Protocol for a qualitative study exploring the roles of 'Diffusion Fellows' in bridging the research to practice gap in the Nottinghamshire, Derbyshire and Lincolnshire Collaboration for Leadership in Applied Health Research and Care (CLAHRC-NDL)

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

Background

Knowledge and innovation transfer (KIT) is recognised internationally as a complex, dynamic process that is difficult to embed in organisations. There is growing use of health service–academic–industry collaborations in the UK, with knowledge brokers linking producers with the users of knowledge and innovation.

Aim

Focusing on KIT ‘agent’ roles within Academic Health Science Networks in England and Partnerships in Wales, we show how individual dispositions, processes and content contribute to desired outcomes.

Methods

We studied the KIT intentions of all Academic Health Science Networks in England, and the South East Wales Academic Health Science Partnership. Using a qualitative case study design, we studied the work of 13 KIT agents purposively sampled from five networks, by collecting data from observation of meetings, documentation, KIT agent audio-diaries, and semistructured interviews with KIT agents, their line managers and those they supported (‘Links’). We also used a consensus method in a meeting of experts (nominal group technique) to discuss the measurement of outcomes of KIT agent activity.

Findings

The case study KIT agents were predominantly from a clinical background with differing levels of experience and expertise, with the shared aim of improving services and patient care. Although outside of recognised career structures, the flexibility afforded to KIT agents to define their role was an enabler of success. Other helpful factors included (1) time and resources to devote to KIT activity; (2) line manager support and a team to assist in the work; and (3) access and the means to use data for improvement projects. The organisational and political context could be challenging. KIT agents not only tackled local barriers such as siloed working, but also navigated shifting regional and national policies. Board-level support for knowledge mobilisation together with a culture of reflection (listening to front-line staff), openness to challenges and receptivity to research all enabled KIT agents to achieve desired outcomes. Nominal group findings underscored the importance of relating measures to specific intended outcomes. However, the case studies highlighted that few measures were employed by KIT agents and their managers. Using social marketing theory helped to show linkages between processes, outcomes and impact, and drew attention to how KIT agents developed insight into their clients’ needs and tailored work accordingly.

Limitations

Level of KIT agent participation varied; line managers and Links were interviewed only once; and outcomes were self-reported.

Conclusions

Social marketing theory provided a framework for analysing KIT agent activity. The preparatory work KIT agents do in listening, understanding local context and building relationships enabled them to develop ‘insight’ and adapt their ‘offer’ to clients to achieve desired outcomes.

Future work

The complexity of the role and the environment in which it is played out justifies more research on KIT agents. Suggestions include (1) longitudinal study of career pathways; (2) how roles are negotiated within teams and how competing priorities are managed; (3) how success is measured; (4) the place of improvement methodologies within KIT work; (5) the application of social marketing theory to comparative study of similar roles; and (6) patients as KIT agents.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Establishing and implementing best practice to reduce unplanned admissions in those aged 85 years and over through system change [Establishing System Change for Admissions of People 85+ (ESCAPE 85+)]: a mixed-methods case study approach

Background

In England, between 2007/8 and 2009/10, the rate of unplanned hospital admissions of people aged 85 years and above rose from 48 to 52 per 100. There was substantial variation, with some areas showing a much faster rate of increase and others showing a decline.

Objectives

To identify system characteristics associated with higher and lower increases in unplanned admission rates in those aged 85 years and over; to develop recommendations to inform providers and commissioners; and to investigate the challenges of starting to implement these recommendations.

Design

Mixed-methods study using routinely collected data, in-depth interviews and focus groups. Data were analysed using the framework approach, with themes following McKinsey’s 7S model. Recommendations derived from our findings were refined and prioritised through respondent validation and consultation with the project steering group. The process of beginning to implement these recommendations was examined in one ‘implementation site’.

Participants

Six study sites were selected based on admission data for patients aged 85 years and above from primary care trusts: three where rates of increase were among the most rapid and three where they had slowed down or declined. Each ‘improving’ or ‘deteriorating’ site comprised an acute hospital trust, its linked primary care trust/clinical commissioning group, the provider of community health services, and adult social care. At each site, representatives from these organisations at strategic and operational levels, as well as representatives of patient groups, were interviewed to understand how policies had been developed and implemented. A total of 142 respondents were interviewed.

Results

Between 2007/8 and 2009/10, average admission rates for people aged 85 years and over rose by 5.5% annually in deteriorating sites and fell by 1% annually in improving sites. During the period under examination, the population aged 85 years and over in deteriorating sites increased by 3.4%, compared with 1.3% in improving sites. In deteriorating sites, there were problems with general practitioner access, pressures on emergency departments and a lack of community-based alternatives to admission. However, the most striking difference between improving and deteriorating sites was not the presence or absence of specific services, but the extent to which integration within and between types of service had been achieved. There were also overwhelming differences in leadership, culture and strategic development at the system level. The final list of recommendations emphasises the importance of issues such as maximising integration of services, strategic leadership and adopting a system-wide approach to reconfiguration.

Conclusions

Rising admission rates for older people were seen in places where several parts of the system were under strain. Places which had stemmed the rising tide of admissions had done so through strong, stable leadership, a shared vision and strategy, and common values across the system.

Future work

Research on individual components of care for older people needs to take account of their impact on the system as a whole. Areas where more evidence is needed include the impact of improving access and continuity in primary care, the optimal capacity for intermediate care and how the frail elderly can best be managed in emergency departments.

Study registration

UK Clinical Reasearch Network 12960.

Funding details

The National Institute for Health Research Health Services and Delivery Research programme.

Delivering the aims of the Collaborations for Leadership in Applied Health Research and Care: understanding their strategies and contributions

Background

In 2008, the National Institute for Health Research (NIHR) in England established nine Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) to develop partnerships between universities and local NHS organisations focused on improving patient outcomes through the conduct and application of applied health research.

Objectives

The study explored how effectively the CLAHRCs supported the ‘translation’ of research into patient benefit, and developed ways of doing applied research that maximised its chances of being useful to the service and the capacity of the NHS to respond. It focused on three issues: (1) how the NHS influenced the CLAHRCs, and vice versa; (2) how effective multistakeholder and multidisciplinary research and implementation teams were built in the CLAHRCs; (3) how the CLAHRCs supported the use of research knowledge to change commissioning and clinical behaviour for patient benefit.

Methods

The study adopted an adaptive and emergent approach and incorporated a formative evaluation. An initial phase mapped the landscape of all nine CLAHRCs and the context within which they were established, using document analysis, workshops and interviews, and a literature review. This mapping exercise identified the three research questions that were explored in phase 2 through a stakeholder survey of six CLAHRCs, in-depth case studies of two CLAHRCs, validation interviews with all nine CLAHRCs and the NIHR, and document review.

Results

(1) The local remit and the requirement for matched NHS funding enhanced NHS influence on the CLAHRCs. The CLAHRCs achieved positive change among those most directly involved, but the larger issue of whether or not the CLAHRCs can influence others in and across the NHS remains unresolved. (2) The CLAHRCs succeeded in engaging different stakeholder groups, and explored what encouraged specific groups to become involved. Being responsive to people’s concerns and demonstrating ‘quick wins’ were both important. (3) There was some evidence that academics were becoming more interested in needs-driven research, and that commissioners were seeing the CLAHRCs as a useful source of support. A growing number of completed projects had demonstrated an impact on clinical practice.

Conclusions

The CLAHRCs have included NHS decision-makers in research and researchers in service decision-making, and encouraged research-informed practice. All the CLAHRCs (as collaborations) adopted relationship models. However, as the complexities of the challenges they faced became clearer, it became obvious that a focus on multidisciplinary relationships was necessary, but not sufficient on its own. Attention also has to be paid to the systems within and through which these relationships operate.

Recommendations for research

Future research should compare areas with an Academic Health Science Network (AHSN) and a CLAHRC with areas with just an AHSN, to understand the difference CLAHRCs make. There should be work on understanding implementation, such as the balancing of rigour and relevance in intervention studies; systemic barriers to and facilitators of implementation; and tailoring improvement interventions. There is also a need to better understand the factors that support the explicit use of research evidence across the NHS, and the processes and mechanisms that support the sustainability and scale-up of implementation projects. Research should place emphasis on examining the role of patient and public involvement in CLAHRCs and of the relation between CLAHRCs and NHS commissioners.

Funding

The NIHR Health Services and Delivery Research programme.

Evaluating the effectiveness of knowledge brokering in health research: a systematised review with some bibliometric information

OBJECTIVE

The aim of this study was to identify the effectiveness of knowledge brokering as a knowledge translation (KT) strategy used in promoting evidence-based decision-making, evidence-based practice or collaboration between researchers, health practitioners and policymakers.

METHODS

A systematised review of literature was performed using MEDLINE (through ProQuest Dialog), PubMed and Scopus electronic databases. A search strategy was developed to identify primary studies indexed in these databases on knowledge translation that reported the implementation of knowledge brokering. Sixty-two titles related to knowledge brokering were identified from the search after the removal of duplicates, and 24 articles met the eligibility criteria following the review of the full text documents. The findings were then synthesised using a narrative approach.

RESULTS

It was found that knowledge brokering has been an effective strategy for knowledge translation.

CONCLUSION

Although this review shows that knowledge brokering has been an effective strategy for KT, it advocates for more empirical studies to compare the effectiveness of specific knowledge brokering approaches with others. It also calls for empirical studies to explicate the role of library and information science professionals in knowledge brokering.

Hearing loss and dementia: an exploratory study of the views of audiologists

Purpose

– The purpose of this paper is to explore audiologists, views and experiences of working with older adults with dementia.

Design/methodology/approach

– An online survey was distributed to audiologists working in the UK NHS and private sector via their professional organisations. A total of 312 audiologists took part in the study. The survey collected both quantitative and qualitative data. Basic descriptive statistics summarised the quantitative responses. The qualitative data were analysed using conventional thematic approaches.

Findings

– The quantitative data demonstrated that the vast majority of audiologists had treated someone with dementia (96 per cent). Despite this, 65 per cent of respondents did not feel adequately supported to help this service user population. Four overarching themes were used to explain the qualitative data: integrated and individualised care; formal (including training) vs experiential knowledge; the interaction between dementia and hearing and using the technology.

Research limitations/implications

– The self-selecting nature of the sample is a limitation which needs to be taken into account when considering the transferability and implications of the findings.

Practical implications

– Given the anticipated increase in rates of dementia within the population and the potential for hearing impairment to exacerbate the symptoms; this study highlights the unique role audiologists have. The need for more training and development for this professional group is also identified.

Originality/value

– This is one of the first papers to explore audiologists, views and experiences of working with people with dementia. As such, it highlights some interesting areas worthy of further research using both quantitative and qualitative methods.

Protocol for an exploration of knowledge sharing for improved discharge from a mental health ward

INTRODUCTION

Strategies to reduce hospital admissions for mental health service users have received vast amounts of attention, yet the transfer of care from hospital to the community has been ignored. The discharge process is complex, messy, disjointed and inefficient, relying on cross-agency and organisational working. Focusing on one acute mental health admission ward, we will investigate whether the discharge process for people with severe mental health problems can be enhanced through the creation, implementation and utilisation of a knowledge sharing proforma that is used on their admission to the ward.

METHODS AND ANALYSIS

The project uses qualitative interviews to understand the complex processes associated with being admitted and discharged from inpatient mental health wards. Practitioners will be asked to identify and map the relevant stakeholders involved in admission and discharge, and discuss any problems with the process. The study team will work with clinicians to develop a knowledge collection proforma, which will be piloted for 2 months. Qualitative interviews will be carried out to collect reflections on the experiences of using the tool, with data used for further refinement of the intervention. Baseline and repeat quantitative measures will be taken to illustrate any changes to length of stay and readmission rates achieved as a result of the study.

ETHICS AND DISSEMINATION

A key issue is that participants are able to comment frankly on something that is a core part of their work, without fear or reprise. It is equally important that all participants are offered the opportunity to develop and coproduce the knowledge collection proforma, in order that the intervention produced is fit for purpose and usable in the real world, away from a research environment. The study has received ethical approval from Nottingham University Business School ethics committee, and has all appropriate National Health Service research governance clearances.

Shared quality data are associated with increased protamine use and reduced bleeding complications after carotid endarterectomy in the Vascular Study Group of New England

OBJECTIVE

The goal of this study was to evaluate whether protamine usage after carotid endarterectomy (CEA) increased within the Vascular Study Group of New England (VSGNE) in response to studies indicating that protamine reduces bleeding complications associated with CEA without increasing the risk of stroke.

METHODS

We reviewed 10,059 CEAs, excluding concomitant coronary bypass, performed within the VSGNE from January 2003 to July 2012. Protamine use and reoperation for bleeding were evaluated monthly using statistical process control. Twelve centers and 77 surgeons entering the VSGNE between 2003 and 2008 were classified as original participants, and 14 centers and 60 surgeons joining after May 2009 were considered new. Protamine use for surgeons was categorized as rare (<10%), selective (10%-80%), or routine (>80%). Outcome measures were in-hospital reoperation for bleeding, postoperative myocardial infarction (POMI), and stroke or death.

RESULTS

Two significant increases occurred in protamine use for all VSGNE centers over time. From 2003 to 2007, the protamine rate remained stable at 43%. In 2008, protamine usage increased to 52% (P < .01), coincident with new centers joining the VSGNE. Protamine usage then increased to 62% in 2010 (P < .01), shortly after the presentations of the data showing a benefit of protamine. This effect was due to 10 surgeons in the original VSGNE centers who increased their usage of protamine: six surgeons from rare use to selective use and four surgeons to routine use. Reoperation for bleeding was reduced by 0.84% (relative risk reduction, 57.2%) in patients who received protamine (0.6% vs 1.44%; P < .001). There were no differences in POMI (1.1% vs 1.09%) or stroke or death (1.1% vs 1.03%) between protamine treated and untreated patients, respectively. Reoperation for bleeding was decreased for surgeons who used protamine routinely (0.5%; P < .001) compared with selective (1.4%) and rare users (1.5%) of protamine. There were no differences in POMI (0.9%, 1.2%, 1.1%; P = .720) and stroke or death rates (1.0%, 1.2%, 1.0%; P = .656) for rare, selective, and routine users of protamine.

CONCLUSIONS

Protamine use increased over time by VSGNE surgeons, most significantly after the presentations of VSGNE-derived data showing the benefit of protamine, and was associated with a decrease in reoperation for bleeding. Improvements in processes of care and outcomes can be achieved in regional quality groups by sharing safety and efficacy data.

Protocol for a qualitative study of knowledge translation in a participatory research project

INTRODUCTION

In this article, we present a methodological design for qualitative investigation of knowledge translation (KT) between participants in a participatory research project. In spite of a vast expansion of conceptual models and frameworks for conducting KT between research and practice, few models emphasise how KTs come about. Better understanding of the actions and activities involved in a KT process is important for promoting diffusion of knowledge and improving patient care. The purpose of this article is to describe a methodological design for investigating how KTs come about in participatory research.

METHODS AND ANALYSIS

The article presents an ethnographic study which investigates meetings between participants in a participatory research project. The participants are researchers and primary healthcare clinicians. Data are collected through observation, interviews and document studies. The material is analysed using the analytical concepts of knowledge objects, knowledge forms and knowledge positions. These concepts represent an analytical framework enabling us to observe knowledge and how it is translated between participants. The main expected outcome of our study is to develop a typology of KT practices relevant to participatory research.

ETHICS AND DISSEMINATION

The project has been evaluated and approved by the Norwegian Social Science Data Services. Informed consent was obtained for all participants. The findings from this study will be disseminated through peer-reviewed publications and national and international conference presentations.

Research into practice: Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Nottinghamshire, Derbyshire, Lincolnshire (NDL)

BACKGROUND

To address the problem of translation from research-based evidence to routine healthcare practice, the Collaboration for Leadership in Applied Health Research and Care for Nottinghamshire, Derbyshire, and Lincolnshire (CLAHRC-NDL) was funded by the National Institute for Health Research as one of nine CLAHRCs across England. This paper outlines the underlying theory and its application that CLAHRC-NDL has adopted, as a case example that might be generalised to practice outside the CLAHRC, in comparison to alternative models of implementation.

DISCUSSION

Conventional approaches to health research frequently generate evidence in isolation from the environment in which it is intended for use. The premise of the CLAHRC-NDL model is that barriers to implementation can be overcome if knowledge is co-produced by academic and clinical service staff, taking account of the organisational context in which it is to be applied. This approach is founded on organisational learning theory, recognising that change is a social and political phenomenon. Evidence is produced in real time, taking full account of the environment in which it is to be implemented. To support this process, senior health service staff are seconded to the CLAHRC as 'diffusion fellows' (DFs) to actively bridge the research to practice gap by being a full member of both the research team and their area of clinical practice. To facilitate innovation and embed change in the local health community, existing communities of practice are enhanced and new ones are fostered around specific themes. Our approach has been adopted by 16 clinical research studies in the areas of mental health, children and young people, primary care, and stroke rehabilitation.

SUMMARY

The CLAHRC-NDL model of implementation applies organisational learning theory by addressing the social and situational barriers and enablers to implementation, and adopting a philosophy of co-production. Two key mechanisms for translation of innovation have been utilised: DFs, to actively bridge the research to practice gap, and communities of practice, to underpin and sustain improvements in healthcare. The model shows promising results in putting research into practice, which may be transferable to other healthcare contexts.

Randomised controlled trial of the clinical and cost effectiveness of a specialist team for managing refractory unipolar depressive disorder

BACKGROUND

Around 40 per cent of patients with unipolar depressive disorder who are treated in secondary care mental health services do not respond to first or second line treatments for depression. Such patients have 20 times the suicide rate of the general population and treatment response becomes harder to achieve and sustain the longer they remain depressed. Despite this there are no randomised controlled trials of community based service delivery interventions delivering both algorithm based pharmacotherapy and psychotherapy for patients with chronic depressive disorder in secondary care mental health services who remain moderately or severely depressed after six months treatment. Without such trials evidence based guidelines on services for such patients cannot be derived.

METHODS/DESIGN

Single blind individually randomised controlled trial of a specialist depression disorder team (psychiatrist and psychotherapist jointly assessing and providing algorithm based drug and psychological treatment) versus usual secondary care treatment. We will recruit 174 patients with unipolar depressive disorder in secondary mental health services with a Hamilton Depression Rating Scale (HDRS) score ≥ 16 and global assessment of function (GAF) ≤ 60 after ≥ 6 months treatment. The primary outcome measures will be the HDRS and GAF supplemented by economic analysis including the EQ5 D and analysis of barriers to care, implementation and the process of care. Audits to benchmark both treatment arms against national standards of care will aid the interpretation of the results of the study.

DISCUSSION

This trial will be the first to assess the effectiveness and implementation of a community based specialist depression disorder team. The study has been specially designed as part of the CLAHRC Nottinghamshire, Derbyshire and Lincolnshire joint collaboration between university, health and social care organisations to provide information of direct relevance to decisions on commissioning, service provision and implementation.