From the ivory towers to the
swampy lowlands
making research more useful to practitioners
Laura Eyre, Martin Marshall
University College London
CHILL seminar, Nottingham
24th February 2016
Challenges
1. Improvement activities are insufficiently
influenced by science
2. Science is insufficiently focused on the needs of
those undertaking improvement activities
Some norms
in academia
in practice
we are experts in our field and
know what is important to research
WE are experts and know what
questions need answering
we do things that are valued by our
peers and employers
we aren’t interested in your
measures of success
the more rigorous our work, the
greater the impact it will have
we are more interested in
relevance than rigour
it takes time to do good research
time is our enemy
for evidence to be useful it needs
to be generalisable
for evidence to be useful it needs
to be locally relevant
The changing drivers for HSR in the UK
Government is most interested in funding
research which makes a difference fast
The Research Excellence Framework will
be increasingly focused on impact
Researchers will be rewarded for making a
difference
The NHS is slowly becoming a more
demanding customer
Patients and the public are questioning
traditional researcher assumptions
Mobilising knowledge
Nature of
decision
process
Solution
A product
One-off
event
Improved dissemination of
evidence to users (‘Push’) or
demand for evidence from users
(‘Pull’)
A process
Iterative
social
process
Work together to define, refine,
generate and implement
evidence (‘Co-creation’)
Nature of
evidence
Problem
Knowledge
transfer
Knowledge
production
Adapted from Canadian Health Services Research Foundation, 2003
Participatory research
“No research
without action, no
action without
research”
“Evidence-based
practice needs
practice-based
evidence”
Kurt Lewin 1890 - 1947
Larry Green, 1974
• Different locus of control from conventional research
• Collaboration across a range of relevant stakeholders
• Desire to solve practical problems – researcher functions as
facilitator and catalyst as much as investigator
• Focus on initiating change through reflection, greater
understanding and shared learning
• Willingness to find common ground through negotiation,
compromise and a focus on agency
Participatory research
contractual
consultative
collaborative
How effective is PR?
Evidence from narrative review that it results in:
•
•
•
•
•
Refined research questions
Good recruitment of participants
Capacity and capability building
Conflict resolution
Substantive and sustainable change
collegiate
The in-residence model
Barnsley FC
Poet-in-residence
All England Tennis
Club
Artist-in-residence
British Library
Innovator-in-residence
The Researcher-in-Residence Model
1. The researcher is a core member of
an operational team
2. They are explicit about their expert
contribution to the team:
• the evidence base
• theories of change
• evaluation, both formal and
informal
• use of data
3. Their focus is on negotiation and
compromise of their expertise rather
than imposition – ‘a meeting of
experts’
Example: a participatory
evaluation of a safety
improvement initiative in the
care home sector (PROSPER)
PROSPER
Aims
• To reduce the prevalence of falls, pressure
ulcers and UTIs in care homes
• To reduce unnecessary A&E attendance
and hospital admissions
Intervention
• QI training, data feedback, cultural
awareness
Researcher expertise
• HSR, improvement science
PROSPER
Established knowledge mobilised
• Evidence underpinning the effectiveness of
QI interventions in the NHS
New evidence generated
• Demonstrable changes in care home
culture
• Positive response to comparative data
• Front line staff highly innovative
• Measureable reductions in prevalence of
falls and pressure ulcers
Rate of pressure
ulcers in 3 cohorts
of care homes
before and after
intervention
Example: a participatory
evaluation of the East London
integrated care pioneer
programme
East London integrated care pioneer programme
What’s the problem?
• Changing health and care needs of
an aging population
• Fragmentation in commissioning and
delivery of care
• Financial concerns
What’s the solution?
Integrated care  “I can plan my care
with people who work together to
understand me and my carer(s), allow
me control, and bring together services
to achieve the outcomes important to
me.” (National Voices, 2013: 3)
East London integrated care pioneer programme
Aims
• To build an integrated care system
across physical health, mental
health, and social care
• Empower patients and service users
• Provide more responsive,
coordinated and proactive care
• Ensure efficiency of care
Interventions
• Case management,
navigators, promoting self
care, care planning, rapid
response, discharge support
East London integrated care pioneer programme
Researcher expertise
• Social scientist with expertise in
policy analysis, linguistics and critical
discourse analysis
Stakeholder expectations
• “…the executive group want a more
embedded and process oriented
evaluation…focuses less on
whether the programme ‘works’
and more on how to use research
evidence to optimise effectiveness
of the programme…”
Getting embedded: practical challenges
• 9 health and social
care organisations +
GP practices
• 3 East London
boroughs
• Access to sites
• Travel time
• Remote working
Getting embedded: emotional and personal
challenges
• 9 health and social care
organisations + GP
practices
• 3 East London
boroughs
• One university
• One researcher
• Lone working
• Belonging everywhere
and nowhere
Friday 3rd October 2014
This week has seemed almost
overwhelmingly full of new and
increasingly complex information. No
amount of reading has, to date, prepared
me for the often impenetrable language
and complex practices of the people,
workgroups and teams engaged in the
IC programme.
The process is slow and often
bewildering.
Getting embedded: strategies for developing
effective relationships with stakeholders
• Get comfortable with being
uncomfortable (!)
• Networks and contacts
(‘gatekeepers’ and ‘key
informants’  ‘sponsors’)
• Be visible (physically and
electronically)
• Use key forums to negotiate
your role and your position
within the programme
(Evaluation Steering Group)
• Develop key contact points,
i.e. meetings, and attend
regularly
Not physically embedded in one organisation/place but embedded in the space
between strategy and delivery
Getting embedded: strategies for developing
effective relationships with academic colleagues
• Be prepared to get
uncomfortable (!)
• Importance of supervisory
relationships
• Networks and contacts
outside the programme
– Mentors
– University research
groups
– Network of embedded
researchers
• Research diary – this
is valuable learning!
Generating evidence and negotiating
knowledge: challenges
• Managing demands and
expectations
• Time
• Being useful AND doing
academically rigorous
research
• Negotiating a critical and
qualitative approach in a
traditionally positivist field
• Being a ‘critical friend’
Generating evidence and negotiating
knowledge: strategies
• Be clear about skills (and limitations) from the beginning
• Clarify expectations prior to starting the evaluation
• Be clear about position within the programme  e.g. between
strategy and delivery
• Collaborative development of evaluation protocol
• Ongoing communication, negotiation and reflection based on
emerging findings, programme developments, etc.  reflective
discussion and action planning sessions
• Be clear about milestones, timelines, processes, etc.
Having an impact: challenges
• Demonstrating value
• Influencing development across a large
scale programme with limited time and
resources
• Timeliness of findings
• Language and communication
• Personalities
Having an impact: strategies
Learn the social and linguistic norms and conventions of any
particular situation… and use them!
•
•
•
•
•
Regular updates to all stakeholders
Negotiate timelines – be honest
Phased approach to data analysis and negotiation  start with
thematic analysis for initial feedback and early discussions; buy time
for more detailed linguistic analysis
Be reflexive and embrace interpretivism  knowledge and learning
are co-created so don’t be afraid to share early and emerging
findings (but do caveat)
Find tangible areas to demonstrate value and impact
East London integrated care pioneer programme:
learning to date
Established knowledge mobilised
• HSR literature describing effectiveness of integrated care
programmes
• Other literature as required e.g. care plans, MDTs etc.
New evidence generated
• Staff are unified in their belief that IC is ‘the right thing to do’
• A significant disconnect between strategy and delivery
• The roles of clinicians and front line staff are contested
• Staff are disengaged with the programme
• The realities of operational and relational issues often
overlooked at strategic level
• Lack of continuity of leadership
• Absence of patient and public involvement
What we are learning (1)
• Letting go of control (power?) can be very difficult
for a researcher!
“The training of researchers makes it hard for them to relinquish
control and embrace community diagnosis and local
knowledge……They are taught to consider themselves and the
knowledge they have learnt as superior….Training instils in
researchers notions of ‘objectivity’ and of the ‘purity’ of science which
numbs them to the political realities of life in the real world”
Cornwall and Jewkes, 1995
• Not everyone wants to be engaged:
‘local people may be highly sceptical as to whether it is worth
investing their time and energy in the project, particularly if it seems
to offer little in terms of direct benefit.’
Cornwall and Jewkes, 1995
What we are learning (2)
• The model seems attractive to many
commissioners and providers
• Some academics like the idea – particularly early
career researchers - but many have concerns
• The current service environment is a challenging
one in which to build relationships – takes time
• Balancing engagement and objectivity is hard –
risk of capture
• There are ethical challenges – handling sensitive
conversations, gaining ethics approval
• The role of patients in the model is not yet clear
• Hard to make the business model work in the
university sector
• The required skill-set of participatory researchers is
becoming clear – requires a high level of emotional
intelligence
Self
awareness
Patience
INFLUENCING
Empathy
The power to sway or
affect emotions, opinions
or behaviours by
informing, persuading or
negotiating
Comfort
with conflict
Facilitation
Brent and Dent, 2010
Cialdini, 2014
Kopalman, 2014
Next steps
• Continue to encourage and monitor new in-residence
programmes, building international network
• Explore the key challenges
• Formal evaluation through HS&DR grant application
• Narrative literature review
• Scoping exercise
• In-depth case studies
• Stakeholder engagement and influencing programme
martin.marshall@ucl.ac.uk
www.ucl.ac.uk/pcph/isl
@MarshallProf
Group work
What do you see as the merits and risks of
the in-residence model?