Roman Kislov

The NIHR collaboration for leadership in applied health research and care (CLAHRC) for Greater Manchester: combining empirical, theoretical and experiential evidence to design and evaluate a large-scale implementation strategy

BackgroundIn response to policy recommendations, nine National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) were established in England in 2008, aiming to create closer working between the health service and higher education and narrow the gap between research and its implementation in practice. The Greater Manchester (GM) CLAHRC is a partnership between the University of Manchester and twenty National Health Service (NHS) trusts, with a five-year mission to improve healthcare and reduce health inequalities for people with cardiovascular conditions. This paper outlines the GM CLAHRC approach to designing and evaluating a large-scale, evidence- and theory-informed, context-sensitive implementation programme.DiscussionThe paper makes a case for embedding evaluation within the design of the implementation strategy. Empirical, theoretical, and experiential evidence relating to implementation science and methods has been synthesised to formulate eight core principles of the GM CLAHRC implementation strategy, recognising the multi-faceted nature of evidence, the complexity of the implementation process, and the corresponding need to apply approaches that are situationally relevant, responsive, flexible, and collaborative. In turn, these core principles inform the selection of four interrelated building blocks upon which the GM CLAHRC approach to implementation is founded. These determine the organizational processes, structures, and roles utilised by specific GM CLAHRC implementation projects, as well as the approach to researching implementation, and comprise: the Promoting Action on Research Implementation in Health Services (PARIHS) framework; a modified version of the Model for Improvement; multiprofessional teams with designated roles to lead, facilitate, and support the implementation process; and embedded evaluation and learning.SummaryDesigning and evaluating a large-scale implementation strategy that can cope with and respond to the local complexities of implementing research evidence into practice is itself complex and challenging. We present an argument for adopting an integrative, co-production approach to planning and evaluating the implementation of research into practice, drawing on an eclectic range of evidence sources.

Managing boundaries in primary care service improvement: A developmental approach to communities of practice

BackgroundEffective implementation of change in healthcare organisations involves multiple professional and organisational groups and is often impeded by professional and organisational boundaries that present relatively impermeable barriers to sharing knowledge and spreading work practices. Informed by the theory of communities of practice (CoPs), this study explored the effects of intra-organisational and inter-organisational boundaries on the implementation of service improvement within and across primary healthcare settings and on the development of multiprofessional and multi-organisational CoPs during this process.MethodsThe study was conducted within the Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester—a collaborative partnership between the University of Manchester and local National Health Service organisations aiming to undertake applied health research and enhance its implementation in clinical practice. It deployed a qualitative embedded case study design, encompassing semistructured interviews, direct observation and documentary analysis, conducted in 2010–2011. The sample included practice doctors, nurses, managers and members of the CLAHRC implementation team.FindingsThe study showed that in spite of epistemic and status differences, professional boundaries between general practitioners, practice nurses and practice managers co-located in the same practice over a relatively long period of time could be successfully bridged, leading to the formation of multiprofessional CoPs. While knowledge circulated relatively easily within these CoPs, barriers to knowledge sharing emerged at the boundary separating them from other groups existing in the same primary care setting. The strongest boundaries, however, lay between individual general practices, with inter-organisational knowledge sharing and collaboration between them remaining unequally developed across different areas due to historical factors, competition and strong organisational identification. Manipulated emergence of multi-organisational CoPs in the context of primary care may thus be problematic.ConclusionsIn cases when manipulated emergence of new CoPs is problematic, boundary issues could be addressed by adopting a developmental perspective on CoPs, which provides an alternative to the analytical and instrumental perspectives previously described in the CoP literature. This perspective implies a pragmatic, situational approach to mapping existing CoPs and their characteristics and potentially modifying them in the process of service improvement through the combination of internal and external facilitation.

Rethinking capacity building for knowledge mobilisation: developing multilevel capabilities in healthcare organisations

BackgroundKnowledge mobilisation in healthcare organisations is often carried out through relatively short-term projects dependent on limited funding, which raises concerns about the long-term sustainability of implementation and improvement. It is becoming increasingly recognised that the translation of research evidence into practice has to be supported by developing the internal capacity of healthcare organisations to engage with and apply research. This process can be supported by external knowledge mobilisation initiatives represented, for instance, by professional associations, collaborative research partnerships and implementation networks. This conceptual paper uses empirical and theoretical literature on organisational learning and dynamic capabilities to enhance our understanding of intentional capacity building for knowledge mobilisation in healthcare organisations.DiscussionThe discussion is structured around the following three themes: (1) defining and classifying capacity building for knowledge mobilisation; (2) mechanisms of capability development in organisational context; and (3) individual, group and organisational levels of capability development. Capacity building is presented as a practice-based process of developing multiple skills, or capabilities, belonging to different knowledge domains and levels of complexity. It requires an integration of acquisitive learning, through which healthcare organisations acquire knowledge and skills from knowledge mobilisation experts, and experience-based learning, through which healthcare organisations adapt, absorb and modify their knowledge and capabilities through repeated practice. Although the starting point for capability development may be individual-, team- or organisation-centred, facilitation of the transitions between individual, group and organisational levels of learning within healthcare organisations will be needed.SummaryAny initiative designed to build capacity for knowledge mobilisation should consider the subsequent trajectory of newly developed knowledge and skills within the recipient healthcare organisations. The analysis leads to four principles underpinning a practice-based approach to developing multilevel knowledge mobilisation capabilities: (1) moving from ‘building’ capacity from scratch towards ‘developing’ capacity of healthcare organisations; (2) moving from passive involvement in formal education and training towards active, continuous participation in knowledge mobilisation practices; (3) moving from lower-order, project-specific capabilities towards higher-order, generic capabilities allowing healthcare organisations to adapt to change, absorb new knowledge and innovate; and (4) moving from single-level to multilevel capability development involving transitions between individual, group and organisational learning.

The Evolution of the Communities of Practice Approach Toward Knowledgeability in a Landscape of Practice—An Interview with Etienne Wenger-Trayner

Since its introduction by Jean Lave and Etienne Wenger in Situated Learning: Legitimate Peripheral Participation in 1991, the concept of communities of practice has been widely adopted by researchers and practitioners in different fields. This has been accompanied by continuous expansion and development of the theory behind the concept. In this interview, Professor Etienne Wenger-Trayner discusses the evolution of the theory of communities of practice in his own work over the past two decades. He talks about the origins of communities of practice as a theoretical approach, identifies three phases through which this theory has evolved, and reflects on his professional trajectory as a theorist and consultant. Using his career as an example, Wenger-Trayner elaborates on the notion of knowledgeability as a relationship individuals establish with respect to a landscape of practice that makes them recognizable as legitimate actors in complex social systems.

A qualitative study of a primary-care based intervention to improve the management of patients with heart failure: the dynamic relationship between facilitation and context

BackgroundThere is currently a growing emphasis in primary care on upscaling the provision of evidence-based services for specific conditions, such as heart failure (HF), which have traditionally been seen as part of a specialist’s domain. While contextual challenges associated with improvement in primary care have been documented previously, we still know relatively little about how the intentional, theory-informed facilitation of evidence-based change is shaped by contextual factors within this healthcare setting. Hence, a qualitative study was conducted to address the question: How is the process of facilitating evidence-based practice affected by the context of primary care?MethodsData collection took place across general practices in northwest England as part of a process evaluation of the Greater Manchester HF Investigation Tool (GM-HFIT) - a programme of work aiming to improve the management of HF in primary care. Semi-structured interviews, with purposefully selected GM-HFIT team members (n = 9) and primary care practitioners (n = 7), were supplemented by observational data and a three-month diary reflecting on facilitation activities. Framework analysis was used to manage and interpret data.ResultsWe describe a complex and dynamic interplay between facilitation and context, focusing on three major themes: (1) Addressing macro and micro agendas; (2) Forming a facilitative unit; (3) Maintaining momentum. We show that HF specialist nurses (HFSNs) have a high level of professional credibility, which allows them to play a key role in making recommendations to practices for improving patient care. At the same time, we argue that contextual factors, such as top-level endorsement, the necessity to comply with a performance measurement system, and the varying involvement of practice nurses produce tensions that can have both an enabling and constraining effect on the process of facilitation.ConclusionsWhen facilitating the transfer of evidence, context is an important aspect to consider at a macro and micro level; a complex interplay can exist between these levels, which may constrain or enable efforts to amend practice. Those involved in facilitating change within primary care have to manage tensions arising from the interplay of these different contextual forces to minimise their impact on efforts to alter practice based on best evidence.

The ‘dark side’ of knowledge brokering

Deploying knowledge brokers to bridge the ‘gap’ between researchers and practitioners continues to be seen as an unquestionable enabler of evidence-based practice and is often endorsed uncritically. We explore the ‘dark side’ of knowledge brokering, reflecting on its inherent challenges which we categorize as: (1) tensions between different aspects of brokering; (2) tensions between different types and sources of knowledge; and (3) tensions resulting from the ‘in-between’ position of brokers. As a result of these tensions, individual brokers may struggle to maintain their fragile and ambiguous intermediary position, and some of the knowledge may be lost in the ‘in-between world’, whereby research evidence is transferred to research users without being mobilized in their day-to-day practice. To be effective, brokering requires an amalgamation of several types of knowledge and a multidimensional skill set that needs to be sustained over time. If we want to maximize the impact of research on policy and practice, we should move from deploying individual ‘brokers’ to embracing the collective process of ‘brokering’ supported at the organizational and policy levels.

How do managerial techniques evolve over time? The distortion of “facilitation” in healthcare service improvement

ABSTRACT When applied to solving real-world problems in the public sector, managerial techniques are likely to evolve over time in response to the context of their implementation. The temporal dynamics of this evolution and its underlying processes, however, remain under-researched. To address this gap, we present a qualitative longitudinal case study of a UK-based knowledge mobilization programme utilizing “facilitation” as a service improvement approach. We describe the processes underpinning the distortion of facilitation over time and argue that an uncritical and uncontrolled adaptation of managerial techniques may mask the unsustainable nature of the resulting improvement outcomes captured by conventional performance measurement.

R&D CONSORTIA AS BOUNDARY ORGANISATIONS: MISALIGNMENT AND ASYMMETRY OF BOUNDARY MANAGEMENT

The paper presents a qualitative multiple case study of three multilateral public–private RD (2) boundary crossing arrangements; and (3) collaborative governance arrangements. Drawing on interviews, documentary analysis and observational data, we describe the misalignment between the deliberate and emergent aspects of boundary management, which can be caused by the funders’ reporting requirements, power differentials between collaborators and lack of contextual understanding. These factors, accompanied by path-dependency and confidentiality issues, may result in asymmetrical boundary management, whereby a selective focus on a specific boundary (or set of boundaries) combined with an unequal development of boundary bridges within the collaboration may lead to the crossing of some boundaries being prioritised at the expense of others.

A new stationary analytical model of the heliospheric current sheet and the plasma sheet

We develop a single-fluid 2-D analytical model of the axially symmetric thin heliospheric current sheet (HCS) embedded into the heliospheric plasma sheet (HPS). A HCS-HPS system has a shape of a relatively thin plasma disk limited by separatrices that also represent current sheets, which is in agreement with Ulysses observations in the aphelion, when it crossed the HCS perpendicular to its plane. Our model employs a differential rotation of the solar photosphere that leads to unipolar induction in the corona. Three components of the interplanetary magnetic field (IMF), the solar wind speed, and the thermal pressure are taken into account. Solar corona conditions and a HCS-HPS system state are tied by boundary conditions and the “frozen-in” equation. The model allows finding spatial distributions of the magnetic field, the speed within the HPS, and electric currents within the HCS. An angular plasma speed is low within the HPS due to the angular momentum conservation (there is no significant corotation with the Sun), which is consistent with observations. We found that the HPS thickness L decreases with distance r, becoming a constant far from the Sun (L ~2.5 solar radii (R0) at 1 AU). Above the separatrices and at large heliocentric distances, the solar wind behavior obeys Parkers model, but the magnetic field spiral form may be different from Parkers one inside the HPS. At r ≤ 245 R0, the IMF spiral may undergo a turn simultaneously with a change of the poloidal current direction (from sunward to antisunward).

New Game, Old Rules? Mechanisms and Consequences of Legitimation in Boundary Spanning Activities:

Despite the increasing deployment of formalized boundary spanning roles and practices, the mechanisms and dynamics of their legitimation remain under-explored. Using the Bourdieusian lens, we theorize legitimation of boundary spanning as accumulation, mobilization and conversion of several forms of capital unfolding in a configuration of intersecting fields. Drawing on a qualitative longitudinal case study of a collaborative partnership between a university and healthcare organizations, we describe changes in the structure, sources and mutual convertibility of capital assets over time. We also analyse the implications of this evolution for the relationships between the intersecting fields and the social trajectory of boundary spanners. We argue that legitimation of boundary spanning roles and practices is a highly transformative, collective and political process that increases the capital endowments and authority of individual boundary spanning agents but may lead to the erosion of the very same roles and practices that were being legitimized.