisation’ ‘translation’, ‘management’, ‘mediation’, ‘dissemination’, ‘diffusion’, ‘utilisation’. Likewise, those working in roles to support this activity attract a variety of labels, including: ‘knowledge brokers’, ‘translators’, ‘boundary spanners’, ‘diffusion fellows’, ‘research navigators’, ‘research liaison officers’, and so forth. 13 There is both confusion of terms and confusion in the meaning of terms. 90 Knowledge translation, for example, can refer to the job of ‘translating’ lengthy and complex research reports into digests more suitable for busy practitioners; the translation of knowledge into action or practice arising from collaboration between researchers and practitioners;82,91 or the ‘transfer’ of research from one group to another with little interpretation or amendment. 7

Transfer needs to be understood in relation to definitions of knowledge and different models of KIT will prescribe the role for people and organisations responsible for enabling it.

Context factors

Macro-level context factors relating to the wider social, political and economic environment in which the health-care service, researchers, collaboration and KIT agents sit have been suggested to affect the success of KIT. 6,132 Factors in the external environment known to inhibit KIT include the rapid turnover of policies, ministers and civil servants. Major shifts in health care and other policy, singly and in combination, can have disruptive effects on knowledge transfer and mobilisation. 56

External context factors relating to funders or commissioners of research are a recognised, and under-researched, translational gap. 90 At an organisational level, short-term funding does not support sustainable partnerships. 94,133 Operating within a ‘closed system or fixed budget’,134 commissioners with shorter time horizons risk losing the insight that can arise from longer-term studies, and can be too preoccupied with immediate policy priorities, government targets and financial imperatives, all subject to change at short notice. 94 Thematic funding has also been suggested to engender fragmentation. 135 Restricted time and resources can also limit effective brokering or mobilisation. 15,93,134

Meso- or organisation-level context factors are often overlooked,4,136 but have a major impact. 134 A key factor in the internal context relates to the nature of the organisation – its attitude to research, to knowledge, to change – and the ability of the organisation to receive and process information. 113,137,138 In tune with Currie et al. ,43 Kitson et al. 3 reported that contexts that had ‘transformational leaders . . . learning organisations, and . . . feedback mechanisms’ were better able to implement evidence into practice. A similar conclusion was reached by others: when attempting to implement innovations, organisations face challenges such as professional barriers, inertia,139 misaligned incentives and competing priorities. 139,140 The supporting infrastructure needs ‘effective and inspiring institutional leadership’64,141 to create a ‘consistent and psychologically safe culture’. 134 An evaluation of CLAHRCs revealed a lack of emphasis on leadership (the ‘L’ in CLAHRCs) and concluded with an argument for the selection of leaders with a more systems-level approach who ‘have the capability to work across organisational and professional boundaries’. 43

King et al. 99 explain variation in outcomes and impact by differences in the ‘individual and organisational receptiveness’ or the state of preparedness of the workplace environment. The organisational value of using evidence may be limited. 100 The organisational culture needs to be adaptive142 or absorptive if it is to make use of knowledge, and increasing emphasis is given to organisational readiness. 18,82,138,143 The level of an organisation’s ‘absorptive capacity’144–147 is defined as ‘a firm’s ability to recognise the value of new information, assimilate it, and apply it to commercial ends’. 146 This ‘adaptive and responsive capacity’ is important to knowledge use in practice and is affected by the organisation’s ‘prior related knowledge, a readiness to change, trust between partners, flexible and adaptable work organisations and management support’. 145 Implementing innovations is demanding – cognitively, emotionally, physically, and spiritually. 139 If this capacity to learn, demand and generate new knowledge for the purposes of improvement is absent, then the impact of a KIT agent or knowledge broker is likely to be limited. Traynor et al. 148 concluded that the use of knowledge brokers had increased both individual capacity (improved knowledge searching, appraisal and application skills) and organisational capacity (management support and policies) of the target group.

Oborn149 indicates that ‘absorptive capacity is a strategic level capability which should be developed and nurtured by leadership teams’. Differences in hierarchical structures, leadership, power and professional cultures130 contribute to organisational receptiveness and cross-professional communication. 104,130,150 Cross-organisation and cross-discipline communication and collaboration are seen as vital. 134,150,151 However, Tasselli150 reported that professionals tend to be ‘embedded in distinctive professional cliques’.

Other studies have identified personal challenges for KIT agents around professional boundaries. 137 Career pathways and progression may be uncertain for KIT agents, particularly those in dedicated knowledge brokering roles. 133,137 Support, in the form of collective forums (i.e. communities of practice) and a physical home,137 help individuals to navigate the isolating aspect of the role. The provision of space benefits others; Dopson et al. 115 found that having access to ‘formative spaces’, removed from their organisational context, where managers could engage with knowledge, aided their appraisal of research. 115

Content factors

The work of some KIT agents entails the identification of the relevance of research to practice and the tailoring of findings to service need. Walker et al. 128 use the term ‘content factors’ to refer to the changes being implemented. It is perhaps more helpful to borrow from the PARiHS framework and include in the term issues around the nature of evidence or knowledge. Thus content factors can also relate to the nature and type of knowledge (explicit or tacit) that may be more or less readily transferred and mobilised, and to the type of evidence, varying from research findings to professional experience and local information. It concerns the social nature of knowledge and evidence; what counts, to whom and when.

Before knowledge or innovation can be implemented, the new evidence needs to be interpreted for the local context, integrated with existing knowledge and discussed. Arguably, decision-makers and researchers differ in their view of research;115,140 researchers look at the information for academic rigour, whereas decision-makers assess its local relevance. 140 At both the local and national level, new evidence may be supported or sidelined; it may address or be at odds with local needs;39,141,152 it may require change that is demanding (transformational and rapid) or the change may be incremental and require only fine-tuning. Relevance and benefit to the participants is an important enabler. 153 Decision-makers are more likely to engage if the project suits their needs. For example, an evaluation of the Québec Social Research Council (CQRS)’s partnership programme found that all respondents reported benefits to them as a reason for success. The research had relevance because it was linked to wider policy concerns (saliency). 154

Ross et al. 152 similarly found that decision-makers were more likely to engage with the research team when the research questions aligned with their interests, but also when they perceived their contribution to be essential to the success of the project (e.g. bringing local knowledge). Making a meaningful contribution drives practitioners. Bartunek et al. 75 suggested that short-term relationships, which focus on data collection, might result in the practitioners feeling exploited. Being able to help shape research questions is an important activity for some practitioners. 155

Competing agendas and priorities between partners can be a barrier to success156,157 and need acknowledging and managing. 114,155,156,158,159 Academics and commissioners alike have recognised deficiencies in the communication of research findings across boundaries. Researchers felt they should be involved more closely in the calls for research proposals; commissioners were more concerned that the users of research – policy colleagues and public service managers – should be involved more closely to ensure prioritisation of practical over academic concerns. 56 Commissioners found academics preoccupied with creating new knowledge suitable for publication in high-impact journals rather than policy-driven outputs. 56 Arguably, the ‘impact case studies’ that are a part of the Research Excellence Framework160 have gone some way to address this. However, a review of a sample of impact case studies indicated that impacts were relatively short term, often with limited direct impact on patient outcomes such as morbidity and mortality, and with limited consideration of the processes and interactions that may lead to indirect impact. 161 The time lag between identifying a demand for new knowledge and its synthesis for use in decision-making has also been noted, and decision-making time scales are short compared with research time scales. 162 Information relating to the ‘here and now’ is more likely to be used. 10

Process factors

In Walker et al. ’s128 model, process factors refer to actions undertaken by the change agents. In this sense, agents include all those parties involved in the process of change, not just the KIT agents themselves. Gagnon163 suggests that all parties should ‘plan for collaboration with an explicit description of roles and responsibilities and a commitment to regularly assessing its effectiveness’. The lack of clarity of brokering roles can limit success. 16,35,135,164 Against this, flexibility is also seen as important;66 brokerage roles may differ for different individuals127 or at different times. 165,166 Ross et al. 152 conclude that individual partnerships need to be flexible; one size does not fit all and finding the right person for a particular role is key.

Agreeing roles, goals and expectations is a common recommendation. 16,41,42,152,155,163,167 Roles can take time to be established, and may take on different forms based on specific local organisations. 137,168 One reason given for the success of the CQRS’s partnership programme was that participants were expected to show measurable results. 141 Bullock et al. 62 found examples of interactions between the knowledge brokers and their managers that resulted in frustration because expectations had not been openly articulated. Additionally, individuals in the roles will embrace brokering and linking functions at different paces or not at all. In a study of hybrid physician–manager roles, the authors identified three different groups which they term ‘innovators’, ‘sceptics’ and the ‘late majority’ reflecting the different pace of role adoption. 48 Collaborative policy-setting has been suggested as a mechanism for ensuring needs-led evidence is produced, but it was noted that this method can be more time-consuming. 169

Collaborative partnerships seem to work best where there are effective links between researchers and practitioners. Communication and trust-building, and motivation and commitment by all the organisations involved in the CLAHRC partnerships have been shown to be central to making collaborations work. 36,49,50,58 Effective solutions cannot be ‘developed from the knowledge base in the absence of those who will apply the knowledge’. 170 The key to knowledge mobilisation impacting on organisational performance rests on ‘the transfer of knowledge to locations where it is needed and will be used’. 72 KIT agents typically act as a facilitator of this transfer, using guided interaction to support the uptake and use of knowledge. 171 Their work requires a ‘multi-level, multi-strategy approach’. 172 Current evidence suggests that there is benefit in gaining the bidirectional support of middle managers within organisations:173 ‘they may disseminate information vertically from top managers to front-line employees and from front-line employees to top managers, and horizontally, across top managers and across front-line employees’. 86

Building successful long-term, trusting partnerships between knowledge producers and knowledge users supports the use of research in informing decision-making. 174 However, this takes time and commitment. 137,152,156,159,175 Partnerships need people to attend meetings. 152,155 Bartunek et al. 75 suggest a number of physical links between the two communities – web-based discussion boards, practice-focused meetings and conferences. Baumbusch et al. 91 explain how project meetings were used to feed back emerging findings for practitioners to action, and for practitioners to provide context that would assist interpretation of the findings. Kislov et al. 40 describe such events and artefacts as ‘boundary objects’. Others also write of the importance of colocating the partners, which facilitates not only formal face-to-face meetings but also informal discussion ‘at the water cooler’. 137

Knowledge transfer and innovation carries costs. For example, the time required to develop the necessary skills and relationships with organisations takes people away from other tasks and, therefore, imposes financial costs91,113 for both employers and decision-makers. 152 Financial restrictions impede knowledge mobilisation;159 those in the roles are often unable to use their backfill because of organisational pressures. 106,176

Individual dispositions

Walker et al. ’s128 final area of concern relates to ‘individual dispositions’. This focuses on the KIT agents themselves, but needs to be located more broadly; KIT agents are limited by the context and the character and dispositions of their organisations and colleagues. Evidence suggests that other aspects influence their capacity to transfer knowledge and bring about innovation, not only factors to do with their disposition (e.g. patience and approachability). 148 This includes their role and seniority within the organisation and how they are perceived by others; for example,66 Soper et al. 44 note the importance of ‘understanding each other’s incentives and constraints’.

However, the skills and attitudes of the KIT agent or knowledge broker are a recurrent theme in the literature. Alongside excellent communication skills,176,177 they need to have a good understanding of both the research evidence and policy issues, and be able to transform that knowledge into something that is salient to their practitioner collaborators. 91,159 Platt178 warned of the risk of relying solely on ‘intermediaries’ who might not have the skills needed to interpret the evidence or be motivated by their own interests.

There is an argument that knowledge brokers in hybrid roles (e.g. clinical managers) may be best placed for mobilising both explicit and tacit knowledge because of their membership of multiple communities. 54 However, challenges may arise related to dimensions of their role and interorganisational factors. 179,180 For example, those in hybrid roles have been found to show preference to one aspect of the dual role over the other, to broker knowledge only within their professional sector, or to not be best placed to reach all levels of the organisation. 179,181–183

Mutual trust and respect are frequently reported as enablers. 74,91,114,155,158,175 The issues of trust and reciprocity feature prominently in the management literature on planned collaborations. 184,185 Other reported beneficial dispositions include clinical credibility, being known and having a good reputation60,186 and having good knowledge of the organisation’s culture. 187,188 For those from outside sectors, willingness to learn about the other community is stated rarely,75,188 but would seem to be essential.

For researchers to take part in interactive exchange models of knowledge mobilisation, it is likely that they need to have accepted a broad notion of ‘knowledge’. 75 Researchers’ ‘arrogance’ and power differentials can introduce problems. 175 Engagement with potential users of knowledge may be seen as signifying a lack of independence and objectivity in the work. 57 Concerns about academic rigour and violations to objectivity can be off-putting to academics – ‘if what is required is for researchers to do what policy-makers want them to do, then research may fail to fulfil one of its most important functions, namely to be objective, reliable and unbiased’. 189 Ross et al. 152 note that none of the researchers in their study identified this as an issue.

Theoretical frameworks

Within the case study design, data gathering was shaped by Kirkpatrick’s framework,198 which provides a useful structure for ensuring data collection beyond immediate reactions to an initiative and has been widely used in business and education. 199 The original Kirkpatrick framework comprises four levels. Level 1 is concerned with assessing the participants’ reactions to the activity; for example, did they think it was relevant to their needs? Level 2 relates to learning gains (knowledge acquired by the practitioners). Level 3 focuses on behaviour change as a consequence of participation (application of knowledge to practice). Level 4 is about impact (what difference changed behaviour makes). This framework fits well with social marketing theory and its focus on behaviour.

In earlier work,62 we modified the framework to address known limitations199,200 and to maximise its relevance to innovation and knowledge transfer in the NHS. These adaptations recognise that reactions, learning gains and behaviour change all contribute to outcomes and are themselves ‘impacts’; that these ‘impacts’ are linked to each other and are not arranged hierarchically; and that the processes and dynamics of initiatives (including motivations) and the wider context are important. 62

Our approach to data analysis is described later. In this, we drew on other classifications or frameworks in the literature, notably Walker et al. ’s128 work on factors affecting organisational change and the PARiHS framework. 201

To inform our understanding of the consequences and implications of our findings, we used social marketing theory. Social marketing is defined as ‘the systematic application of commercial marketing concepts and techniques to achieve specific behavioural goals relevant to the social good’. 202 It is focused on understanding (or having ‘insight’ into) why people (e.g. NHS managers) do what they do now (in relation to innovation and knowledge) and what ‘competition’ the new behaviour faces. Social marketing theory recognises that this may vary by subgroups and may require different kinds of support (‘segmentation and targeting’). These insights can be used for ‘creating attractive exchanges’,203 which can encourage the effective uptake of the new behaviour. Part of this is taking account of, and most likely modifying or adding an ‘offer’. 203 The strength of such an approach is that it starts with investigating KIT from the perspective of people who are being asked to do it. It seeks to understand the meaning they attach to it and the barriers to, and enablers of, doing it, without attempting to prejudge issues. The approach allows factors that challenge or enable KIT to be identified and context-specific solutions to be developed. Do different managers, clinicians, innovations, questions and health-care organisations require different activities or transfer pathways? What are the implications for practice? For example, managers with limited access to information technology and statistical support might find it impossible to apply modelling techniques, even if they know about them. The solution lies in improving hardware and support, not in communicating research findings differently. To give another example, to enhance knowledge mobilisation in a setting in which a KIT agent’s line manager expects them to ‘deliver’ without senior support may need a solution that focuses on the line manager and not the agent.

Advisory group

A project advisory group was established that comprised NHS managers, chief executives, representatives of the HSDR programme, academics with expertise in knowledge mobilisation (including from overseas), patient representatives and other partners. These are listed in Appendix 2 along with the main focus of each meeting.

Primary communication with the advisory group was by teleconference, preceded by an e-mailed agenda and supporting papers. Nine meetings were held over the course of the study. The advisory group helped to resolve practical issues and acted as a sounding board for sampling, data collection and analysis decisions. Most notable was its contribution to the discussions of early findings. Throughout the project, we presented drafts and questions to the advisory group members who used their knowledge and experience to inform our way forward. As a group, they provided a strategic voice for service users and service leaders. By facilitating the ongoing validation of research findings, the advisory group enhanced the credibility and relevance of the research project and contributed to early feedback of findings to stakeholder communities.

Patient and public involvement

As this project arose in response to a specific HSDR programme call for ‘research to improve knowledge transfer and innovation in health-care delivery and organisation’, patients and the public were not actively involved in identifying the research topic. 204 Public involvement was defined broadly in the call to include ‘local communities . . . members of the public, users of services, carers and minority ethnic groups as well as healthcare practitioners and managers’. 204 Our proposal was developed with the direct input of the research networks lead (de Pury), the director of an AHSP (Denman) and a health board manager (Howell). They made a significant contribution to prioritising and adding detail and contextual understanding to the objectives. Their views and opinion of their needs regarding innovation and knowledge transfer shaped the detail of the questions we asked.

Users are motivated to take part in research management when they feel they can make a contribution given their own expertise, experience and interest. For this reason, we focused our inclusion on patient representatives in the advisory group and the nominal group, in which discussion could be informed by their first-hand experience of services.

Mapping and typology development

For the national mapping of the KIT intentions of the networks (AHSNs and SEWAHSP) and the development of a typology of KIT agents we collected data from desk research and telephone interviews.

Case studies

Nominal group

Ethics and approvals

After seeking advice from a number of local, regional and national quarters [Cardiff University Research and Commercial Division and the Research Governance Officer, the NISCHR Clinical Research Centre, Aneurin Bevan R&D office and Queries National Research Ethics Service (NRES) Health Research Authority], it was confirmed that the project was deemed a service evaluation and, therefore, NHS research ethical approval was not required. Research ethics approval was then obtained from a Research Committee of Cardiff University (reference number 20/08/13) and the project registered on the Welsh portfolio (16/10/13; number 15479). Prior to fieldwork, we obtained any required approvals from the AHSNs and from the health board for each of the agents in Wales.

We prepared participant information sheets and consent forms (see Appendix 7) and sent these to all participants in advance of data gathering. Data were gathered in confidence and all individuals and places associated with the case studies were anonymised for analysis and presentation.

Snapshot 1: intentions of networks at prospectus or strategy stage

The AHSNs laid out their initial plans for their region in a prospectus document and accompanying business case in September 2012. Out of the 16 networks (15 AHSNs in England and one AHSP in Wales), the majority had plans in place to support KIT agents or to provide role support through training or buying time. The range of different approaches are summarised here and detailed in Appendix 4.

Snapshot 2: intentions of each network as described by their leaders

We interviewed 14 representatives of the 16 networks to understand how their intentions for KIT roles were developing from the original prospectus. At this stage a number of general observations were made about the networks:

• They were at different stages of development. This ranged from senior management teams in post with over 50 active projects to still recruiting for senior roles and agreeing priorities.

• They started with different existing structures. This ranged from establishing completely new structures to inherited projects and staff from old structures (for example from Health Innovation and Education Clusters and CLAHRCs). One interviewee commented ‘We have spent the last 5 years building relationships’.

• They had unique operational models. Models included a core network team providing central support along agreed themes; a separate organisational entity working alongside partners; and regional teams specialising in different aspects of the network’s clinical themes.

• As a result of these differences, the operational challenges also differed. For example, some were challenged by the sheer size of their geographical footprint, others by trying to create partnerships when none had existed before, yet others by one dominant organisation in the network.

• However, the core objective to drive improvement through innovation was common across all networks, and the influence of the growth agenda was common across all sites in England.

Role types

Different types of KIT agent roles were identified across the networks. Roles varied across a number of dimensions, including how the agent would be supported by the network, duration of the role and percentage of time spent on the role, number of agents in each organisation, and whether the role was focused on research and data gathering or on the implementation of research findings. Other features included whether the role was aimed at clinicians, managers, or both; the primary location – the NHS, university or industry; and the focus of the strategy delivered through the role – health, wealth or both. We also noted variation in relation to proposed training for agents: in knowledge brokering or improvement methodology; and bespoke or à la carte. The various roles are summarised in Table 4, and we note that a number of networks proposed more than one type of role.

We note that fellowship or secondment roles and network building activity were still the main strategies for supporting KIT roles during early network formation. However, we found that most networks ‘have moved on from the prospectus’ (Managing director, network 750) focusing more on working with local organisations to deliver joint KIT support and less on introducing new training or protecting time. We also note the emergence of roles that are described as operational leaders with specific duties around promoting improvement and innovation. These differ from fellowships, as they are seen as more permanent members of the network team. Many network leaders describe these changes as a response to a funding shortfall and central policy changes.

Role typology

Based on the findings from the review of the network intentions and the discussions with managing directors and alternates, we developed our classifications into a general typology of KIT roles. These ideal types are presented in Table 5. We then plotted these ideal types along a set of features related to level of support or training, role duration, full- or part-time, numbers in post, and extent of focus on research or implementation (Table 6).

TABLE 6 - A mapping of KIT agent ideal types against role features

High level of training provided   Low level of training provided
Dedicated KIT fellow	Dedicated KIT lead	KIT within research role	KIT within role	Programme implementer	Project implementer	Hobby project champion
Short duration of role   Long duration of role
Project implementer	KIT within research role	Dedicated KIT fellow	Hobby project champion	Dedicated KIT lead	Programme implementer	KIT within role
Part-time KIT role   Full-time KIT role
KIT within role	Hobby project champion	KIT within research role	Project implementer	Programme implementer	Dedicated KIT lead	Dedicated KIT fellow
Low numbers in post   High numbers in post
Dedicated KIT fellow	Dedicated KIT lead	KIT within research role	Programme implementer	KIT within role	Project implementer	Hobby project champion
Research-focused role   Implementation (adoption)-focused role
KIT within research role	Dedicated KIT lead	Hobby project champion	Project implementer	Programme implementer	KIT within role	Dedicated KIT fellow

Case study sites

Our case study site selection was informed by the mapping exercise described in this chapter. Specifically, five networks were selected from the range of planned KIT roles described in the typology in Table 5, and also the different stages of network development (i.e. from a de novo network to an established partnership in research and innovation). The features of the five selected networks and their proposed KIT roles are summarised in Table 7.

The agent

James led a relatively new unit designed to improve services by supporting staff through the use of improvement methodologies, making space for innovation, and bringing organisations and people together for, in the terms of their website, ‘co-creating solutions’. A medical consultant by background, with significant experience in management and leadership roles, he directed the unit on a part-time basis. He was viewed by colleagues as a robust and charismatic leader who, in his own words, was prepared to cause ‘constructive disturbance’ and be the ‘grit’ in the system. Near to retirement, James saw the importance of building trusting relationships and viewed his role primarily as supporting coproduction, helping people to feel valued, enabling them to take ownership and to ‘grow their own stuff’. His skills were complemented by his team, who were recruited for their expertise in areas such as leadership, change management and patient safety.

Context

Although James characterised the internal organisational context as one of high-level support from the executive team, he nevertheless felt pressure to demonstrate his worth. Other challenges included handling territory sensitivities in relation to who provides change management training and not alienating staff wary of change. In contrast, however, he also described parts of the organisation as ‘open’ and ‘healthy’ as demonstrated by two teams agreeing to his observing them. James also alluded to challenges arising from the changing external context:

Demand has changed . . . A&Es [accident and emergency departments] were built for 25-year-olds with broken legs. The demand is now 85-year-olds with six conditions, dementia and frailty. A&E is a terrible place for them: no matter how you describe it, it is never going to work for these people. Or technology changes: well we used to do that with surgery, now we can do it with drugs. Or economics have changed: we used to have a million pounds to spend on this now we’ve only £750,000. So all those things tell you that improving is not going to deliver.

James

Content

James worked across various clinical and non-clinical work streams, including waiting lists and care in the community. This often involved cross-organisational working, for example with primary care, the local authority, charities and universities.

Activities

James deemed the leadership training the most important part of his and the unit’s work. The unit also provided staff training in QI methods. Other activities related to brokering meetings between organisations for developing improvement projects. James repeatedly highlighted the importance of bringing people together to discuss solutions to problems. An innovative element of their approach was the application of mathematical modelling.

Clients

James worked with clinical leaders and managers in his senior-level role, but also linked with others external to his organisation including patients.

Outcomes

James described how his initial attempt at developing an improvement culture ‘created a bit of hostility’. He revised his approach and talked about simply ‘having a conversation’, avoiding others feeling intimidated by the consequences.

Learning outcomes arose from leadership and QI training. James thought that the leadership training was ‘really nurturing a new breed of leaders’.

Changed behaviour was also linked to James’s work. He was seen as pivotal in challenging ‘silo’ thinking and working. One Link interviewee described his changed thinking thus:

Other people that are not working . . . in your field of practice . . . actually when you talk to them . . . they’ve got the wider vision, if you like, of the whole organisation . . . So I could be quite siloed really in dealing with older people, but it makes me think, well, what I’m doing for the older people now can actually be transferred to mental health services.

James’s Link

Tangible results from James’s work included joint research proposals, awards and QI projects linked to staff training. QI training was being embedded into appraisal systems, a step described by James as a mechanism for building capacity and critical mass. This was increasing the numbers of people engaging in projects, which in turn was leading to desired cultural change in the organisation. Although in the time scale of the research we cannot demonstrate the impact of James and his unit’s work, he felt that they were making strides in the right direction:

When I started this off I interviewed all the Execs [Executives] and they all said, ‘. . . but it will feel different, the organisation’ and, it does now. How much of that is related to us, how much of it isn’t, I don’t know. . . . And others are now looking to us to emulate the same thing.

James

The agent

Grace headed up a unit with a remit for improvement programmes and innovation. Clinically trained as a nurse, she had held a variety of roles in research and nurse education, and had developed a very strong network of contacts in the region as well as internationally. She had received training in Institute for Healthcare Improvement (IHI) methodologies and held a Master of Business Administration (MBA) degree. Her job was concerned with nurturing, guiding and developing clinical innovation and encouraging linkage. Grace explained that to develop trust and set up the conditions for learning, she needed to ensure that her approach was transparent, open and encouraged sharing. She was known for her ‘personal skills to make things happen and to bring people with her’ and ‘resilience’ to cope with obstacles (Link interviewee). Another Link described her hard-working approach and passion: ‘I know Grace is here till way past she should be in the evening . . . Grace is passionate. She believes in the cause’.

Context

Grace worked in a large NHS organisation located on the same site as a medical school. At the time of the study she was seeking a better physical home for the unit. Grace’s response to Greenhills-wide initiatives, such as the high profile patient flow programme, was similar to that of James: she saw them as both a challenge and an asset. She experienced some difficulties engaging with some members of the collaborative.

Content

She described her focus as on problems ‘that matter to patients’. Examples included electronic handovers, debriefing, the transforming theatres and scheduling programme, modernising health records, use of diagnostics, and patient pathways.

Activities

One of Grace’s chief activities was creating linkages and brokering relationships. One Link described her as a ‘key facilitator, gate keeper to the right people and the right departments and the right projects’. The role included information sharing and maximising ‘clinical innovation’. One Link reported, ‘Grace’s been very good at inviting me to various talks and every time I give a talk, people go ‘it’s amazing . . . why aren’t we doing more of this?’ Grace and her team tried ‘to bridge the gap’ between the NHS organisation and the university ‘and move from translation to transformation’. She supported staff in developing and progressing their ideas: ‘through to business cases, contracts, and negotiating intellectual property, patents, copyrights and all those good things’ (Grace). Another Link also described how she helped write funding applications and got letters of support.

Grace had established faculty meetings in which quality and safety improvement projects were shared. The meetings brought together people from ‘research, education, clinical innovation, improvement, service delivery all in one room’ and provided a network for those pursuing higher QI training. She herself was involved in providing improvement training to clinical teams and staff, although she sought to focus increasingly on the strategic mandate – embedding an improvement culture in the organisation – rather than actually doing the improvement projects.

A regular conference speaker, she engaged internationally with visits to or visitors from Sweden and the USA, for example. She presented on ‘the pragmatic approach to implementation and also the learning and the experience of our group’ (audio-diary).

Clients

Grace worked to bring together clinicians, academics and external stake holders (such as industry and the voluntary sector) with a view to solving problems.

Outcomes

Reactions were generally positive. Her narrative about her work with a group of junior doctors working on improvement projects expresses their enthusiasm and the energy they created:

We were all completely inspired by the positivity and the energy that was in the room. I had a couple of e-mails from some of the junior doctors afterwards, all fired up . . .

Grace

One form of tangible learning arose from the QI projects. She reported that ‘to date we have about 100 people who have gone through the second level of the programme’. She thought that capacity development was contributing to ‘sustainable change across the organisation’. The development of the QI faculty was described by a Link interviewee as one of her ‘greatest achievements’. In terms of results, one project – the placement of nasogastric tubes – had ‘significantly reduced the number of X-rays that patients were unnecessarily enduring’ (audio-diary) and had led to an award for the work. Another result related to bidding for and securing funding. She had success with the Health Foundation, for example.

The agent

Sophie started her career in a front-line clinical role and, following completion of health-care management and leadership courses, worked her way up to a regional management position. She was well-known locally and had a wide-ranging knowledge of the organisation. At the time of interviewing, Sophie had been leading on all aspects of unscheduled care for 2.5 years. She reported directly to the chief operating officer. After 18 months in the position, she took on an improvement role addressing patient flow and length of stay. This part of her role initially took all her time, but after 1 year it had reduced to about 75% and was declining further.

She was described by Link interviewees as ‘responsive’, ‘tenacious’, and a problem-solving, ‘can-do’ person. While Sophie thought she was not good with the ‘softer’, ‘touchy-feely’ side of management, a Link interviewee described her supportive side:

When things aren’t going well, she will tell you and she would expect something to be done about it, but equally she’s highly complementary and supportive, very supportive.

Link

Context

The organisation in which Sophie was based serves a culturally and economically diverse population of 300,000 and employed > 8000 staff members. Problems pertinent to Sophie’s work included those arising from patients crossing authority boundaries and getting patients discharged into care homes. Despite this, emphasis on patient benefit provided a common motivator across organisations in the patch: ‘although the cultures are different across the organisations, they all want to do the best for their patients’ (Sophie). She was well supported by her line manager, who was in a senior position.

Content

The need for an improvement programme was prompted by a crisis in service delivery arising from high occupancy and delays in the system. Sophie’s focus was streamlining patient flow.

Activities

Sophie’s work addressed unscheduled care and patient flow in two district general and three community hospitals across the region. Sophie also mentored a clinician on secondment who supported the patient flow work.

Sophie was very hands-on: she held twice daily meetings with nursing teams at the two general hospitals, regular in-depth meetings with ward managers and the wider multidisciplinary team, and weekly ward ‘walk-arounds’, during which she spoke to staff and patients. She observed, ‘I’m in the thick of it with them. So I’m not a distant leader of this change I suppose’. She was in the process of gradually withdrawing to let the heads of nursing run the process and she was looking for suitable people to help with the role in the future.

At a team/management level Sophie gathered, brokered and disseminated information about performance from departments in an effort to challenge the culture around delays, encouraging them to be seen as ‘everybody’s responsibility’. Through sharing data she hoped to minimise silo working and to increase openness and visibility of performance – both good and bad.

She also shared relevant literature, including from outside health care (e.g. from business). Outside the organisation, Sophie regularly presented the organisation’s achievements at conferences and national programme events.

Clients

She linked with all tiers of medical staff at these hospitals, liaising with departmental managers, clinicians and nurses and other front-line staff. Sophie also linked with colleagues in other regions to manage patient flow.

Outcomes

Link interviewees valued Sophie as a sounding board and felt comfortable discussing options and decisions with her:

We work in a very stressful environment and . . . it’s highly valuable to have somebody that you feel comfortable approaching to get advice and somebody to just listen to you and she will help you to make your decisions really.

Link

Through Sophie, departments learned about each other’s performance. This had the effect of challenging the status quo:

It’s just challenging traditional practice, you know, historic practice and say ‘why do you do it like that?’

Link

Sophie was instrumental in creating a more target-driven atmosphere in which departmental performance levels were set and outcomes displayed on the intranet. Sophie met with teams regularly to review targets and set new challenges. She gave an example related to wait times: if the department meets a 12-hour target, they might be set the challenge of trying to average an 8-hour target the following month. As a result, tangible service improvements were noted in several departments; ambulance handover delays were reduced from ‘hundreds of hours delayed a month’ to 50 hours, and surgery cancellations were greatly reduced.

The agent

A nurse by background, Amy was on a 1-year secondment, working across patient safety projects but majoring on a specific sepsis project. She also facilitated several QI projects with partner organisations. One Link commented that Amy was ‘very active, very involved’ and had been ‘visible on the shop floor’. The agent was known as a good communicator, both verbally and in writing.

Context

Riverside covers a large urban area known for medical discovery, health-care innovation and education, yet also containing many socioeconomically deprived communities. At the network level, there was considerable variability within the partner organisations in terms of supportiveness. Other challenges included lack of resources to free up clinician’s time for improvement work and agents reported apparent confusion about overlapping mandates related to QI:

It’s become quite apparent that there are quite a few groups in the hospital whose job is QI – like clinical effectiveness, like quality improvement, safety patient groups, and what is everybody doing? They’re not joined up.

Amy

Amy described the immediate working environment as supportive. The three case study agents in Riverside used informal mechanisms from outside their department or line manager to make connections across the network and facilitate cross-fertilisation of ideas.

Content

Amy led an authority-wide QI project on sepsis.

Activities

She applied IHI QI methods, and a large part of her role involved improving measurement, specifically how data were collected, shared and applied to inform practice within the health authority. Amy worked with the information team to ‘build mortality tracking software’. This enabled staff to look at their own data in real time.

Amy was building capacity in the organisation by training and mentoring front-line clinicians in QI methods. This included delivering QI courses in various forms, leading learning sets, educating foundation doctors on sepsis during induction sessions and leading on training-the-trainer QI sessions. The mentoring involved regular meetings to discuss challenges, measurement approaches and QI tools, and to provide direct support where it was needed.

Amy also took on other duties including supporting the development of a health foundation bid and helping to co-ordinate a site visit for an international delegation. This aspect of the role helped to ensure that she was ‘taking some of the shared learning from one partner to another’.

Clients

Amy worked with front-line clinicians in her knowledge brokering role.

Outcomes

In relation specifically to the sepsis QI project, initially there was some negativity and resistance to the methods and approaches proposed as well as on selected measures from which to judge improvements. Unwilling to engage with the data presented, reactions from some senior clinicians had been defensive.

Despite this, others spoke of learning gains and a different way of thinking:

They’ve [Amy and the team] given us some really good feedback around what we need to be doing – how we can achieve our goal, how to approach things . . . They’ve kept us on a track . . . How it’s changed now is that the teams are really starting to think about using the QI methodology.

Link

The organisation had become more data driven, helped by the mortality tracking software that had contributed to driving improvement. She had been instrumental in improving processes around measuring and generating real-time data for sepsis.

The agent

Isabelle had a policy background and, after spending several years as both an in- and outpatient, now worked to improve patient engagement. She held two part-time jobs, but treated them both as full-time and admitted to working long hours to keep on top of both portfolios of work. Her KIT role was described as matchmaking across the network in terms of linking patients with those working clinically in a specific field and facilitating the involvement process. One Link thought that her personality, networking and influencing skills all contributed to her success in this role.

Context

Isabelle worked at Riverside alongside Amy.

Content

Isabelle’s main activity was to build on the insights gained from public engagement. She worked with people to help them make good use of the data that they had acquired.

Activities

Her role was facilitatory; she built relationships, connected people and provided advice on involving patients:

I use her as a network . . . So actually, you know, I need X group of patients. How do I get them? She’s quite linked in to all of those things . . . It saves me thinking about it.

Link

Isabelle reported spending the first few months in the role working out what currently happened around PPI in the network and building connections with key individuals. One Link described it as a ‘huge mapping exercise . . . across Riverside, nationally, globally’.

There was also a training and mentoring element to Isabelle’s work in order to build capacity for engagement. She was involved in planning both internal and external-facing events for the network related to patient involvement and contributed to bimonthly webinars.

Clients

Isabelle’s matchmaking role meant that she worked directly with patient groups, patient engagement leads and clinicians to improve patient engagement.

Outcomes

From her experiences of working with patient groups, reactions had been both negative (disruptive individuals with an agenda, difficult to recruit and engage) and positive (good access to people, worked well). Feedback on the learning set was said by Isabelle to be ‘overwhelmingly positive’.

She had developed learning about PPI and was known to ‘get people to think differently’ (Link). She had created learning communities, both online and in person, and learning sets.

In terms of tangible results, Isabelle, working with collaborators, had won an award at an ‘emerging leaders’ competition. Partner agencies had advanced their patient engagement strategies; for example, one had a patient and public engagement strategy.

A notable ‘movement’ around patient involvement could be detected by Links:

What’s happened is people have gone, ‘wow!’ ‘What an energising, exciting opportunity. We want to maintain this . . .’.

Link

The agent

Fran was a trainee doctor on a 1-year fellowship pursuing her interest in management and QI. For the last part of her fellowship she worked part-time. She reported to the medical director. Fran was credited with getting initiatives off the ground through her ‘enthusiasm’ and ‘commitment’ and by understanding the challenges of working on the front line. She was also approachable and diplomatic:

Very, very, very nice. So she’s very approachable and she is really good at not . . . treading on anyone’s toes. So she went about it in a really delicate way.

Link

Context

Fran worked at Riverside alongside Amy and Isabelle. She described the work environment as supportive, stating that ‘everyone who works there is really passionate and enthusiastic’ and ‘is really encouraging you’.

Content

Fran’s focus was on facilitating QI across a number of clinical areas. Examples included treatment escalation plans, falls prevention, patient safety and prescriptions at hospital discharge.

Activities

Her main activity was supporting clinicians in their own QI initiatives:

So I’ve been doing a lot of work with front line staff trying to get them to do quality improvement. So that’s for all junior doctors, non-medical allied health professionals. So I’m coaching them through smaller projects that they’re undertaking.

Fran

One Link interviewee explained how Fran had really helped her to progress her project, in part because of her understanding of the clinical setting:

In a way, it’s sort of access to supervision for me because she just asks the right questions . . . which is a luxury because nurses don’t get supervision.

Link

She taught QI methods, adapted QI training material for local audiences and professional groups, and also trained others to deliver courses after her departure. Over the course of the year, her role had shifted from supporting all the QI projects throughout the hospital to doing little direct support. That job had been taken on by Wendy in the clinical effectiveness unit.

She facilitated linkages, notably putting junior doctors in touch with a ‘tower block full of patient safety officers, the board, the audit team or the quality people’. She identified a notable achievement as ‘making sure we had buy-in from the exec team and getting them to board meetings’.

Links described how Fran helped them to become more aware of how and where to disseminate their QI projects:

So she’s really good at making you aware of what you can do with your quality improvement work. I didn’t even know that you could publish it or I didn’t know that, you know, there would be events at other hospitals where people would discuss it, and she’s kind of like opened my eyes.

Link

Fran had suggested that the Link should present her work at a regional event. She did, and won an award.

The agent also picked up a number of tasks that she described as ‘ad hoc’. Examples included writing up a pro forma for a team to adapt, developing e-learning on QI and looking up evidence in the literature. Fran also contributed to the development of the improvement advisor role in the network and set up a regional falls forum.

Clients

Fran primarily connected with front-line clinicians in her role, as well as facilitating linkages between these clinicians and hospital leaders (e.g. executive and board teams) as needed on specific QI projects.

Outcomes

Lack of interest was an initial reaction from some: Fran commented, ‘I was trying to coax them into using the improvement methodology . . . and . . . nobody was really that interested in . . . taking on that approach’.

Those she did work with developed learning in QI methods. Fran also spoke of her personal learning, which included better knowledge of hospital systems:

I think I understand structures of hospitals so much better – who does what – in a non-clinical sense actually more than clinical . . . I’ve learnt a lot about not being a doctor in sort of knowing what other people do with their time.

Fran

Fran’s role in training and mentoring front-line clinicians was credited with helping to drive projects further and faster, reaching outside the organisation through wider dissemination and helping to create change in the individuals themselves.

Tangible results included those she had helped to win awards and one trainee who gained a QI fellowship based on the training provided by Fran. The trainee stated that ‘the fellowship wouldn’t have happened without her influence’.

The agent

Jessica was a practice-facing academic who worked between commissioners and researchers and created linkages between academics and practitioners. She had a long history of working on the region’s KIT strategy in the CLAHRC and now provided senior oversight of the organisation’s evidence review and evaluation work. For Jessica, the importance of context meant that it was not possible to simply apply KIT templates in a formulaic fashion. She described her role as fostering knowledge interaction and implementation, and supporting knowledge agents.

Jessica was pragmatic and perceptive. One thing she found challenging was the lack of organisational affiliation and not having a practitioner background.

Context

Moorlands covers a large geographical area with local variation in terms of demographics, political situations and drivers. The region had CLAHRC funding over 2008–13, but the network was relatively new at the time of the research. Projects were carried out across the region, in collaboration with a range of organisations, although relationships with industry were thought by the case study agents to be less well developed.

The KIT agents in Moorlands had relative autonomy to manage their roles within the context of national drivers and network guidelines. Although Moorlands cultivated a collaborative environment, the pressure to deliver was palpable. Faced with changing political drivers, funding uncertainty and organisational reconfiguration, a general lack of stability in the region was noted by the agents and influenced their thinking (i.e. only taking on projects that could be accomplished within a relatively short period). The agents’ line manager highlighted this uncertainty and emphasised the importance of demonstrating their contribution to improved patient care:

We’ve got to be able to demonstrate that we are a resource in support of improved patient care in partnership with our members, but I think it could all come to a crashing halt if we don’t do that. So I think this next period is critical. In terms of sustainability . . . I think the future is uncertain.

Line manager

Moorlands was transparent about its workings, posting on its website information about how projects were selected and commissioned and publishing outputs of recent projects.

Similar to other regions across the UK, the challenge of freeing up time from clinical or managerial roles to work on implementation was noted:

The hindrance is the extraordinary pressure under which the NHS is operating and the inability to lift one’s head in a senior management capacity above the parapet or as a middle management capacity. So it is the pure pragmatics of finding either the intellectual or physical capacity to implement change.

Line manager

A further challenge was noted by Jessica, who reported how eligibility restrictions caused problems when recruiting to roles that cross NHS–academic boundaries.

Content

A primary focus of Jessica’s work was commissioned and client-focused evidence-based reviews.

Activities

Her role involved dissemination of specialist knowledge to practitioner collaborators, as well as sharing tacit knowledge about the NHS environment with researchers, which helped them to gain access to NHS sites and recruitment participants. She had also contributed to the development of an integrated clinical academic pathway for a cohort of master and doctoral students who sought to develop a clinical academic career.

Jessica also provided support for others working in KIT roles. She counselled them about the problems they encountered and helped them to manage expectations. She encouraged other agents to adopt more reflective implementation practices.

Clients

Leading on evidence review and evaluation, Jessica worked with practitioners and academics.

Outcomes

Discussing the theoretical or more academic side of implementation with practitioners could sometimes be met with resistance: ‘unless you’re really lucky, the minute you start talking about the social science or theory of implementation it’s just like you can see like kind of the barriers go up’.

The evidence reviews were well received and informed future practice:

They have been excellent in producing the report for us in a relatively short period of time . . . and making sure that actually it would be a helpful product for us.

Link

Jessica expected her work to shift thinking and work practices:

If I’m doing my job properly they start talking about implementation, knowledge brokers and community of practice and it just becomes the norm to them.

Jessica

The agent

Holly had a nursing background and had held director-level positions within her profession, so was well-known and respected within the region. She worked 1 day per week as a KIT agent and the remaining time in one of Moorlands’ partner organisations. She was on the organisation’s executive group responsible for clinical programmes and provided the link between the board and what was happening at the coalface.

The agent’s communication skills, in what could sometimes be a difficult role (managing expectations with partners and promoting the Moorlands work to external organisations) were highlighted by her line manager. The benefit of successful implementation for patients was her key driver: ‘ultimately we want to just get this into practice for patients’.

Context

Holly worked in Moorlands alongside Jessica. One of her main challenges was getting practitioners to take time out of their clinical roles to engage in research and implementation. Other challenges arose from system reconfigurations and turnover of senior staff; relationships had to be rebuilt and alliances re-established: ‘You’ve got people on side and then the next minute they’ve gone’.

Content

Holly summarised what she thought the clinical professionals wanted: ‘they just want the practical help, you know . . . “It all sounds marvellous – how can we get these into practice to improve patient safety?” That’s what they want to know’.

Activities

Engaging with senior leaders and managers was a significant part of Holly’s role. Oversight of various network projects took up half of her time. This entailed early identification and resolution of issues. If a project encountered a delay then Holly convened a meeting with the project manager, the principal investigator and the practitioners involved. For the other part of her role, Holly provided a link between the NHS and academia. Through presentations and meetings, she brokered the benefits of using the network to both the clinical and academic sectors. She explained that the aim of these meetings was to ‘procure relationships and establish contacts with senior teams across the partner organisations’. Through her project management and linkage work, Holly was able to suggest personalised, appropriate contacts for people.

Her approach highlighted the need for organisations to be ‘on board’ and supportive of new interventions and innovations:

. . . more of the same is not the answer. We need to create a sustainable NHS and part of the way that we do that is to innovate and adopt and spread, and actually through coming on board with us and supporting implementation of new interventions.

Holly

Other activities included working with a colleague in a consultancy role to create a set of priorities for the region, focused on local pressure areas. She had also developed a brochure on capacity-building opportunities for organisations: ‘the short courses that we offer, research exchange placements, knowledge broker roles, PhD [doctor of philosophy] opportunities’.

Clients

Holly’s knowledge brokering role involved working with senior leaders and managers in NHS organisations, often connecting these individuals with academics.

Outcomes

Holly’s line manager noted that people were responsive to the brochure and other information/materials that she distributed. One Link interviewee expressed the value of the information that came from outside their own organisation; it was viewed as unbiased and, therefore, was more readily accepted. However, another Link interviewee highlighted that although the evidence reviews were useful, practitioners were busy and so the ‘easy one-liners’ were most useful. Yet for another Link, the simple dissemination of evidence or information was not enough. She valued personal communication as a source of new information.

As well as furthering individuals’ progress with their projects, Holly spoke of these linkages helping to form an interlinking ‘network of champions’ to help with ‘general implementation in change adoption improvement work’. It was through the implementation of new interventions that she anticipated improved quality of care and cost efficiencies, although Holly’s line manager acknowledged that these were slow and gradual changes: ‘we all know from experience you have to keep drip, drip, drip, drip all these things’.

The agent

Originally trained as a nurse and experienced as a service improvement manager, Daisy was working as a research fellow, supporting implementation of the network projects as well as pursuing her own research. At the time of the study Daisy had only been in post for a few months. She initially found it difficult to balance the dual demands of the operation; support of research into practice, and researching that process (her own research). Later, she was assigned to a large, cross-organisational research project. She adopted a proactive approach; if she heard about a project that she felt she could contribute to or learn from, then she would request to take part in some way.

Context

Daisy worked in Moorlands alongside Jessica and Holly and noted their ‘strong team culture’. Although new in post, she was already aware of the uncertain future:

I am conscious, you know, everyone’s roles are being reviewed, that the environment that we’re working in might change, etc. etc. So I think I’ve got to, sort of, be realistic about what’s really, really important to deliver in the next, what, 3 to 6 months.

Daisy

Content

Daisy’s work aimed to improve thinking around the implementation and use of evidence. The review topics to which she contributed were suggested by practitioners and developed in line with their needs.

Activities

Daisy worked closely with project managers in organisations to understand the knowledge needs of users and areas in which implementation challenges exist. In a context described by her line manager as one in which clinical academics develop innovations but expect others to implement them, she saw Daisy’s role as being ‘about helping people think about their implementation and translation plans. Nudging them along the right way, or helping them develop networks’.

The complexity of the projects required a variety of methods rather than a set approach. Daisy’s methods were pragmatic but theoretically informed. She reported taking a systematic approach to the discussion of implementation with teams: ‘That’s when we really go through it in minute detail about the three areas of context, content and process’. Part of these discussions involved challenging teams to ascertain their current readiness and whether or not they were in a position of readiness for change. These steps were seen as ‘central to translation’ and the development of ‘a resource that will make a difference’.

Daisy also led on increasing the transparency of the network and its processes on their website.

Clients

Daisy worked with lead clinicians and others (e.g. project managers) proposing an improvement project within the network.

Outcomes

Importantly for organisations, the reviews were accessible and contained information that could be applied directly to aspects of their work. For example, one Link interviewee reported that the material was directly useful, and that employing the information given in presentations was ‘very easy to do’. Link interviewees observed that the reviews were not oversimplified and succeeded in covering all aspects relevant to the topic: ‘So, you know, depending on who you are and what your interest is there’s sort of something in there for everybody’.

By publishing on the website a flow chart with time scales and identifying relevant staff members, she had improved communication both inside and outside of the organisation.

Given her short time in post, it was difficult to identify changed behaviour or results. Daisy was aware that this was a more general difficulty: ‘It’s quite a hard role to demonstrate, I think, a clear impact’.

The agent

Erin was a PhD-level manager with a long history of working in the heath innovation infrastructure in her region. In her role she supported the commercialisation of new products and ideas, and split her time between NHS Innovations and the network.

She described herself as adaptable, loyal and hard-working, and was described by others as ‘approachable’ and accessible, with a friendly personality. She admitted that she could ‘adapt [her] personality dependent on who I’m speaking to’. Others saw her as motivated ‘to see that innovation developed for the benefit of patient care’.

Context

With a well-defined small geography, the largely rural region with an ageing population had high levels of deprivation and lower life expectancy than UK averages. Erin saw benefits arising from size and described herself as ‘lucky . . . it’s a small place. Everyone knows one another’. She reported that the board was ‘very, very powerful’, composed of NHS leaders supportive of the network’s ambitions, particularly in the wealth creation agenda. Not unlike other networks, political changes at the national level were front and centre on the agents’ minds, and they reported an uncertain future for the network. She reported close relationships between the local universities and clinical community, and a number of well-developed professional networks in the region.

Content

Erin led on the wealth creation agenda for the network, including developing service-level agreements, as well as monitoring due diligence and peer review of new products.

Activities

Erin operated at a senior-level in the organisation to create linkages and broker new relationships across organisations such as small and medium-sized enterprises (SMEs), local education partnerships and the Clinical Research Network. She facilitated the product development process by working closely with local staff to test and challenge their ideas before further resources were invested. She described this as ‘sense-checking’ and ‘idea health checking’ to determine ‘is it worth doing?’ and if so, whether or not a UK patent is appropriate. She described this as demystifying the patenting process.

Erin was supported by a team who provided more of the transactional activities, including working with partners to prepare them for board meetings and providing evidence and data to partners to support their market research, product development and business processes. The specific kinds of information were detailed as ‘potential sales volumes, how many hospital events . . . around the UK, how many cases that have happened, where there’s been patients that have been potentially injured’.

A Link interviewee described Erin’s contribution:

Erin was able to facilitate meetings and arrangements and we’re now in negotiation with the Health Authority about being a proper deliberate partner for them and looking at different ways of working with them.

Link

Erin reported working the wealth agenda at the national level with other commercial directors of networks.

Another key activity was developing funding bids and securing new contracts. Erin had been successful in securing matched funding, attracting notable amounts of European funding. She also delivered education and training, in particular related to the innovation and the intellectual property process.

Clients

Erin’s senior-level position within the network meant that she worked with senior leaders in the innovation space from across the various organisations in the network (e.g. SMEs, local education partnerships).

Outcomes

The support provided to local SMEs by Erin and her team was seen to be ‘really, really helpful . . . When we’ve been struggling to get decisions or struggling to get in front of the right people, they’ve always been useful on that front’. Brokering new relationships was allowing SMEs to engage at earlier stages of the development process with those in the health service who were the intended target for their new products.

The provision of data and information was also valued by local stakeholders. One Link interviewee commented: ‘We knew what we needed but we didn’t know where to get the information from. So that was Erin’s team that did that for us’. Having the relevant information enabled the Link to ‘negotiate better terms’.

In this way, Erin’s work was contributing to a shift in thinking around wealth agenda and a normalisation of innovation processes.

The agent

Janice was a clinical researcher with experience of conducting primary research, based at a local university. She divided her time between a knowledge mobilisation fellowship and completing her PhD. She worked as a clinician for several years before transitioning into a research role. She wanted practitioners to ‘feel that research is not an ivory tower’ thing undertaken by people ‘who are only in that for the paper’. She exhibited a belief in coproduction and believed in the need to engage service users if services are to improve.

Janice’s line manager described how she had ‘always been able to work independently,’ adding that Janice’s career path necessitated ‘a certain amount of resilience’ because ‘it’s not like there’s lots of handy signposts. You’re kind of making it up as you go along really’. She reflected that ‘a big part of what Janice does well is the fact that you can send her in to talk to anyone and she’ll do a good job and that she’ll leave a positive impression’. Another Link worked closely with Janice on her fellowship project and reflected that ‘Janice’s communication is really good . . . She’s really accommodating’. Janice described herself as ‘enthusiastic about every problem’ and ‘slightly relentless’.

Context

Janice worked in Wetlands alongside Erin. She commented that people were on ‘redundancy alert’ and awaiting the impact of the outcome of the general election (which was pending at the time of the interview in 2015).

In terms of internal context, Janice felt able to act with some autonomy and valued being based in a university rather than a hospital.

Content

The focus of Janice’s work was engaging with clinical staff and service users, specifically about maternity care.

Activities

Janice described what she did as ‘perhaps bringing a bit of reality into academia and a bit of academia into reality’. She collated and shared research evidence and information with the community of practitioners and service users depending on their needs. This involved working directly with the target audience to ‘decide which evidence the actual people want and which would be useful’. She used existing networks of mothers and babies to find out what their interests were and ‘how to explain research to them in a way that would make them want to be engaged with us’. She also presented to clinicians and attended local informal meetings to share the results of her work. In addition, Janice had a role in supporting fellowship applications.

Clients

Janice engaged with maternity clinical staff (e.g. midwives) and service users.

Outcomes

The Links responded positively to Janice.

Janice informed others of new research in the field as well as ‘the bigger picture of what’s going on at the hospital’. This Link was then able to share this learning with her patients: ‘So that’s been really beneficial in a very practical way for them. You know, just to inform and empower and allow them to know what their options are which has been really useful’.

One Link commented that ultimately she would expect to see ‘tangible outputs, resources for people to use in the future’.

The agent

Chloe was a lecturer at a local university, completing a PhD and working as a knowledge agent on a part-time basis. Originally trained as an allied health professional, she had many years’ experience, including management roles, and was recognised as a leader in her health professional community. Chloe described her role as one centred on engagement and increasing the two-way flow of knowledge between the university and the community.

Context

Chloe also worked in Wetlands.

Content

Chloe was a subject matter expert in her allied health field and engaged directly with practitioners in that field within the region to update their knowledge base.

Activities

Chloe’s role encompassed a number of related strands, notably identifying knowledge gaps, providing training in accessing and using evidence from research to inform practice, co-ordinating events and supporting colleagues to apply for fellowships and other funding in knowledge mobilisation.

Clients

Chloe worked with practitioners in the allied health field.

Outcomes

The training in using research evidence to inform practice was initiated and led by Chloe, and appeared to have resulted in learning gains and changed behaviour. Chloe reported that practitioners were increasingly incorporating evidence into their practice: ‘I’m seeing people and they’re saying, “actually . . . we ‘ve changed what we’re doing and we’re using the evidence”’. Chloe was able to look at available local data to see whether or not new evidence was being used in practice.

The agent

Molly was an experienced programme manager with a background in patient safety and QI. She was trained in improvement methodologies and applied IHI methods. As a member of the core network staff, her role was that of expert in patient safety and manager of a broad spectrum of the network’s activities.

Molly adopted a listening approach, believing in the importance of setting priorities for the work programme after hearing what the local population had to say. As a team leader, team-building was really important to Molly and she made an effort to work in the same office as other members of the team.

Context

The region this network site covers has a stable, older, population. Geography can be a challenge because other regional organisations have different boundaries than the Homefields network and the region itself is large. The region had an established CLAHRC with which they collaborated. The economic pressures were described by the line manager as ‘particularly acute here at the moment and much like other regions, our authority partners are struggling’. Despite the challenges, one observer noted a ‘very collaborative spirit’ in the region. The network benefited from strong, vocal, representative and engaged leadership from their board. Challenges also arose from the network having to shift its priorities according to central policy and funding decisions. For example, the patient safety agenda became one of the main programmes during the period with a budget and political importance attached to it.

There was a notable entrepreneurial spirit within the Homefield team, driven in part by their own funding uncertainty and evidenced by a long-term business model with sustainability as its goal. The organisational structure was purposely relatively flat, allowing a more flexible approach and giving individuals scope to experiment. The organisation was described by Molly as ‘complicated’, yet also ‘a really nice organisation to work in’.

Content

Integrating care from an individual patient point of view rather than integrating disease pathways was the priority. However, Molly also referred to traditional disease-specific projects such as strokes and diabetes.

Activities

The core network team, of which Molly was a key player, invested its time in an early listening exercise before determining the regional priorities. Molly used the term ‘honest-broker’ to describe the role of the network as it functioned as a conduit between various silos. Molly and the team were data driven and strove to connect new groups of people in the general field of patient safety.

Molly’s core role was project management and she led on the patient safety portfolio of activity. She worked across what she described as two types of projects, fact finding and field testing, and across different levels – macro and miso – in the system. She was concerned with how projects were prioritised and how the network achieved regional oversight of their activity, given the number of initiatives in the region. Molly looked to reduce duplication of improvement activity across the patch, and sought to link similar initiatives and to collaborate. She described a number of tools that were being created by the network, including a public-facing central repository of projects and a project management system. They were developing regional standardised, co-ordinated approaches in patient safety and patient feedback systems. Establishing the regional patient safety collaborative across all sectors (not just acute settings) became a significant part of Molly’s role during the study.

Molly was credited with co-ordinating a series of training sessions in IHI methodologies for a large cohort of practitioners. She also performed a range of roles in regional engagement events, from speaking at the event to co-ordinating registrations.

Clients

Molly worked with lead clinicians and others (e.g. project managers), proposing an improvement project within the network.

Outcomes

Responses to the honest broker role were positive. The line manager was ‘impressed’ with the QI training programme.

The organisation learned about the community’s priorities and regional improvement initiatives. Participants in training developed skills in QI methods.

Describing themselves as a listening organisation, Molly and her colleagues felt that they were contributing to a shift in culture.

Knowledge and innovation transfer agents’ expectations of their role

Knowledge and innovation transfer agents performed diverse roles and held many responsibilities that exemplify their boundary-spanning function. Their primary accomplishment was to link quite different communities and individuals. These linkages were made both within their organisation, across different departments or levels of management, and between organisations, notably linking academic and health services practitioners (managers and clinicians). They led change initiatives and challenged local practice by introducing and employing different knowledge sets (including both research-based and experiential knowledge). Another element of their role was building local capacity around KIT.

Role ambiguity and learning on the job was common across agents, but those who were well supported by line managers (e.g. James, Janice) were able to actively define their role, which played a part in their success. In several cases when the role was ill-defined or misunderstood, the agent took on work outside their scope or skill set, which could lead to feelings of anxiety and inadequacy. For example, Amy reflected in her audio-diary how she was being asked to take on too much:

So the meeting finished and I felt really anxious, really overwhelmed. My boss didn’t have time to hang around and catch up with me but I did speak to [Name] and I said that I felt really uncomfortable that I was going to be the core person trying to bring all this together, for lots of reasons . . . I felt way out of my depth, really uncomfortable in the job I was doing and really inadequate.

Amy

Another agent at Riverside, Fran, described how she took on work that ‘wasn’t actually meant for me’ and ended up doing a lot of the project rather than advising and coaching as was intended in the role. She reflected:

I wasn’t there as an extra pair of hands. I was there to improve their skills to do it.

Fran

Knowledge and innovation transfer agents expressed longer-term expectations for their role, including changing local culture, improving patient care, and improving relationships between academia and the NHS. For example, Sophie described how introducing a different format to ward meetings helped remove professional hierarchies, encouraging everyone to challenge each other. She felt that the process helped people to think differently and reflected that ‘the whole organisation feels different’. This suggests a way in which the KIT role could lead to a change in local culture.

Line managers’ expectations of knowledge and innovation transfer agents

Line managers had expectations that corresponded with all of the functional expectations held by agents. These included the centrality of building relationships as part of an engagement role, facilitating change and building capacity. Line managers also felt that the engagement role should ultimately lead to improved ways of doing things and improved patient care. However, this was viewed as a long-term goal as the role developed. James’s line manager described the first year as one to ‘raise awareness to have some warm feelings’ but expected beneficial outcomes arising from year 2 and beyond. He described these outcomes in terms of empowering others and building capacity: ‘. . . whether people feel that they are empowered to get on with changing their individual areas and whether they feel skilled’. He expected that such outcomes could be measured:

. . . and I think we can track some of those kinds of measures through.

James’s line manager

Other expectations about outcomes expressed by the line managers included the view that outcomes were delivered through a collective partnership and not held by one individual (Molly’s line manager) and that these roles do not necessarily generate financial savings, but recovering investment was a more appropriate framing around costs (James’s line manager). For this line manager, recovering investment meant that the KIT agent’s work would generate a level of savings within the organisation over time making the original investment cost neutral. However, measuring improvement or efficiency savings was described as challenging by Grace’s Link.

Links’ expectations of knowledge and innovation transfer agents

Links also expected KIT agents to make linkages between various parts of the organisation and individuals (e.g. between operational staff and the executive board) and to facilitate practice change. Uncertainty about the role and poor communication by the line manager were identified as problems. However, Links did not fault the agents for poor communication but rather reflected that they themselves needed to take time to find out more about the agent.

Knowledge and innovation transfer agents were also seen as experts by their colleagues, either based on their professional experience, subject expertise or experience in the specific organisation (e.g. the Links of Isabelle and Sophie). One of Amy’s Links expressed anxiety over the KIT role and had expectations that ‘they wouldn’t link in with our usual processes’. This hints at the importance of understanding and working within local contexts.

The knowledge and innovation transfer role: risks and sustainability

Knowledge and innovation transfer agent roles are seen as risky and lacking traditional forms of recognition in terms of progression and opportunities. Agents who left their clinical or managerial jobs to take on these roles expressed concern about future uncertainty:

I’m taking a bit of a personal risk, you know, I’ve dropped 70% of a job to be able to do this and at the end I have no, you know, I’ve got nothing lined up particularly. So I think there’s a real risk.

Janice

This agent went on to reflect that at the end of the fellowship she might end up back in a clinical role in which she would be ‘extremely restricted in how much [she] could do’. A related issue is the lack of a career trajectory as emphasised by Janice’s line manager: ‘the reality is that people don’t get promoted or don’t get career recognition on the basis of these things. Not yet anyway’.

We also found that academically oriented KIT agents were taking on a risk in moving away from traditional academic outputs and focusing on knowledge transfer and mobilisation. Jessica felt relatively secure in her current role, but expressed the lack of recognition from her university employers:

But then do my employers recognise that? Not a chance. I’m OK with my current [profession]. If my [profession] changes I will be in big trouble about that one.

Jessica

Another challenge for sustainability and attractiveness of these roles is that KIT work seemed to be undervalued and invisible compared with clinical duties. Fran’s Link reflected that the work of the KIT agent was something that was squeezed in alongside real (‘actual’) work: ‘I think it’s really about finding time to do this because obviously you’re doing it while you’re doing your actual work’. The invisibility of the role raised challenges around attribution and costing the role against organisational targets.

Agents on short-term fellowships (Amy and Fran) discussed having trouble finding a go-to person for a proper handover at the end of the fellowship. They felt personally responsible, but others felt it was an organisational responsibility. One of their Links suggested that there should be some kind of an agreement from the trust to fund the position after the fellowship: ‘maybe for sustainability that actually when you enter into that partnership within the organisation, . . . that there’s the agreement that they will support the sustainability once that fellow’s gone’. She likened this to the model adopted by some pharmaceutical companies who only invest in funding a short-term role when the organisation agrees to continuation funding.

Aware of these challenges (summarised in Table 9), many of our agents adopted proactive strategies including planning for hand-over from the onset by training others and developing capacity, pursuing other funding opportunities and focusing on demonstrating value.

Factors related to individual dispositions

Although technical knowledge is essential, many participants identified dispositional enablers as critical to the KIT role. These include outlook or attitude, having a supportive and skilled team, and the status of the individual. Links also described the importance of the agents’ leadership skills and interest in the change process.

Attitude and outlook

Six of our agents were described by their Links as having a can-do attitude and presenting as enthusiastic when working with front-line staff. One agent (James) reflected: ‘it’s about taking an attitude that this is possible rather than what’s difficult about it. To say, “this is the way forward, how do we overcome the problems” rather than be deterred by them’. This agent’s approach did not go unnoticed: one of his Links described it as ‘being solution focused, not talking about problems but talking about, “what are the issues here?”’.

In line with KIT agents’ own expectations, line managers expressed how a proactive approach to the role was a critical ingredient for success:

It’s doing the horizon scanning rather than waiting . . . Someone proactive, I suppose. Yeah . . . they need to have demonstrated that they can be proactive and will be.

Janice’s line manager

Fran, for example, described how in the first few months in post she had been proactive and met with different teams to define her projects.

Leading change, whether through innovation or implementing research, takes time and agents needed to be able to sustain their interest. One Link described Sophie as ‘tenacious’, adding that ‘it’s not been a 1-minute wonder. She’s sustained her interest in it’. Large system changes in particular required sustained attention.

The status of the agent

Agents with status in the organisation enabled engagement, especially with hard-to-reach groups such as consultants. One agent (James) reflected that being a senior doctor and directly accountable to the chief executive were two critical factors that facilitated his role. Another agent brought along a senior consultant when she facilitated a QI session with a group of challenging consultants. This approach proved useful and led to further reflections on the value of bringing together clinicians and managers:

So it was really useful for her [senior consultant] challenging them and making them think. So we’ve sort of reflected that where possible we need someone of that level, ideally a consultant peer in the room. Equally they’re all feeling quite frustrated that they have tried to get . . . quality improvement, but they feel they can get blocked by managers . . . So we’ve reflected that we really need some sort of senior manager in the room or they need to bring their managers.

Amy

The agent is unlikely to have the relevant status in all groups; one solution is to directly involve others (such as clinicians, managers) to complement the status of the agent.

Being known and having an established network of contacts within a region enables an agent’s capacity for brokerage. Chloe, for example, mentioned how she is often approached by members of her profession’s clinical network to provide the latest evidence on a subject because she is ‘well-known’ and knows who to contact within the network. Being well networked also helped agents gain buy-in from the ‘right’ individuals.

Leadership style

One of the qualities that KIT agents associated with good leadership was being a team player. Sophie’s line manager spoke of her leading from the front, saying ‘[Sophie] would pick a trolley up, you know, and help move a patient to a ward, if she was based on one of the sites at the tail end of the day’. Humility [e.g. ‘I demonstrate. I don’t always have the answer’ (Sophie)], creativity and celebrating success were valued. Another facet was a coaching or nurturing style:

You’ve got to make the conditions right, really, for people to share, to be transparent, trust and to learn. I think we all know that no one is perfect, but actually by working together and by applying improvement methodology you can really make change happen.

Grace audio-diaries

However, agents’ style differed and not all our agents felt they were always performing as a leader. Sophie’s style was perhaps less nurturing: ‘I don’t need that positive stroking to get me where I am and I sometimes struggle with other people requiring that’. What worked for one agent in one circumstance might not work for another in a different context. Factors related to individual dispositions are summarised in Table 10.

Organisational and network (meso) factors

Our study coincided with the initial stages of the AHSN and SEWAHSP development. Here, we explore the AHSN and SEWAHSP context as it relates to the KIT role and organisational factors facilitating or hindering KIT role success.

Network context

The agents in our study related to their host network in different ways:

• employed and based in the network (n = 4)

• based in network partner NHS organisation (n = 5)

• joint appointment (n = 2)

• employed by a university (n = 2).

Being employed by the network provided the agents with dedicated time away from their usual clinical or managerial duties to perform their knowledge brokering work. Agents reported a number of other enabling conditions including being based in a less hierarchical organisation with an entrepreneurial culture and having a peer group for knowledge exchange in their home network. However, the network-based role meant job insecurity in the long term; they needed to demonstrate their added value and secure longer-term funding. They were not performance managing those involved in change, so sometimes had limited influence and the networks were themselves complex organisations, as noted by Daisy:

So there’s something about the fact of what the AHSN does. They seem to be implementing or looking at issues at lots of different levels within health care. So, surprise, surprise, it’s even more complex and we’ll require a variety of methods, I think, rather than one approach.

Daisy

Agents also reported a competitive environment between the networks at a national level. For example, although directors received support from a national network of AHSNs, agents reported this support did not extend beyond the senior level.

Agents based in partner organisations reported similar enabling/hindering conditions and also felt they had to take the initiative to develop and articulate their role within their NHS organisation.

Agents on joint appointments were less susceptible to some of the challenges mentioned by those based in the networks but were faced with other issues around splitting their time and negotiating the different organisational practices. Molly remarked that ‘shared posts’ were a good idea but ‘a challenge for whoever fulfils the post because the two organisations are so different in terms of the way we work’.

Being based in a university gave KIT agents access to library resources including librarians providing literature reviews and training resources. Both our university-based KIT agents had a clinical background that they used to secure buy-in with their NHS-based clients. Chloe described this advantage as being able to say ‘I’ve done it’, which helped remove the barrier to being seen as external to the client’s clinical community.

Network characteristics

Case study networks were selected to cover four points of divergence as explained in the sampling section in Chapter 3. Here, we briefly explore our findings across the different categories of network characteristics.

Resources to support knowledge and innovation transfer work

Organisational leadership and support

Agents reported that support from the executive boards and their line managers helped them to achieve desired change. Board and executive leader support were mentioned as enablers by several agents:

I think the exec[utive] leadership in that particular organisation is an enabler because it’s visible, it’s palpable . . . The chief exec is around all the time saying hello to people.

Isabelle

The change, certainly the change in attitude for the chief executives . . . and the support that they give is massive, and I can’t stress how important it is to have such a strategic board.

Erin

James outlined the importance of getting senior decision-makers interested and engaged at an early stage. He also emphasised the importance of developing leaders through targeted training programmes and reflected that his unit’s leadership programme was ‘probably the most important thing we’ve done’.

Molly’s line manager was inspired by some of the more innovative and entrepreneurial companies that provide their employees with freedom and he reflected ‘I think we’ve got to be in that space’. He created a relatively flat team structure and tried to avoid heavy top-down management.

Organisational culture and receptiveness

We heard from many agents that the organisational culture supports KIT work. One line manager (for James) described his guiding philosophy as valuing the input from grassroots: ‘. . . rather than feeling that we [Executives] are always right . . . the best value you can do is listen to your front-line staff who often know the best way of doing these things’. Another site (Homefields) very deliberately became a ‘listening’ organisation and used feedback from partners and the community to prioritise their work programmes. Agents reflected that organisations that do not listen to the needs of their stakeholders will erode trust and ‘set the relationship back’ which undermines the change programmes (James’s audio-diaries). One Link reported how Sophie helped to create a culture in which people were encouraged to question members of their team, from the doctors to the porters:

Well now everyone will challenge everyone, which is very healthy. It’s very, very, very well done.

Sophie

Aspects of the local culture that were described as unhelpful included a ‘very silo approach’, failure to cascade information from leads to the front line, and overlap of departmental missions leading to role confusion and duplication. Agents were challenged by the conflict between national and local policies. James, for example, described the ‘separate’ but overlapping initiatives:

People working on [improvement initiative] project internally and then there’s the national [improvement initiative] but they’re separate and we‘ve met quite a lot of resistance to trying to refocus the people internally, from one or two people who are quite senior.

James

Another challenge was described as ‘initiative-itis’ by the Moorlands line manager. Juggling different projects simultaneously without any additional resource was judged to be disabling for all concerned.

Interestingly, organisational culture was not seen as set in stone or immutable. James’s line manager spoke of redefining the executive team’s core values and introducing the improvement unit as part of an organisational ‘recalibration’. In Sophie’s site, the line manager explained how the creation of a space for professionals to meet and ask questions of each other had contributed to an organisational ethos that underscored the patient, as opposed to the professional hierarchy, as the central focus.

Organisational receptiveness, or lack thereof, influenced KIT agent activity. Jessica reflected that receptiveness towards researchers was ‘the greatest one that we’ve found’ when asked about barriers to KIT. Molly’s line manager summed up the idea of working with the willing:

People when they want it and embrace it, that’s where you get change happening. So, you know, if you look at some of the projects . . . where they’ve been successful is because the organisation wanted change and where they commissioned that piece of work, and that’s when they drive it. When they don’t want it, it’s just . . . it’s painfully, painfully difficult.

Molly’s line manager

Organisational enablers and barriers are summarised in Table 11.

External (macro) factors

Constraints manifest at the meso level often emanated from pressures in the wider NHS context. We consider briefly the influence on the work of the KIT agents of national politics and the culture at the system level.

Politics

National policy drivers are seen as both enabling and constraining. A key barrier was frequent changes to national policy. Table 12 summarises policy changes in England and Wales alongside key network developments.

Erin expressed concern about the consequences of political change:

HIECs [Health Innovation and Education Clusters] had just come into force. They’d just got up and running . . . If there’s a change in Government, will the AHSNs be scrapped?

Erin

A shortfall in central government funding for the networks was mentioned during the meetings and events we attended (e.g. Homefields observation, 2 July 2014). Delays in licensing meant network teams risked spreading themselves too thinly early on. During the course of our study we witnessed how the networks in England shifted their original plans as they responded to new programmes of work making them, as Molly observed, ‘incredibly chaotic’.

The different geographical boundaries introduced by recent national policies in England presented another barrier. For some agents the boundaries varied across different organisations within a region. The landscape that agents operated within was complex and constantly changing.

On the other hand, the political scene could be enabling, for example if the agent could position their work within an emerging priority. Jessica observed: ‘So, you know, politics can hinder but equally can be an amazing driver for something to happen both nationally or at a micro level’. Molly was able to take advantage of the patient safety initiative to grow her contribution.

System-level culture

The culture at the system level in the NHS also affected the KIT agents. The culture was characterised as one that was focused on short-term budgeting rather than better quality of care in the long run; dominated by command and control/hierarchical structures; driven by targets and performance instead of understanding patients and demands; and a relationship between primary and secondary care that was negative and competitive (James). Another agent (Sophie) drew attention to what she described as a ‘risk averse’ culture, which means that patients could not be discharged until the potential risks at home had been solved, yet they are running similar risks in the hospital on a daily basis. Table 13 presents a summary of external barriers and enablers.

Content

Agents adapted their language and knowledge approaches to the local context and found some hooks by simplifying the process of knowledge mobilisation or by using metaphors to engage their clients.

Concepts and definitions

Project-level factors

Agents (Amy and Molly) mentioned a number of enabling factors at the project level, including starting from the beginning of a project rather than halfway through, setting clear boundaries for deliverables, timing (e.g. engaging with junior doctors once they had had a chance to settle in) and working on a tangible or visible change project. Also, having a shared set of outcomes with other professional groups working on the project was referenced as an enabler to keeping all parties engaged or accountable. Some agents mentioned logistics as a barrier in terms of travelling across their geography on certain projects.

Customising evidence

Tailoring emerged as a common strategy across agents. We found KIT agents focused on understanding the local context and the knowledge needs of their clients or partners. Janice described how she interviewed her clients to understand the context around use of evidence: ‘where the people do use evidence and how they use it and when they use it, and why they use it and what’s important to them about it’. She stressed the importance of understanding the content from their point of view so that ‘when we’re taking it back to them then we have a much better understanding about how it could be useful to them’.

Moorlands introduced evidence summaries as a tailored response to questions from their partners on topics not well evidenced in the academic literature. Daisy described a similar approach to the evidence summary work and emphasised the importance of context and knowing what was needed: ‘I think it’s just about having an awareness and understanding what’s going on in each of those trusts, what that person wants’. She explained that the role was not simply about producing the summaries but also the ‘pre-work’, which involved having a conversation with the individuals requesting the evidence to find out what practices were currently used, whether or not they have the capacity to act on the evidence and what other things they need to consider.

Despite customisation efforts, Links could still be challenged by the volume of information. One of Janice’s Links mentioned receiving 400 e-mails a day, and Holly’s Link referred to looking for one-liners to peak their interest. Table 14 shows a summary of content-related factors.

Conducting knowledge and innovation transfer activities

This section explores the factors that helped or inhibited the KIT agents in carrying out their role. It is noteworthy that more than half of our sample of agents (n = 7) were applying QI methodologies, sometimes described as continuous improvement. This is in contrast to four who focused more on implementation of research knowledge and two on engagement. The importance of being able to engage others was a common observation across the agents. James commented, ‘most of this is about engagement’.

Engaging others

Supporting and encouraging were key means by which the agents developed engagement:

I feel like my relationship with everybody I’ve worked with has been much more of a support motivator, providing clarity, positivity, holding hands, a lot of holding hands with people, coaching them, encouraging them. Sort of really saying, ‘you’re doing well, you’re doing well’. Saying to people, ‘you know the Board know you’re doing this and that’s really good’.

Fran

Amy was described as visible, attending every meeting and visiting front-line teams to help progress the project. She acknowledged the challenges the team were facing in terms of low morale as a result of a vacant unit lead role. One of her Links reported how she brought doctors and nurses together in the morning.

The importance of ‘going out to where people are’ and making them feel valued was echoed by Janice. She describes herself as ‘enthusiastic about every problem that’s put to me, because I think you have to be because . . . if you can’t be enthusiastic then you can’t expect anyone else to be’. The danger of having a charismatic individual leading the change is that they become the face of the improvement or innovation and their departure is a risk to the overall success of the initiative.

Several agents reflected that, although the tendency is to send e-mails or telephone, there is no substitute for face-to-face engagement. Isabelle mentioned scheduling quarterly visits to the trusts in her region as one method to ‘keep up the contacts and relationships’. Amy described how building relationships was central to getting clinicians to participate in training or capacity building. Another agent, Jessica, reflected that her efforts to meet with a project lead early on in the process contributed to them developing a productive relationship:

Even though it’s just like a 2-hour journey to it, I physically went and met the person . . . I had to wait I think an-hour-and-a-half . . . until he actually turned up . . . Even though it basically wiped out the day, it was a valuable thing to do because . . . we have developed a relationship.

Jessica

Our Link interviewees highlighted how being responsive to requests helped KIT agents achieve positive engagement. Ignoring or not paying attention to requests made by those involved in the change process inhibited success. One agent (James) described a situation in which a professional group requested a paper to go to them prior to publication but this request was not granted. James reflected on the consequences:

This feels like a common theme, that we don’t pay enough attention to what other people want and deliver on it when we say we will and this leads to a lack of trust.

James

Engagement facilitated further engagement: agents described an approach that encouraged front-line staff to come up with ideas which they then take forward. Such ownership enabled them to ‘take it forward in a much more meaningful way’ (Amy).

Challenging

Much in this section suggests that agents should be amenable, encouraging and responsive to requests (Table 15 provides a summary).

Such tactics seemed to facilitate engagement and from this position, practitioners could be encouraged to progress things themselves. However, there was also an argument for agents to adopt a more challenging stance, as some did (for example Sophie, James). James clearly articulated the tension between nurturing and challenging:

What we’ve got to be careful of we just don’t become part of the same fabric as everybody else because the whole point of this is that we’re an irritant to the system. We shouldn’t be in bed with the system. We should be poking it. Asking it difficult questions, saying, ‘why are you still doing this?’ So there’s something around how you manage that tension, if that makes sense.

James

Question 1: with whom should knowledge brokers connect?

The first question was amended slightly from ‘who do knowledge brokers serve?’ The panel agreed that our focus should be on the ideal (‘should’) rather than what might happen in practice (‘do’), and ‘connecting with’ was thought to be a better reflection than the more subservient and limited term ‘serve’.

A large number of responses (n = 30) were given to this question. Following discussion, items 24 and 30 were combined into item 17 prior to voting. The participants were given six voting cards (two 3-point cards, two 2-point cards and two 1-point cards). Thus, if all eight panel members used all their cards, a total of 96 voting points would be assigned. The results of the voting are displayed in Table 16. Each response was assigned a number reflecting the order in which it was suggested. The table is ordered by the results of the first round of voting. The two items that were combined (29 and 30) are marked with an oblique (/) and a dash (–) is recorded in the voting columns. In the first voting round, the item attracting most votes by some margin was ‘front-line clinicians’ (22 votes). The next highest number of votes was eight; five responses attracted seven or eight votes in the first round of voting. Nine responses attracted no votes.

The pattern of voting changed markedly between the voting rounds. Although ‘front-line clinicians’ still came out on top, the number of votes reduced from 22 to 13. Two items attracted the next highest number of votes (n = 11): service users and other knowledge brokers. In this second round of voting, two new items entered the top five: organisation and development change agents (nine votes) and researchers (eight votes).

We note that one panel member chose to not use three votes (hence vote 2 totals 93).

In summary, on the basis of two rounds of voting, the panel thought that knowledge brokers should connect with:

• front-line clinicians

• service users

• other knowledge brokers

• organisation and development change agents

• researchers

• managers

• policy-makers

• everybody necessary.

Question 2: what outcomes should knowledge brokers try to achieve?

The second question was amended slightly, to keep the focus on the ideal (‘should’). Forty responses to this question were provided. Item 33 was discussed and deleted prior to voting as it was a duplicate of item 11. The results of the voting are displayed in Table 17. Between the voting rounds there was some consolidation of voting; although there was no change to the top two ranked items, the votes were spread between fewer items (24 on the first vote; 15 on the second). In the first voting round, the two items attracting most votes by some margin were ‘safe, effective and efficient treatment and services’ (17 votes) and ‘better quality of life for population’ (16 votes). No other item attracted more than seven votes.

In the second round of voting these two items (i.e. ‘safe, effective and efficient treatment and services’ and ‘better quality of life for population’) pooled 19 and 16 votes, respectively, and were joined by ‘build capacity and capability (around knowledge mobilisation, use of knowledge)’ (16 votes). Four items were awarded 6–8 votes (‘informed decision-making/policy-making’; ‘adoption, spread, scaling up at pace’; ‘evidence of improvement’). No other item attracted more than three votes.

In summary, on the basis of two rounds of voting, the panel thought that knowledge brokers should try to achieve:

• safe, efficient, effective treatment and services

• better quality of life for the population

• increased capacity and capability (around use of knowledge, knowledge mobilisation)

• informed decision-making/policy-making

• adoption, spread, scaling up at pace

• evidence of improvement

• increased research use and impact.

Question 3: what should knowledge brokers do to contribute to the achievement of outcomes?

The third question was amended (from ‘what do knowledge brokers do to achieve these outcomes?’) to keep the focus on the ideal (‘should’), and ‘contribute’ was added to recognise that knowledge brokers might be only a part of the process.

This question elicited 42 responses. On discussion, items 10, 13, 15, 20 and 21 were identified as personal skills or attributes and so seen as part of item 1 (‘personal skills and credibility to make connections – interpersonal, being present and known’). In addition, overlap between items 28 and 38 was noted. These were combined and, on further discussion, added to item 5 (‘motivating others to use knowledge’) prior to voting. The leadership part was added to item 12.

The results of the voting are displayed in Table 18. In the first voting round, the item attracting most votes by some margin was ‘personal skills and credibility to make connections (interpersonal), being present and known’ (22 votes). The next highest number of votes was for item 12 (‘teach, train, support, mentor, counsel, lead’). It is perhaps not surprising that these attracted most votes as they each included a number of elements.

In the second round, a further two items attracted notable numbers of votes: item 5 (‘motivating others to use knowledge’; 17 votes) and item 3 (‘facilitate access to knowledge, evidence, information’; 12 votes). No other item attracted more than six votes. We note that not all panel members chose to use all their votes in the first round (hence vote 1 totals 88).

In summary, on the basis of two rounds of voting, the panel thought that to contribute to the achievement of outcomes, knowledge brokers should:

• use their personal skills and credibility to make connections

• motivate and influence others

• teach, train, support, mentor and lead

• facilitate access to knowledge and evidence.

Questions 4 and 5: how can we measure (by proxy) the achievement of outcomes?

The panel decided to take the fourth and fifth questions together as they felt that discussion of ‘how to measure’ could not be separated from ‘what data’. Before suggesting responses, the panel commented on it being a highly complex question and that direct measures would be difficult to identify. They decided to allow for the inclusion of ‘proxy’ measures.

There was extensive discussion around the need to focus on one specific outcome when suggesting responses to this question. As a consequence, measures were suggested just for the most important item from question 2 (what outcomes should knowledge brokers try to achieve?); thus, the suggestions, and subsequent voting, were in relation to how we can measure the achievement of ‘safe, efficient, effective treatment and services’. In principle, the group could have repeated the exercise for the other main outcomes for question 2 [i.e. ‘better quality of life for population’, ‘build capacity and capability (around use of knowledge, knowledge mobilisation)’, ‘informed decision-making/policy-making’, ‘adoption, spread, scaling up at pace’, ‘evidence of improvement’, ‘increase research use and impact’]. However, this was not feasible in the time available. The important generic point of note was the need to relate the measure to specific intended outcomes.

Twenty-eight responses were given to ‘how can we measure the achievement of safe, efficient, effective treatment and services?’. On discussion, ‘of knowledge broker services’ was added to item 17 to clarify that these self-reported outcomes from ‘users’ were in reference specifically to the services provided by knowledge brokers. The results of the voting are displayed in Table 19. Three items pooled between 13 and 15 votes each. Four other items attracted between six and eight votes.

Considerable discussion followed the first round of voting and the group decided against a second round. Points of discussion included the following.

• The challenge of causality: the work of knowledge brokers may only be indirectly related to impacts; for example, it is not possible to attribute causal links between their work and mortality rates. An attempt to relate their activity to impacts encounters too many confounding, intervening variables, making causal relationships untenable. Here we note that more discussion of the difference between more immediate ‘outcomes’ and wider ‘impacts’ might have refocused attention away from measures related to patient or population groups.

• The value of case studies: in the context of indirect relationships between impacts and knowledge brokering activity, the panel highlighted the value of case studies.

• The need to link specific goals to outcomes: again the panel emphasised the need for measures to be specific to intended outcomes. They rejected the idea of generic measures.

• Who determines the knowledge broker role? Leading on from discussion of the need for measures to be specific to intended outcomes, the panel discussed how the work of knowledge brokers varies and is determined by whoever decides on the role specification.

• Context and complexity: the complexity and relevance of context in determining the success or otherwise of knowledge brokering activity was raised – what works in one context might not work in another.

• The unmeasurable: for example, influence – the panel recognised that an inherent risk in presenting responses to this question was that attention would necessarily focus on what might be ‘measurable’, which would ignore important ‘unmeasureables’.

This was an important discussion and resonated with findings from the case studies.

Learning

Link interviewees highlighted the importance of the agents’ role in achieving increased capacity. This was sometimes spoken of in general terms, and sometimes more specifically, in relation to improvement methodologies. For example, one of the interviewees linked to Fran referred to the ‘growth’ she created in others. One of James’s Links described what he saw as the limited skill set in QI methodology, which ‘is ill-understood in the front line and very rarely utilised’. In his view, the number of people or projects using QI methodology was a good metric. An agent at Moorlands described how she planned to track downloads of their evidence reviews to understand spread of the product and seek qualitative data on how they were being used.

Behaviour

A number of agents watched for signs of cultural change within the organisation as a result of their role. They looked for changes in behaviours – people doing things differently. Chloe, for example, saw her success in terms of ‘evidence of people incorporating evidence and to put it into practice’. More rarely, agents mentioned specific behavioural change measures:

I’m looking for how well we’re doing at sepsis to get that looking better. That was our aim. That’s why I was brought in.

Amy

Implicit in Amy’s example is the importance of relating the measures to the intended outcomes. Erin provides another example of measures linked to intentions:

We’ve already attracted £600,000 worth of European monies . . . So I think really I’m probably the one individual . . . that is responsible for business development and bringing in, attracting in other contracts.

Erin

According to one of Isabelle’s Links, she saw that as the KIT role related to ‘influencing organisational strategy . . . influencing training and development,’ it should be measured by ‘how people change their behaviour or change what they’re doing as a result of interacting with her role’. Isabelle herself admitted to ‘struggling’ with measurement and drew attention to some of the easier-to-measure things such as ‘the number of people that are reaching out or the number of interactions that are going on’. Chloe saw her role as engagement and judged it appropriate to look at ‘the number of collaborative projects . . . between the university and the community’. Sophie also approached the question from an engagement perspective and referred to things that could be easily measured: ‘number of people willing to work with them’, ‘being invited to chair regional groups and lead on external reviews’. In a similar vein, Amy counted relationship building as a measure of success: ‘when I walk into the A&E department people say, ‘Hi Amy’, that they know who I am. They say hello to me’. Of course these quotations do not report anything about how such interactions change what people then do, a gap that was identified in the nominal group and by participants in Mansfield and Grunewald’s221 workshop.

Some agents spoke in terms of changed norms or ways of thinking:

The level of conversation that now starts with . . . ‘what about these patients, they’re delayed. How can we work together to change that part of it?’ It’s no longer the muddle. There’s still loads to do. This is probably 1 year of about a 5-year change process, but it’s . . . people are engaging all the time now.

Sophie

I was hoping to make . . . people kind of feel that research is not an ivory tower, people who are only in that for the paper, but there is a role for people to work together.

Janice

Results

At this level, measures would relate to improvements in organisational performance. These were rarely identified, although Sophie described outcome measures at this level:

I think the outcomes that have come out of this piece of work have been enormous and far reaching to the point of organisational reputation as well. So, you know, I can pull up umpteen graphs around our 4-hour, 8-hour, 12-hour, for months. I can look at the 15-minute handover. I can look at how many operations. So there’s those outcome measures but actually the fact that the whole organisation feels different. The fact that we are viewed very differently by . . . Government because we’re delivering on what we said we’d deliver on.

Sophie

Of course the risk associated with narrowly equating the impact of the KIT agents’ work with ‘results’ is that it underplays their contributions, and, as we have argued, learning and behaviour are also forms of impact.

We summarise these KIT agents’ suggestions in Table 20.

Principles

• Distinguish between measuring what agents do and the effect of their actions on the behaviour of others.

• Relate the measures to role specification and specific intended outcomes (rather than more distant population health improvements).

• Do not try to claim causality: the work of knowledge brokers will be indirectly related to outcomes and confounded by other factors.

• Take account of context: the success of knowledge broker activity will be facilitated and inhibited by local internal and wider external factors.

• Tailor measures to specific circumstances.

• Do not ignore the unmeasurable (e.g. a knowledge broker’s influence).

Framework

Drawing on experience of case study preparation for the Research Excellence Framework 2014,160 Morton231 developed a framework designed to explain and provide evidence of how research contributes to policy and practice. Based on logic modelling, the framework sets out a pathway from inputs and activities to change in practice and, finally, outcomes.

Morton231 acknowledges that the process of research utilisation is complex and that assessing research impact is challenging. In recognising the ‘context-specific and variable nature of impact’ she endorses the value of the case study approach. In addition to context challenges, she describes attribution as a key difficulty in the assessment of research impact; the results of research are integrated into practitioners’ existing beliefs and practices and moulded to particular circumstances, which makes it problematic to attribute outcomes to research in a causal fashion. Thus, her framework is based on the principle of research contribution.

Although Morton’s research contribution framework is intended to be used to assess research impact, and by contrast our focus is on the impact of knowledge brokers (which may be one factor in a research impact pathway), there is considerable value in considering the framework and adapting it in light of our research, to devise an approach to measuring outcomes of knowledge broker activity. We decided to use Morton’s231 framework to inform our own because it accords well with our proposed principles. Also, we note similarities with Kirkpatrick’s198 model of programme evaluation.

We set out our framework in Table 21. It is organised around five areas of contribution: inputs, activities, capacity development, behaviour and outcomes. In the second column we add a brief description about the concerns of each area, and in the subsequent three columns we provide example indicators, evidence and likely barriers to, and enablers of, the achievement of desired outcomes.

Strengths

The qualitative approach taken with KIT agents and their clients (the professionals we have called Links for the purposes of the study) provided rich data on their real-life experiences. These data enabled us to better understand their role and the context of their practice. By setting the study in a complex, natural environment, we achieved high ecological validity. 252 Our engagement with agents typically extended over more than 1 year, from negotiating initial access to the final feedback discussions. This gives our experience of agents a longitudinal aspect, which was facilitated by the KIT agents’ audio-diaries. For agents who kept them, these audio-diaries captured their experiences and reflections after initial interviews and proved to be a valuable way of providing a more comprehensive coverage of their experiences. Data from the audio-diaries served to confirm and extend information gathered from interviews. We triangulated our data from agents with data from other sources: the observation of meetings and events; documentation research; and semistructured interviews with KIT agents’ line managers and Links. The validity of our findings was further strengthened by engaging nine case study agents in three networks in checking the analysis and interpretation of their case studies. Any bias as a result of the Hawthorne effect was reduced by conferring anonymity on the respondents.

The use of existing theoretical frameworks to guide study design, data gathering and analysis enhanced our consistent approach. These included the Kirkpatrick framework198 and Walker et al. ’s 128 classification of factors influencing change, and have been reported in Chapter 3. In data coding and analysis, we took measures to ensure internal consistency, and as a research team we regularly reviewed and discussed our interpretation of the data and periodically took data to the advisory group for discussion. Our advisory group was strengthened by the contribution of two service users who kept us focused on patient outcomes. Their feedback drew our attention to the lack of consistent approaches to patient engagement across the AHSNs (advisory group meeting on 4 February 2014), and helped us to understand why PPI did not feature prominently in most sites. The PPI advocate in the nominal group ensured that within that process the question ‘what does this mean for patients and the public?’ remained in the foreground. More by chance than design, the main focus of one case study agent (Isabelle) was to help others work out how to use insight from PPI.

Limitations

The degree to which individual KIT agents participated in the process was variable and, therefore, the number of data gathered for each differed in quantity. Some KIT agents gave several interviews, others only one. Participation in audio-diaries was relatively low. We asked diarists to submit a short recording (2–3 minutes) per week for 4 months. Four case study agents submitted no audio-diaries, although one of these did provide a written account. Of the nine who submitted audio-diaries, despite weekly reminders, the number of entries ranged from 2 to 18 and lasted 8–115 minutes. In terms of observations, some organised several but others were not able to co-ordinate a single observation within the time frame of the fieldwork. One KIT agent withdrew from the study after the first interview for personal reasons. Lack of time was an expressed concern of most of the participants, and was a key reason for not running the action learning sets as planned and set out in the original protocol. The varying degrees of commitment might reflect the way in which the KIT agents were recruited, that is, through senior staff at the network rather than directly. However, this method of recruitment was the preference of the AHSN leadership as the teams were in the early stages of setting up their networks.

Our access to the KIT agents’ network also varied. In total, five line managers of the KIT agents (one of these was line manager to three agents) and 22 Links were interviewed. In no case did anyone refuse to participate, but finding time to meet was very difficult. This is not surprising, given the challenges that the service faced at the time of our study, combined with the newness of the networks.

Despite notable disparity of data collection across agents, we have data from at least three of five sources (agent interviews and diaries, observations, line manager interview, Link interviews) for all agents apart from the one who withdrew from the study (Chloe). For 10 agents we collected data from at least four sources. We recognise that we had least data from Wetlands.

Another limitation of the study relates to the cross-sectional nature of data collection with regards to Links and line managers. Although efforts were made to follow up the KIT agents and use the audio-diaries to keep track of change, the line manager and Links were interviewed only once. It is likely, therefore, that the findings reflect how the process was working at the time for the line managers and Links. This ‘snapshot’ perspective was mitigated by the research design, which permitted a time lag between the initial interview with a KIT agent and their line manager/Links. When line managers attended feedback sessions, they were invited to offer further reflections. Links were not part of those meetings. Had resources permitted, it would have been helpful to reinterview the Links to provide additional insight on questions about sustainability. However, the study took longer to set up than planned for several reasons besides the participants’ lack of time. Reasons included delays in the establishment of AHSNs; reluctance on the part of some senior gatekeepers (KIT agents’ line managers or those above) to involve staff in the study; and a concern on the part of some KIT agents about the impact of them taking part in the research on their link organisations. Some were particularly concerned about anonymity. This led to an additional process of permission-seeking and negotiation. Delays within the AHSNs meant that some KIT agent programmes planned for inclusion in the study were not set up in time.

A further potential limitation of the study is the lack of ‘objective’ measurement of outcomes and impact. They tended to be self-reported and potential, rather than actual. Some line managers and Links gave relatively superficial appraisals of the agent and the role, focusing on personal characteristics in place of harder information about how they perform their role. We might have had more robust responses had we asked line managers and Links to comment on how they perceived social marketing concepts as fitting with the role. Instead we chose to use social marketing theory in our interpretation. We did this because the timing of our study meant that the networks were in the early stages of formation and we anticipated that our interviewees might struggle to interpret the agents’ work through a social marketing lens.

Although it was not the intention of the study to measure predefined outcomes, some will see it as a weakness. The study itself brings insight to the difficulty of objective measurement of outcomes and impact in two ways. First, data gathering and analysis were structured around an explicit and, therefore, transparent evaluation approach used in continuing professional development. 70 Second, one objective was designed to address the question of how success could be measured. This part of the study used the nominal group technique to develop group consensus. We also addressed this question with KIT agents and their line managers and Links during the interviews. Both sets of data highlight the difficulty in devising a set of generic measures and the risk that the application of a formal approach might not capture ‘softer’ outcomes such as enhanced relationships, capacity development and shifts in organisational culture. It is hard to measure the effect of the KIT agent, for example, who is the ‘grit’ in the system or the one who works across ‘silos’ to break down barriers. However, being mindful of such difficulties does not rule out the possibility that broad measures could be identified that might be evidenced using a combination of quantitative and less formal qualitative data, and tailored to particular circumstances. To this end we have proposed a set of principles and suggested a framework for measuring outcomes of knowledge broker activity.

With these limitations in mind, we report how the study has addressed the research questions.

What are the commonly shared expectations of the knowledge and innovation transfer agent role?

This question can be answered in two ways: the ways in which the expectations were shared by the agents in our study and, adopting the language of social marketing, how the KIT agents’ expectations were shared with their ‘clients’ – line managers and Links. In this study it appears that, despite variation in specifics, the broad expectation of the role was largely shared across both groups. In short, despite ambiguity at a detailed level, the role was about engaging with practitioners to help them develop their service in order to improve it for patients and, in some cases, also to save money. The focus of KIT agents’ work was on supporting and helping practitioners to develop, rather than doing things for them (although sometimes the former was a goal they were moving towards). The results of our nominal group exercise (see Chapter 7, Question 3: what should knowledge brokers do to contribute to the achievement of outcomes?) show that the group also agreed with role expectations around making connections, motivating and influencing others, teaching and training, and facilitating access to knowledge.

This result differs from earlier studies253 on research partnerships and knowledge brokers that showed a degree of mismatch in goals and expectations between parties. It may be that this is linked to the straightforward focus of the KIT agents in taking on the role within a network; in general, the KIT agents studied here appeared to be motivated to improve health-care provision rather than, say, explore career options. 66

The literature on intermediary roles in health groups their functions into three broad categories: ‘knowledge management’, ‘linkage and exchange’ and ‘capacity building’. 97,112 Our findings overlap with these three functional categories, but provide additional insight into the challenge of undertaking a KIT role and the necessity to define role expectations on an ongoing basis so that longer-term expectations are realistic. Others16,110,152,155,163 have also reported the importance of agreeing roles and expectations.

What, in practice, do the knowledge and innovation transfer agents do?

It was possible to answer this question in some depth and breadth because the sample was selected for maximum variation based on each network’s declared intentions for the roles. KIT agents were identified as such by network senior staff. In many cases the specifics of the role developed over time. Details are provided in Chapter 5, but the overall pattern of what the KIT agents did is summarised here.

Only one agent (Erin) focused directly on the growth agenda, although others included industrial partners in their engagements as a source of learning, and another agent (Grace) supported intellectual property development. Erin’s activities included providing market research, signposting people around the innovation systems, and linking people developing a service to commissioners. Two teams (Moorlands and Wetlands) were closest to more mainstream ideas of knowledge mobilisation7,54,57,93,108,117,168 and provided formal research evidence to clinical/management teams. Some teams (Greenhills, Riverside and Homefields) were responsible for introducing or developing approaches to health-care management, such as QI methodologies and PPI approaches, through formal training and support of topic-specific networks (e.g. leadership, new research, or evaluation approaches). Other KIT agents (e.g. Chloe, Amy, Fran) worked directly with practitioners on local projects. Most often these were related to QI. A number of KIT agents did more than one of these activities.

Recent studies of the CLAHRCs in England also found that mixed approaches to knowledge mobilisation were used by those in KIT roles. 60,179 These included service improvement, converting evidence into practical products, implementing national and/or local guidance into practice and mobilising local evidence. 60

Some KIT agents worked with people in different roles who focused on a single issue (e.g. patient safety). This meant that the agents thus linked not only with doctors but also with PPI leads, for example, in the case of Molly and Fran. Others worked with people around a particular project (e.g. doctors, nurses and managers addressing the issue of the deteriorating patient – Amy). Several linked academics and health-care practitioners, sometimes around a specific project (e.g. Jessica, James and Grace). Others dealt with non-NHS service providers or providers of services that were not NHS based (e.g. patent experts and antenatal groups – Isabelle and Janice). Most linked with multiple levels of organisations and, in some cases, provided links between levels of organisations for whom they did not work (e.g. Grace).

All the KIT agents were involved in bringing people to new knowledge with the intention of helping them to work differently (i.e. better). This was accomplished by providing that knowledge themselves, drawing people into an engagement in which they could acquire this knowledge from other people or documents, or signposting people to others from whom they could learn or who could learn from them.

Despite the difference in content of the KIT agents’ experiences, they shared a number of features. It is perhaps these features that differentiate the KIT agent approach from more traditional ‘information-deficit’ models254 of knowledge transfer and may in part account for their relative success in achieving desired outcomes. The KIT agents and Links reported a series of repeated and ongoing interactions, and the details of the actions taken were tailored to the needs of the Links (‘clients’). The importance of tailoring has been reported by others. 179 Repeated interaction also gave the KIT agents opportunities to provide feedback to Links and update their learning.

Building relationships was a critical part of KIT agents’ work. As one KIT agent put it, ‘you have to build relationships and there’s no substitute and knowledge transfer happens in the context of a relationship. It doesn’t happen in the middle of the ether’ (James). Rycroft-Malone et al. 60 also found that building relationships was a central ingredient in the success reported by knowledge brokers in CLAHRCs. Yet these relationships were typically intended to be finite. Most engagement aimed to embed knowledge, a set of skills, approaches, or set of contacts that would stay with the Link’s organisation beyond the interaction. In other words, the KIT agents entered the engagement with a view to the succession or termination of the engagement. While supporting Links in a practical way (teaching them about QI methodology, for example) they were consciously trying to extract themselves for more direct support (e.g. Erin, Isabelle, Fran) and develop the Links’ independence so they could continue the work when the KIT agent moved on. Many repeatedly reminded Links that this was their project, their data and their responsibility (Fran, Amy). A successful KIT agent is one that is no longer needed by specific Links at the end of their engagement with them.

How does the work of knowledge and innovation transfer agents impact on health-care practice?

Despite the recognised challenges of understanding what impact means and demonstrating it, we are able to point to a number of direct ways in which the work of KIT agents impacted on health-care practice (‘results’ in the Kirkpatrick framework). It is in no small measure problematic to do this, as discussed, but we are able to draw attention to the few specific projects with measurable outcomes to which agents contributed. These include working with a team to reduce ambulance handover time significantly (Sophie); and improvement in compliance with the sepsis care pathway that was reflected in mortality outcomes (Amy). Others reported a reduction in cancelled elective surgeries, reduced delays in patient flow, a reduction in the number of patient complaints, decreased infection control rates and a decrease in the number of patient falls. In these cases, the KIT agents worked with Links to gather data, analyse the problem, develop the intervention and measure its success. One team (Wetlands) was reported to have assisted the development and commissioning of a new rehabilitation centre (and a new approach to care). This has been described as providing quality care for patients and being cost-effective in an external evaluation. One of Sophie’s Links reported that by tracking patient flow to social workers, which was characterised by long wait times, they were able to secure more resources for these professionals.

A number of KIT agents also worked alongside practitioners to develop skills and organisational capability to improve care. One team (in Riverside) trained and supported audit staff in QI methodology. The team manager reported that the team had refocused their efforts, away from audit (counting) and towards improvement. They asked all staff who presented with an audit idea to consider it from an improvement perspective. The team offered training to staff to support them in this goal. Another Link (one of Janice’s) reported how useful she had found working with an academic team. This relationship gave her access to information about service provision, which she could then use with clients who were making choices about their own care.

Knowledge and innovation transfer agents and their Links also reported outcomes not directly related to health care, but showing potential for future practice. This included the development of research proposals and Links thinking differently about how to use feedback from patients to redesign the service. There were specific outcomes around improved capacity, including training staff in QI methodology and QI becoming part of the performance system.

How can knowledge and innovation transfer agents be best supported?

Our study provides useful pointers on how KIT agents can best be supported. Before considering this in more detail, we highlight some of the features of the role that make it unusual and potentially challenging. Similar to findings in previous studies,136,140,255 the roles are largely temporary, do not fit into a recognised career structure with progression and rewards, and do not always allow KIT agents to return to their original posts. Some KIT agents were working in, or with, organisations that did not employ them and over which they had no managerial control. Some reported a degree of disconnect with their employing organisation. A number of KIT agents also covered large geographical areas requiring travel, and were isolated. It is noteworthy that all bar one of the KIT agents in our study were women. This raises questions around whether or not knowledge brokering is a gendered role in health care. Alongside this, most of the KIT agent roles could be characterised as requiring some emotional labour,256 providing significant support to individuals and substantial effort to understand the needs of others and adapt to them. References to ‘hand holding’, managing hostility and the need for resilience were commonly mentioned and have been reported elsewhere. 178 Some KIT agents also felt underequipped for aspects of their roles, although this was not reported by their Links.

The KIT agents could benefit from better assistant support and a team approach: this addresses the implication of them wanting to engage with colleagues face to face, which is time-consuming and makes them unavailable to others at that time. Given the geography of some networks, travel time was not insignificant. Support from senior colleagues is essential, both directly and in helping the KIT agent keep their ‘clients’ motivated. Support from ‘the board’, ‘the exec team’ and similar was consistently mentioned as being of help, a finding echoed in the literature. 3,43,141 In most cases, but not all, in which there was more than one KIT agent in a network, individuals commented on the value of being able to draw on each other’s support (a finding similar to that reported by Chew et al. 137). This support did not necessarily relate to the specific content of the role (e.g. the details of the QI methodology), but was more often about managing a difficult relationship or issue and having the opportunity to express concern. Ensuring that KIT agents do not feel emotionally isolated is likely to be a useful support.

Flexibility with respect to how the KIT agent is managed is a related concern. The KIT agents were successful because they could be responsive and adapt their role and way of working to the needs of the Links, a finding echoed by Chew et al. 137 In most cases, this may have been necessitated by a lack of detailed planning about the role and work, but it seems to have worked well in these cases. KIT agents therefore require senior-level agreement to work flexibly and with a degree of independence to meet local needs while also actively engaging in their work. It appears that the role depends on a level of openness to the identification of projects. On paper this might look like excess capacity as the KIT agent is not recruited to do a specific job, and the potential for erroneous perception needs to be managed.

Timely training (e.g. within the first couple of months in post) was identified as a necessity for KIT agents who felt less confident in discharging some aspects of their role. For example, Fran and Amy both reported a sense of vulnerability at times as they were using approaches that were new to them and in some instances with people who had not sought their help. Others, however (e.g. James), embraced challenging others and being the ‘grit’ in the system.

What measures can be used to assess the impact of knowledge and innovation transfer activity?

This study suggests that generic measures, despite their attractiveness, would not adequately assess the impact of KIT activity, as KIT agents do a number of things towards different goals. Roles are difficult to measure and evaluate in the short term,137,168 and a generic measure is likely to be too non-specific to provide any meaningful measurement. Furthermore, KIT agents should be measured only against those things over which they have control (i.e. proximal to their work, rather than distal outcomes). Findings from the nominal group and interviews suggest ways forward. Like the KIT agent themselves, a system to measure results or impact most likely needs to be flexible. It needs to link processes to outcomes; specific actions linked to what the KIT agent and their clients agree they are trying to achieve, and the steps being taken towards it. Logic models170,257,258 might provide a useful tool for planning and evaluation. This process would have the additional benefit of requiring the active parties to articulate what they would like to achieve, how they would like the KIT agent to help, and the role of wider constraints, and to provide a basis for review.