Revisiting the research objectives
In the following sections we summarise how our findings meet the objectives we set out to address.
To identify and track the implementation mechanisms and processes used by Collaborations for Leadership in Applied Health Research and Care and evaluate intended and unintended consequences (impacts) over time
Undertaking a longitudinal study meant we were able to successfully track the journey of three CLAHRCs over time, including identifying their strategies and approaches to implementation. Being able to study CLAHRCs over time led us to identify the potential of a life cycle or ecology of implementation as they evolved and developed. The temporal thread was evident in their evolution, and in one site more of a revolution, around the implementation agenda. The life cycle of the CLAHRC, and more fundamentally the stage of development of the collaboration itself, provided the conditions for collective action around knowledge mobilisation. Individuals, groups and therefore the CLAHRCs went through a process of sense making. Over time, through engagement and reflection on events, meaning and understandings about CLAHRCs were constructed. In contrast to previous conceptualisations, this sense making did not necessarily result in a consensus about a shared identity or cohesiveness114,115 CLAHRCs were not born within a vacuum, and our findings indicate that CLAHRC-like entities need time to learn and develop,51 particularly in the absence of history50,116 or any pre-formative work.16,54,73
Their ongoing formation and development, rather than reflecting the stages and phases that others have proposed (e.g. Centers for Disease Control and Prevention117), was more iterative and dynamic. Furthermore, their evolution was influenced by factors that were sometimes not in their sphere of control (e.g. changes to NHS structures and funding arrangements). Their response to such events was a function of their perspective on, and approach to, evaluation and learning, and their perceived capacity to adapt and adjust. More reflection and potential learning could result in greater potential to evolve within a shorter time frame. The 5-year funding period was both enabling (need to get on and do something) and constraining (direct impacts were difficult to realise).
The ebb and flow of the CLAHRC’s life cycle points to the notion of an ecology of implementation. Collaborations as well as implementation projects have lifespans in that they are conceived, live and potentially degenerate and/or transform in response to their particular conditions of existence. The complex relationships and interactions between actors (‘organisms’ in ecological terms) and their environments (including territories) create the dynamic in which both collaboration and implementation evolve.
As reported, a CLAHRC’s specific attention to implementation was in some part shrouded by its focus on fulfilling the remit around the conduct of applied health research. However, as described, we identified a number of different types of knowledge mobilisation operating within CLAHRCs. Overall, however, implementing home-grown research within the initial 5-year funding period remained an unattained aspiration. The predominant focus and most common mechanism for mobilising knowledge were through the use of boundary spanners. These individuals had varied functions, from training, sharing knowledge and linking people and groups together, to engaging in the facilitation of ‘evidence into practice’ activities and projects.
Perhaps unsurprisingly, given what is already known about the gap between implementation activity and direct impact on practice and policy, the direct impacts from CLAHRCs’ activity were slow to be realised. Service improvement activities appeared to be having an impact on service delivery, which was translating into patient outcomes (e.g. early detection). Additionally, we observed a number of different types of other effects of project-related activity, including perceived changes to thinking, knowledge, skills, attitudes and practice, and impacts on the personal and professional development of those involved in CLAHRCs, particularly those in boundary-spanning functions. Scaling up project-related impacts into an effect that was demonstrative of a CLAHRC’s ‘footprint’ was difficult for us to detect and for those in CLAHRCs to articulate. An unexpected consequence we observed was the tension and rivalry within a CLAHRC (e.g. internal competition for resources) and across the interface between CLAHRCs, which was made visible as speculation mounted about the potential of funding for CLAHRC 2. This element of competition resulted in reluctance to share and reduced communication: features that are the antithesis of collaboration.
To determine what influences whether or not and how research is used through Collaborations for Leadership in Applied Health Research and Care, paying particular attention to contextual factors
Our investigation was focused on how context influenced whether or not research was used in CLAHRCs. Specifically, realist inquiry focuses the investigator’s attention on context as a condition rather than a backdrop for action. In this way we were able to gain a detailed understanding and develop an explanation of how particular conditions in the contexts of CLAHRCs affected fulfilling the programme’s remit around the application of research.
Collaboration was expected to provide both the structure and the opportunity for developing a shared space or spaces in and around which knowledge mobilisation could occur. Sharing of both physical space(s) and cognitive space(s) was realised by the three CLAHRCs in this study to varying extents. Approaches to coproduction118 and engaged scholarship26 emphasise a positive link between stakeholder engagement and the production and implementation of knowledge. However, achieving genuinely shared space requires the blurring of epistemological, role and practical boundaries and therefore the relinquishing of power and influence held by individuals, teams and organisations, which is notoriously challenging.119 As Orr and Bennett point out, politics and other ‘tricky issues’ arise from ‘co-producing research involving cooperative interactions between members of two communities that have distinct interests, expectations and priorities’.120
Preceding conditions influenced the subsequent course and journey of the CLAHRCs. This included where they started from in their relationships with partners, including the presence or absence of a history of working together. These conditions determined how long it took to engage in meaningful collective action around implementation. Their interpretation of the brief in relation to the specific expectations about knowledge mobilisation in the context of conducting more applied research and building capacity and capability (the vision) played out in the way they engineered their structures and processes and in how resources were allocated.
The context of action was critical in that there was an interconnection and interaction of enabling and restraining forces that interlocked and had an impact on how each CLAHRC delivered on its implementation function. These interactions not only included actors but extended to interactions between the actors and context. Negotiation and renegotiation of a shared space in the development of genuine and collaborative action was explained by multiple contexts including:
temporal (historical, longitudinal and living history of relationships and working together)
cognitive (collective and individual differences and similarities about notions of collaboration, evidence, knowledge and implementation)
emotional (thoughts and feelings of individuals and the collective – what people thought about the CLAHRC, how they enacted ‘what’s in it for me’)
professional (epistemic, professional)
physical (structures and processes, geography).
These contexts then acted and reacted so that they became more than a backdrop to action but coalesced to create the conditions and contingencies that explain relationships, activity and subsequent outcomes.
Governance arrangements were a condition or context that linked to different opportunities for connectivity and engagement. Collaborations that pay attention to structures, infrastructures and management are those that have the potential to facilitate the success of centres and people working together.50,69,70 Additionally we found that distribution and use of resources, including financial as well as social and intellectual capital, was a precursor to a CLAHRC’s attention to implementation. A collaboration’s engineered social and aesthetic architectures provided both a tangible (e.g. organisation of activity/projects, resource management) and a less tangible (e.g. clarity around decision-making, buy-in and belonging) collaborative scaffold for aligning strategy, people and activity.
Given that CLAHRCs are networks of stakeholders, governance arrangements that facilitate connectedness and connectivity, particularly through face-to-face interaction, provided greater scope for creativity and for sustainable activity around implementation. This includes a network of actors who are systematically arranged and managed to pursue a set of activities under a collective goal around implementation. Therefore the flexibility of these arrangements and how they operate across all levels of the collaboration – from the project(s) to the ‘organisation’ or network as a whole – will help explain a collaboration’s ability to ensure appropriately resourced activity and the capacity to respond to wider issues and pressures as they arise. It has been suggested that an organisation’s ambidexterity, that is its ability to be aligned and adapt to demands, has been found to be a prerequisite of organisational survival and success,121 and arguably for its resilience too. The way in which concepts such as these might transfer to a ‘constellation of interconnected practices’122 such as CLAHRCs, is in their potential to explain how these networks evolve and then sustain themselves (or not). Walter et al.123 observed that sustainable partnerships provide the conditions that allow researchers to better support users to test and implement research findings and encourage collaborative reflection beyond the knowledge production process and on to research use processes.
Leadership (designated and distributed style and approach) were a critical part of a CLAHRC’s governance arrangements and therefore vital to establishing the collaboration, and to determining and then enacting a vision around implementation. Research shows that a blend and alignment of designated leadership with distributed leadership has been shown to provide a necessary condition and mechanism for collective action around implementation.16,113 It has been suggested that leadership within collaboration is concerned with making things happen – specifically, the formulation of the collaboration’s plan/policy and activity agenda.76 The importance of leadership for successful change, innovation and implementation is reflected in existing theory and frameworks (e.g. Pettigrew and Whipp,124 Greenhalgh et al.,16 Rycroft-Malone et al.15) and was reinforced in this study.
As we observed, leaders contributed to shaping the context of collaboration through structure and agency.125 A number of principles have been identified that include facilitating interorganisational collaboration demands of leaders, including inspiring commitment and action, leading as a peer problem solver, building broad-based involvement, and sustaining hope and participation.126 Additionally, leaders need to attend to their personal style and approach, as the practice of leadership for collaboration demands power-sharing, practice-based leadership, systems thinking and being ‘managers of meaning’.125 This resonates with our findings. In a context where there was more aligning of vision, structures, processes, people and resources through credible, authentic and embedded leadership, the collaboration seemed to be more robust, and there was a greater focus on collective action around implementation. Leadership roles, style and approach are the ‘oil’ that lubricates the system. Furthermore, a life-cycle view of collaboration, including the idea of ecology of implementation, suggests the need for regular renegotiation (e.g. arrangements, relationships, agreements) requiring a flexible approach that is tactical and strategic, and contextually situated.
The potential success of collective action in implementation appears to be at least in part a function of an alignment in organisational structures, processes and the reasoning of those in the collaboration. As Jagosh et al.127 remind us, collaborations are not de facto synergistic but their success is predicated on some effort to align values, goals and purpose. More successful and impactful attempts at collective action in implementation were determined by the alignment of a number of features, including foundational relationships, vision, values, structures and processes (including the potential for greater learning and meta-learning), purpose and thoughts about the nature of the collaboration and knowledge mobilisation (including theory and approaches). Strategically and structurally the potential for alignment was vested in the leaders of the collaborations, and within projects and activities this was entrusted to individuals in boundary-spanning roles. Therefore the presence of both designated and distributed leadership at all levels appears to be important for alignment. Furthermore, Best et al.25 suggest that large-system transformation in health care is enabled through alignment between top leadership and distributed leadership because this can reduce cognitive dissonance and facilitate integration between intraorganisational boundaries. Given this, it could be hypothesised that knowledge mobilisation within a collaborative context could be enhanced by creating opportunities for alignment across all the levels and corners of the collaboration in ways that facilitate synergy between structure and agency.
Within an ecological view of implementation, synergy has the potential to develop and build over time where successful outcomes from collaborative knowledge mobilisation activity provide reinforcement. Additionally, alignment has the potential to develop over time where there is attention to learning and evaluation with appropriate adaptation.127 However, it is unclear if some degree of misalignment or tension within the implementation ‘system’ could potentially act as a form of catalyst for action, which could minimise the potential for entrenchment, habitual thinking and behaviour.128 It is conceivable, for example, that alignment may stop being a catalytic mechanism if consensus and groupthink develop. Creating opportunities for renewal and refreshment through reflection, evaluation and learning may militate against potential stability versus stagnation.
To investigate the role played by boundary objects in the success or failure of research implementation through Collaborations for Leadership in Applied Health Research and Care
The CLAHRC model was predicated on an assumption that providing resources and an architecture would enable the research and practice community to work more closely together – to close the metaphorical ‘know–do’ gap. Within this networked model of collaboration we observed both the creation and blurring of boundaries. The CLAHRCs’ architectures and different perspectives and positions resulted in the construction of a number of different types of boundaries, including:
organisational, between different organisations and divisions/departments within institutions
epistemic, between the different philosophical perspectives about knowledge and its mobilisation
semantic, between people and groups because of different understandings about meaning and language
professional, between different groups in different contexts
geographical, as a result of the physical geography of the CLAHRC, the CLAHRC network and NHS geography.
Collaborations for Leadership in Applied Health Research and Care have been described as an example of an institutionalised ‘constellation of interconnected practices’.129 They comprise numerous boundaries and therefore territories that need to be negotiated and/or bridged if meaningful action is to take place. Furthermore, demarcated boundaries between the ‘worlds’ of researchers and practitioners, each with their different epistemic cultures, can result in communication challenges and tensions. Co-ordinating and sharing knowledge across boundaries have converged around three primary perspectives,130,131 which also resonate with our findings: information processing – knowledge is viewed as objective and therefore needs to be codified, stored and retrieved across people and contexts; cultural – knowledge is embedded within members of the community and therefore shared through creating a shared language and negotiated through the use of boundary objects and/or through boundary spanners; and political – knowledge is rooted in the accumulated know-how of the community and shared through the use of different types of shared communicative devices. Where boundaries were blurred and knowledge sharing and/or implementation occurred this was as a result of the creation of boundary objects and through the agency of those in boundary-spanning roles, including facilitators.
Van de Ven and Johnson132 describe ‘Arbitrage, dialectical inquiry and constructive conflict management among researchers and practitioners’ as central to engaged scholarship. These processes require active management and skilled facilitation, and therefore investment in a network of actors across the collaboration as linking and bridging agents. If people in boundary-spanning and facilitator roles share an understanding of both collaboration and implementation, they have the potential to manage activity, enable interactions, develop shared spaces and negotiate tensions and conflict. Tools to include in their armoury include their skills, credibility and opportunities to collectively develop ‘artefacts’ that have the potential to become boundary objects, to which people in different territories and across various boundaries can attach meaning, resonance and value. We found that what activated boundary objects in theory to be realised as a boundary objects in use was related to how they evolved. Those objects that transformed from objects in theory to objects in use are similar in terms of their collective generation. The creation of, for example, different practice tools through meaningful collaboration provided an opportunity for different stakeholders to come together and engage in a process that involved integrating local evidence and experience with external evidence from guidance. The process of collective design made the artefacts meaningful to different stakeholders in different groups and increased their potential to be used in practice. Therefore, it could be predicted that the potential of boundary objects to mobilise knowledge would be enhanced if developed in contexts in which there is good-quality collaboration, with planned opportunities for joint creation and design among stakeholders.
To determine if and how Collaborations for Leadership in Applied Health Research and Care develop and sustain interactions and communities of practice
The potential of the CLAHRC context to create opportunities to develop and sustain interactions and communities of practice was fulfilled to varying extents. Communities of practice can analyse practice and solve practice-related problems and encourage mutual learning and the sharing of knowledge. Given this, CLAHRCs had created opportunities for groups and teams to come together for sharing knowledge and expertise, but to a lesser extent for learning. Interactions were facilitated through opportunities to engage in specific projects and by those in boundary-spanning roles who were perceived to be credible and helpful. However, their potential was mediated by some role confusion and by the context in which they were operating. In this way, project communities were created and sustained for the life of the project. We do not know whether or not these interactions will be sustained beyond the life of projects and the initial CLAHRC funding period.
Engagement of stakeholders was contingent upon incentives, benefits and/or rewards individuals and organisations perceived they would reap from CLAHRCs. Therefore, the levers or motivations for engagement varied over time so the success of implementation activity within a shared space was also mixed. Different theoretical perspectives from organisational theory help explain potential motivations, which include, for example, learning and communities of practice.133
The notion that communities of practice would work together on ‘something’ is a central element of much of the literature.134,135 However, developing a shared understanding of what that ‘something’ is not a one-off event or exercise; it takes time to develop and involves ongoing negotiation and renegotiation with participating organisations and individuals.70,76 Working on a shared endeavour helps to build group identity and integrate individuals while still allowing them to retain their identity and links with their organisation of origin.136 It is the interaction of individuals and active collaboration137 that creates group identity as individuals create meaning through sense making.138 Within the current study we observed this happening to some extent through specific projects, such as those that employed more interactive methods, for example improvement projects. This supports the idea that the topic or subject area around which a collaboration is focused is also important for its success.51,72
However, the mediating issues of power and, particularly, competition are neglected in the communities-of-practice literature. The motivation to engage in these shared endeavours may build over time as trust is developed through the development of relationships and ties, which may turn into reciprocity. The need to navigate different types of boundaries, including the geographical boundaries that precluded colocation and close proximity between individuals and groups, limited the potential for interaction and therefore the development of communities of practice. Equally, fundamental epistemic differences between groups were difficult to resolve and were challenged by different motivations to engage in joint enterprise and by differentials in power and authority.
Many of the discussions about interaction and engagement make the assumption that members are getting (or perceive they will get) something from being involved in a community of practice. Further, individuals and organisations may be motivated to engage in collaborative activities that minimise transaction and maximise opportunity costs. Therefore, if researchers and practitioners are going to work together productively over time there needs to be recognition of scope for bidirectionality in benefits and rewards, which need to be made visible for individuals as well as organisations.
Sustaining interactions and communities of practice is, at least in part, likely to be related to the capacity of a collaboration to pay attention to evaluation and learning in an ongoing way. Our findings show that there was evidence of within-project evaluation (and potential learning), but structures and processes that paid attention to systematic evaluation and learning at a higher level and between CLAHRCs was absent. Organisational learning theories suggest that the ability of an organisation to learn is a characteristic of an adaptive organisation, that is one that picks up signals from its internal and external environment and adapts accordingly.139 The ability to pick up signals requires deliberate attention to the establishment of feedback loops in which evaluation that blends hard and soft metrics at different levels of the system could both incentivise and reward engagement and activity.
Collaborations for Leadership in Applied Health Research and Care were created to catalyse a step change in the conduct and application of high-quality research in the English NHS within regional contexts and health priorities. Their ability to engineer this could be enhanced by greater attention to systems and processes that accumulate and use (reflect on and adapt appropriately) the knowledge from the experience of individuals, teams and organisations that are part of their distributed network. While there was some evidence of this, their own reflections provided an honest account of how they could have ‘done this better’ (leadership role, CLAHRC core team, Oakdown, interpretive forum), particularly in relation to how CLAHRCs could have combined and learned from a collective intelligence. At this stage, therefore, it is difficult to describe how CLAHRCs were greater than the sum of their parts (i.e. projects, activities and people).
It could be hypothesised that implementation within collaboration may be enhanced if a continuous improvement approach to the collaboration and its component activities is adopted. Paying greater attention to both the structures and mechanisms for ongoing reflection and learning would also increase the potential for meta-learning.
To identify indicators that could be used for further evaluations of the sustainability of Collaboration for Leadership in Applied Health Research and Care-like approaches
Our findings provide a reference point for future evaluations of CLAHRC-like approaches to the mobilisation of knowledge.
These contribute to a potential ‘re-usable conceptual platform’ (p. 86)85 about how implementation within collaborations might work. As a middle-range theory it provides a starting point, some co-ordinates and the conceptual ground for any future evaluation and learning that is cumulative. We also provide a starting point for those at the beginning of the journey in creating the conditions for collection action for knowledge mobilisation, including paying attention to:
surfacing and articulating the different perspectives of all stakeholders around collaboration, knowledge and implementation, including engaging in pre-formative activity and continued dialogue
the organisation and operationalisation of the collaboration, particularly around the structures and processes that will be needed to bring people together, and how activity will be resourced and managed
setting up opportunities and mechanisms to facilitate the bridging and brokering of boundaries, the employment of people in facilitator-type roles
purposefully creating spaces (physical and cognitive) for sharing and learning
tapping into the motivations that different groups, individuals and organisations will have for engaging, and using these to both incentivise and reward them
resourcing and mobilising formal and distributed leadership in a way that galvanises and motivates both the collaboration and its activities for knowledge mobilisation.
Study limitations
Our findings should be read in the context of their potential limitations. First, we focused on three CLAHRCs as in-depth case studies and cannot make claims about the extent to which our findings are representative of all nine CLAHRCs. We gave other CLAHRCs the opportunity to contribute to the study on more than one occasion, including via the interpretive forum in April 2014 and by interviewing an additional stakeholder in a different CLAHRC about PPI. These provided a means through which others could express an opinion on the resonance of our approach and emerging findings. We have provided a rich and detailed description of cases and of the findings, from which readers can make judgements about theoretical transferability to different contexts. We also encourage others to read our findings in the context of the reports and outputs of the other external evaluations, to enable judgements about transferability to be made.
We used a purposive sampling strategy based on a stakeholder analysis to identify potential participants. The stakeholder analysis enabled us to identify those who were perceived to be essential to interview in relation to the focus of interest during particular rounds of data collection. An initial approach was made through CLAHRC directors or their deputies/nominees (as agreed by the NIHR at the stage of funding) to direct us towards the respondents that would be most likely to be able to answer our questions (‘essential’ stakeholders). On interviewing key stakeholders we also then used snowball sampling, asking initial respondents to suggest others who might have knowledge about the focus of data collection during particular data collection rounds. This approach may have introduced some bias. We attempted to minimise the bias of self-report in interviews by triangulating data sources. Where possible we established the trustworthiness of emerging findings by means of observations, documents and feedback sessions with participants.
Opportunities to engage in observation were more limited than we had originally expected or hoped. Reasons for this included that the meetings we were invited to were few (e.g. because there were issues regarding sensitivity about finances, refunding, etc.), the focuses of meetings were not highly relevant (i.e. more or less focused on implementation and related issues) and the timing of meetings/events meant for practical reasons a physical presence was not possible. There was also an over-riding concern from the CLAHRCs throughout this project that the external evaluations were potentially burdensome. We do not know if this influenced decisions about inviting us or not to meetings/events. Not having as many opportunities for observations as we had originally hoped may have affected the interpretation of our findings. As is typical of case study research and realist evaluation, analysis starts with the most prominent source of data, in this case interviews, and then seeks confirming or disconfirming evidence from other sources. It is therefore possible we missed some nuances by being unable to draw on a volume of field notes from observations.
We were also mindful of the balance that needed to be struck between pursuing data collection opportunities to full advantage and burden on potential participants. We were particularly aware of the involvement of the CLAHRCs in more than one of the external evaluations as well as their own internal evaluations. We therefore made two approaches to each potential participant and did not pursue them further if they did not respond.
We fed back findings to the CLAHRCs through meetings/workshops and conference calls. In addition, the interpretive forum included participants from all nine CLAHRCs, and others with an interest in knowledge mobilisation and CLAHRC-like approaches. We used this as an opportunity to present findings from all four rounds of data collection and to check out the resonance of these with participants. Overall, it appeared that participants felt the findings resonated with their experiences and their own theories about implementation within CLAHRCs.
In the interests of transparency it is worth reflecting on the fact that the theoretical starting point for this study was the PARIHS and K2A frameworks and that authors related to both those frameworks are authors of this report. As previously described, these frameworks provided a theoretical starting point for the development of the evaluation framework of the study. As such, they were not retained in their entirety, but their concepts became embedded in the evaluation framework, therefore minimising the risk of the slavish application of our own theories.
Implications
Our findings and conclusions highlight a number of implications for both implementation practice and implementation research.
Implications for implementation practice
Collaboration does not appear out of a vacuum; therefore, attention needs to be given to pre-formative work in which stakeholders have the opportunity to develop relationships and established shared goals. In the absence of pre-formative work, implementation strategies that rely on organisational collaboration should allow time, space and other resources for the creation of partnerships between individuals and teams. Activity around developing relationships and collaboration should be balanced with building in opportunities to achieve some ‘quick wins’ early on in the collaboration’s life cycle. These should be relevant and meaningful to stakeholders, and could therefore be linked to relevant incentives and policy/practice priorities for maximal impact.
Over time, partnerships should use, or allow the creation of, a variety of boundary objects that provide a focus for collective effort around the different interfaces within implementation, for example:
professional boundaries – patient stories, clinical guidelines
organisational boundaries – governance and reporting frameworks, learning events and artefacts
epistemological boundaries – mid-range theories that provide sufficient specification and abstraction for action, and learning across implementation programmes.
Our findings show that the potency and catalytic action of boundary objects is born out of the collective and deliberative processes of their development, which includes involving the right stakeholders.
Reflecting the multiple approaches to implementation observed within our data, organisations contributing to CLAHRC-like programmes/initiatives should provide opportunities for the collaborations to develop a shared vision and common language about implementation. Our findings show that this is best achieved through opportunities for face-to-face interaction between relevant stakeholders, including patients and the public. Implementation models and frameworks may be effective boundary objects in this respect by, for example, providing a useful heuristic around which to begin conversations.
In addition, engaging with multiple stakeholders in the systematic identification of priorities for action on implementation can help enhance the relevance of this vision, and increase organisational buy-in to the collaboration. Ensuring synergy between the vision and the governance arrangements will provide the foundation on which participating organisations’ expectations and commitments, including funding arrangements, can be managed.
Organising implementation activity in cognate themes or programmes provides a focus that has currency with clinicians, managers and other stakeholders. Organising activity within clinical topics was a typical approach used by the CLAHRCs in this study. However, with this approach there is also a danger of working in silos, so a theme-based approach should be balanced with the adoption of strategies that allow cross-theme or cross-programme communication and working to increase access to implementation expertise, and to share learning. The potential for cross-theme working should also be built in to governance, including reporting arrangements. Where this was working well in one of the CLAHRCs, we observed greater opportunities for ongoing review and learning.
Leadership has been identified within the implementation literature as critical for creating the conditions for success. Our findings show that a more distributed approach to leadership within CLAHRC-like programmes appears to be most effective in making strategy around implementation visible. Investing in individuals not in designated leadership roles (such as boundary spanners) can also create some synergy between the different levels and corners of the collaboration.
In this study, implementation was achieved through resource allocation and therefore investment in the establishment of roles to fulfil facilitation and boundary-spanning functions. Generally, people in these roles were successful, although attention needs to be paid to their skills, experience and credibility. We found that credibility was not necessarily related to seniority, but was more about their currency within the context in which they were working. Our findings indicate that, when boundary spanners do not have experience of, and credibility within, a health service setting, their impacts can be dampened. Secondment of clinical staff from service delivery to boundary-spanning roles appears to generate buy-in to the collaboration, and has the potential to increase capability within the system for implementation. Furthermore, clarity about role descriptions, ongoing development and succession planning needs to be built into any organisational investment in facilitation/boundary-spanner programmes.
There is a very limited evidence base for how to involve patients and other lay stakeholders in implementation. Findings from data collected in a CLAHRC that was not one of the three forming the main focus of this evaluation showed that its success in involvement was a result of building on a long history of user-led research. This implies that, where possible, implementation and involvement activity should draw on existing lay involvement initiatives and networks. Furthermore, patient experience should be viewed as a credible form of evidence for implementation.
Individuals and organisations are motivated by different incentives and our findings show that the ‘what’s in it for me’ factor was strongly linked to engagement in CLARHC activities, particularly implementation. Therefore, ensuring that clinicians and academics who are expected to engage in CLAHRC-like initiatives can transparently map their engagement onto relevant professional and career development frameworks will generate buy-in, and ensure that expectations and experiences can be more effectively managed. Engagement in this context should include both project-based activities and more formal capability-building approaches such as embedded doctoral programmes. Similarly, aligning implementation activity where possible around policy and organisational incentives (e.g. QOF) will also increase the relevance and impact of drivers for engagement in implementation.
Minimising any unintended consequences of competition for external funding may be achieved through the sharing of learning about what works in implementation. Virtual repositories of products that could be developed within a CLAHRC as well as ones that are shared across the CLARHC network, such as implementation reports and other artefacts, may provide a platform to facilitate sharing and learning.
A combination of internal and external review has provided some opportunity for learning and a re-evaluation of implementation activity. However, there is still uncertainty about the CLAHRC footprint. Therefore, there are implications about balancing different types of performance metrics, which focus on process as well as outcomes. Learning and research should focus on the core underlying mechanisms of change that are associated with implementation activity. The mechanisms and their contingencies embedded within our programme theory could provide some direction. It would also be important to ensure there is capacity and capability within the system to ensure the potential to scale up from individual project-level metrics to the collaboration, and to the network of collaborations as a whole. Furthermore, our findings imply that it would be useful to identify the different pathways to impact early on in the collaboration’s life cycle. This would provide the platform upon which to develop a prospective evaluation strategy and for tracking impacts as they occur.
In summary, creating the conditions for collection action for implementation requires paying attention to:
surfacing and articulating the different perspectives of all stakeholders around collaboration, knowledge and implementation, including engaging in pre-formative activity and continued dialogue
the organisation and operationalisation of the collaboration, particularly around the structures and processes that will be needed to bring people together, and how activity will be resourced and managed
setting up opportunities and mechanisms to facilitate the bridging and brokering of boundaries, the employment of people in facilitator-type roles
purposefully creating spaces (physical and cognitive) for sharing and learning
tapping into the motivations that different groups, individuals and organisations will have for engaging, and using these to both incentivise and reward them
resourcing and mobilising formal and distributed leadership in a way that galvanises and motivates both the collaboration and its activities for knowledge mobilisation.
Implications for implementation research
Organisational commitment to implementation should be structured to exploit opportunities to advance implementation research by paying attention to two key areas:
identifying opportunities for capability building by, for example, embedding doctoral training programmes
paying attention to the advancement of theory in the development and evaluation of implementation programmes.
As a relatively young field, implementation science provides space for a number of different epistemological positions, and their associated methodologies and methods. Explanatory, mid-range theory of what works in implementation can provide a potential middle ground around which these different contributions can meld. Paying attention to the role of theory and how this plays out in implementation efforts (theoretical fidelity) could provide some useful insights into how to achieve a balance between practical relevance and rigour.
Our data indicate a variety of drivers for implementation operating in different personal, project, team, programme, professional and organisational contexts. Research that further investigates the importance of alignment between these, such as the balance of collaboration, rivalry and competition, is warranted, including a focus on the expected and unforeseen consequences.
Findings demonstrate that there was limited attention to particularising implementation strategies to circumstances. There is still much to learn about how implementation interventions and approaches are tailored to and in different contexts, including how context is assessed and judgements made about selecting and then implementing different strategies.
Although we found that a distributed approach to leadership for implementation was important, further investigation of the influence of different types of leadership and power in implementation over time, how they are constructed and manifested, and their influence in different implementation contexts would be valuable.
Theory comes in many guises, and this study has shown the potential of combining explicit theory with the inductive development of a middle-range theory in studies about implementation processes and outcomes. We advocate the need to pay greater attention to theory use and development within future implementation research efforts.
Although it is a longitudinal study, we had limited opportunity to observe medium-term consequences of implementation activity within CLAHRCs. Further research could usefully investigate a more extended life cycle of implementation, focusing on the cues for both the creation and the refreshment of organisational collaboration on implementation over a longer time. The second wave of funding for CLAHRC might present some opportunities to do this research.
The research team and CLAHRC participants observed that there had been a lack of attention to scaling up of successful implementation approaches/projects. There is the potential, therefore, to study how best to scale up from individual projects/initiatives, and the facilitators and barriers to this in the context of a distributed network structure.
