Background
Addressing the second translational gap (T2), between the development of new research and products and their implementation in clinical practice, is a key concern for policy-makers, practitioners and scholars. The literature on knowledge translation (KT), that is the exchange and utilisation of knowledge in practice, has developed as a response to the problem of closing the T2 in health care, but largely ignores issues of history and context. Drawing on ideas from institutional theory and institutional entrepreneurship, we suggest that attempts to close the T2 require the reshaping of institutional context. In this report we examine how actors may engage in reshaping existing institutional practices in order to support, and help sustain, efforts to close the T2.
Aims
We aim to understand how the institutional context shapes actors’ attempts to close the T2 by focusing on the translational research initiative: the Collaboration for Leadership in Applied Health Research and Care (CLAHRC). CLAHRCs are a time-limited funded initiative to form new service and research collaboratives in the English health system. The study follows all nine CLAHRCs over their formative years in their set-up and then focuses on four CLAHRCs in examining how KT activities evolved over time. In doing so, the aims of the study are (i) to provide a formative evaluation of CLAHRCs in relation to the generation of applied research, and the impact on practice and capacity building, across CLAHRCs; (ii) to apply institutional theory to identify and examine the challenges facing CLAHRCs; and (iii) to apply the concept of institutional entrepreneurship to make a theoretically informed analysis of how to engender and sustain the translation and exchange of research knowledge into service facing innovation in CLAHRCs.
Methods
The study employed a mixed-methods approach, combining in-depth qualitative case studies with social network analysis (SNA). The qualitative fieldwork was organised in two phases. The first phase involved conducting interviews across all nine CLAHRCs, while the second phase employed a longitudinal study design by conducting two further rounds of interviews in four of the CLAHRCs. In developing our case studies, we combined interview data, archival data and field notes from observations over a 4-year period (2009–13). Data analysis was iterative and undertaken in an inductive manner, but was informed by key concepts in the literature, through which we generated and sequenced codes.
The SNA focused on actors’ own individual (i.e. ego) networks of interaction across two points in time (2011, when actors were asked to look back to the inception of CLAHRCs, and 2013, in the run-up to CLAHRC refinancing). The focus of our analysis was to understand the variation across actors in terms of the extent to which they bridge the research–practice divide, and the extent to which actors’ networks had changed over time. Our SNA complemented our in-depth qualitative case studies through providing quantitative evidence as to the extent to which CLAHRCs had enabled the new patterns of working to bridge the T2. The SNA data were analysed employing multivariate techniques.
Results
The study provided novel insights into the formation and introduction of CLAHRCs. The findings are structured around a process-based model of institutional entrepreneurship. The main conclusions from the research are as follows:
The founding conditions played an important role in shaping actors’ work in the set-up and introduction of CLAHRCs. Specifically, the position in which an actor was located, and the extent of existing KT activities and relationships between the NHS and higher education institutions, shaped the degree to which the bid formation was an autonomous or a collective process.
The founding conditions of each of the CLAHRCs, and the associated process through which the bid was developed, then shaped the envisaging process. In envisaging the CLAHRCs, actors, to a greater or lesser degree, diagnosed what they considered to be the problems preventing the closing of the T2, and then developed a proposal for how to deal with those issues. We found significant variation in envisaging, both across and within CLAHRCs, and, that once envisaged, CLAHRCs became locked into a way of working.
In engaging key stakeholders we identified two main forms of work. First, we identified work undertaken in signing up the CLAHRC stakeholders, which centred on (i) drawing on the support of key stakeholders, (ii) doing the rounds and (iii) spreading the word. In addition to encouraging stakeholders to sign up, the institutional entrepreneurs (IEs) also had to work to win over the hearts and minds of actors, which they did through alignment activities and consensus building. Their ability to do so, however, was shaped by the nature of CLAHRC structures that had been envisaged and also the professional status and role of actors.
In embedding CLAHRCs we highlight four mains forms of embedding work: (i) education, (ii) the creation of new roles, (iii) the embedding of tools and routines in practice and finally, (iv) the construction of a CLAHRC identity. Across the four CLAHRCs, we witnessed significant differences in the manner in which CLAHRC focal actors sought to embed the CLAHRCs. We also saw a significant degree of isomorphism over time, whereby CLAHRCs sought to learn lessons from other CLAHRCs.
Over time, those individuals central to CLAHRC reflected on existing practices, especially during the run-up to refinancing. A number of key points of reflection emerged: (i) the difficulties of hitting the ground running (in terms of getting the CLAHRC up and running), (ii) the problems arising from committing to large-scale projects upfront, (iii) the difficulties associated with balancing between research and implementation, (iv) the need for different actors to learn to work together to establish a common understanding of what implementation actually was, and (v) an increasing awareness of the need to develop career structures that reward CLAHRC behaviour.
Our SNA highlighted that there were systematic variations in actors’ ability to bridge the research–practice boundary. We found that practitioners were more likely to develop networks that bridged the divide than academics were that actors with many existing connections in their own professional field (i.e. who are more embedded) were less likely to bridge the divide and that junior actors found it more difficult than their more senior counterparts to bridge the divide. However, our longitudinal analysis suggests that the CLAHRC initiative has led to the development of more relationships that span the research–practice divide.
Finally, our analysis of the emerging models of KT suggests that there are a number of different archetype models that CLAHRCs have drawn on. Drawing on data from across the nine CLAHRCs, we provide insights into the critical institutional work and leadership challenges associated with the different CLAHRC archetypes. The archetypes are not representative of all the characteristics of one particular CLAHRC, but rather are a synthesis of distinctive strategies used by CLAHRC entities into an archetype.
Conclusions
This study adds to our nascent understanding of the processes through which the T2 may be closed through the reshaping of existing institutions. In doing so, the study provides important lessons for those involved with, and those attempting to promote, institutional change that can support sustainable KT practices. First, our research suggests that where there is a high degree of flexibility in the initial call for proposals then this will encourage a greater degree of diversity in the way in which applicants envisage they can achieve and how. Second, it is important to understand both the antecedent conditions to translational research initiative bids and the social position of senior actors leading bid development. Although established and known clinical academics are likely to be trusted to lead translational research initiatives, and the presence of pre-existing organisational relationships important for mobilisation, privileging such dimensions of any bid may constrain more radical change. Our study highlighted that strategic change and outcomes of innovation may be ‘locked-in’ in a way reflecting traditional clinical research at an early stage of bid development. We suggest that this conclusion is germane to all forms of translational initiative, which will fundamentally shape how any initiative plays out over time. To emphasise, strategies for change are not built independently from the structural context in which they are embedded, inclusive of consideration of the social position of the IEs leading translational innovation and antecedent conditions to translational research initiative bid development.
Funding
Funding for this study was provided by the Health Services and Delivery Research programme of the National Institute for Health Research.
