Guidance for research-practicepartnerships (R-PPs) andcollaborative research

John Ovretveit, Susanne Hempel, Jennifer L. Magnabosco,Brian S. Mittman, Lisa V. Rubenstein and David A. Ganz

(Affiliations at end of article)

Abstract

Purpose – The purpose of this paper is to provide evidence based guidance to researchers andpractice personnel about forming and carrying out effective research partnerships.

Design/methodology/approach – A review of the literature, interviews and discussions withcolleagues in both research and practice roles, and a review of the authors’ personal experiences asresearchers in partnership research.

Findings – Partnership research is, in some respects, a distinct “approach” to research, but there aremany different versions. An analysis of research publications and of their research experience led theauthors to develop a framework for planning and assessing the partnership research process, whichincludes defining expected outcomes for the partners, their roles, and steps in the research process.

Practical implications – This review and analysis provides guidance that may reducecommonly-reported misunderstandings and help to plan more successful partnerships and projects.It also identifies future research which is needed to define more precisely the questions and purposesfor which partnership research is most appropriate, and methods and designs for specific types ofpartnership research.

Originality/value – As more research moves towards increased participation of practitioners andpatients in the research process, more precise and differentiated understanding of the differentpartnership approaches is required, and when each is most suitable. This article describes researchapproaches that have the potential to reduce “the research-practice gap”. It gives evidence- andexperience-based guidance for choosing and establishing a partnership research process, so as toimprove partnership relationship-building and more actionable research.

Keywords Knowledge sharing, Action research, Evidence-based practice, Research methods,Implementation, Research methodology

Paper type General review

The current issue and full text archive of this journal is available at

www.emeraldinsight.com/1477-7266.htm

The authors would like to thank Roberta Shanman, Lopamudra Das, Jodi Lui, and Tanja Perryfor assistance with the literature review, and Deborah Delevan for editorial assistance. Theauthors would also like to thank John Midolo for provision of information on QUERI partneredresearch evaluation centers, and Amy Kilbourne for her comments on a prior version of thismanuscript.This project was funded by the US Department of Veterans Affairs, Veterans HealthAdministration Quality Enhancement Research Initiative through core funding to the Center forImplementation Practice and Research Support (Project # TRA 08-379). Additional support forinvestigator time and visiting professorship was provided from the Medical Management Center,Karolinska Institutet, Stockholm, and by a Career Development Award to David Ganz from theUS Department of Veterans Affairs, Health Services Research and Development (HSR&D)Service (Project #VA CD2 08-012-1).

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Journal of Health Organization andManagement

Vol. 28 No. 1, 2014pp. 115-126

q Emerald Group Publishing Limited1477-7266

DOI 10.1108/JHOM-08-2013-0164

IntroductionIt often takes many years for treatments and management interventions that have beenfound to be more effective to be widely implemented. Interest about, and research into“closing the gap between research and practice” has grown over the last fifteen years.There are a number of explanations for the gap. Research and researchers aresometimes criticized as being “too distant” from real practice in health services (Kesslerand Glasgow, 2011; van de Ven and Johnson, 2006). Some practitioners say that thefindings of research do not give useful guides to action (Campbell et al., 2009). For theirpart, researchers point to the apparent disinterest of some practitioners in the findingsof research, and to the work pressures that make it difficult for practitioners to givetime to changing their practice. Sometimes, researchers also note an unwillingness orinability of practitioners to think through what a particular piece of research mightmean for practice in their setting.

Whether, when or how researchers should help practitioners interpret research inorder to improve care is a question increasingly asked. The view that “research in, andwith, practice” might be a more effective way to make better use of researchers andresearch in implementing or adapting research in practice settings (Green and Ottoson,2004), has been gathering weight with research funders and government agencies.Some have called for a greater emphasis on “rapid cycle learning” and “fast cycleresearch” involving closer research-practice collaborations (Gold et al., 2011).Initiatives such as the USA NIH translational research program (National Instituteof Health, 2007) have aimed to respond to this call for improvements in closing theresearch-practice gap. Partnerships between researchers and practitioners have beenestablished with the aim of producing “more relevant” or “more actionable” research(Department of Health, 2007). Another aim of such partnerships has been to enable theimplementation of research (Bosworth et al., 2010).

The purpose of this article is to give an overview of different approaches to“research-practice partnerships” (R-PPs) and to give research-informed guidance forestablishing and developing such partnerships. We define partnered research as “anactivity where researchers and practitioners work together, with different roles, to useresearch both to solve practical problems and to contribute to science”. Throughoutthis article, the term “practitioner” is used to refer to clinicians and managers alike.

The perspective on partnerships given here is based on a synthesis of the literaturecoupled with our own experience conducting “partnered research”, and also oninterviews with individuals in both research and operations roles who have beeninvolved in such partnerships within the US Veterans Health Administration (VA) andin one UK University and National Health Service (NHS) collaborative researchprogram (Øvretveit et al., 2010). More details on one set of partnership research in theVA can be found at VA Health Services Research and Development (2013b). In 2008,the UK NHS started nine “Collaborations for Leadership in Applied Health Researchand Care” (CLAHRCs) between University health research centers and NHSservice-providing organizations and local communities. The aim is to “stimulateinnovation and best practice across local health communities using two-waycollaborative learning and delivery pathways” in order to link researchers withresearch users who include policymakers, managers, front-line clinical professionals,patients and community representatives (“local health community”). More details aregiven by Baker et al. (2009), Rycroft-Malone et al. (2011) and Øvretveit et al. (2010).

JHOM28,1

116

With this background, our conceptualization of partnerships emphasizesrelationships between researchers and practitioners for clinical research and clinicalimprovement, rather than for policy or population public health practice.

Findings from the overview of the literature about research-practicepartnershipsOur review of the literature identified many different “approaches” to partnershipresearch, which overlap both in concept and application. Broad categories of R-PPsdescribed in the literature include:

. Community based participatory research (CBPR): defined in one paper as“conducting research by equitably partnering researchers and those directlyaffected by and knowledgeable of the local circumstances that impact health”(Horowitz et al., 2009).

. Practice-based research networks (PBRN): defined as “a group of clinicians,practices, or institutions that are devoted primarily to the delivery of patient careand are affiliated with each other in order to investigate questions related tocommunity-based practice” (Kutner et al., 2005).

. Practice-based quality improvement research (PBQIR): research by practitionersor academic researchers on changes to clinical practice or organization, where theresearcher works with practitioners to collect data and sometimes to report datato enable improvement.

. Action research (specifically for improving healthcare): defined as “a period ofinquiry, which describes, interprets and explains social situations whileexecuting a change intervention aimed at improvement and involvement”(Waterman et al., 2001).

. Specially-created health services research-practice partnerships involvinguniversities/academic medical centers: examples are the UK University-NHSCLAHRCs (e.g. Baker et al., 2009) or a US academic medical center communitypartnership (Yaggy et al., 2006). These are broad-based “umbrellas” for a rangeof research-practitioner studies and have tended to be university-driven andvehicles for research-into-practice “translational research”.

Our review found information lacking about many practical aspects of partnershipsincluding the nature and level of participation of practitioners in different stages ofprojects, and this made it difficult to assess whether the partnership was in name onlyor more substantive. In exploring how to define key features of a partnership approach,we assessed a range of studies which did give details. Table I gives a sample of studiesshowing the different ways that R-PPs can be established and run. We built on thisreview, our interviews and our varied experience as researchers in the UK, the USA,Europe and Australia to define criteria which differentiate more substantialpartnership research and a framework to specify a particular type of partnership(Figure 1). We return to this after noting other observations from the literature review.

A second finding from our overview is that investigators showed significantlydifferent understandings of “research” and of the role of practitioners with respect toresearch. At least three conceptions of research could be identified in the literature:research as knowledge generation, as existing evidence, and research as referring to

Research-practice

partnerships

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Table I.Examples ofresearch-practicepartnership“arrangements”

JHOM28,1

118

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Table I.

Research-practice

partnerships

119

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researchers, i.e. professionals for whom the main job description is to conduct research(van de Ven and Johnson, 2006).

Similarly, reports describe the role of practitioners in the partnership in differentways. Practitioners can be research “clients”, can facilitate research, or can do both. Inour research in the VA, we are perhaps most familiar with practitioners as“customers”, who seek to use expertise from researchers to improve practice. In someinstances, the partnership with practitioners was primarily established to facilitateresearch, for example by establishing data agreements, patient confidentiality

Figure 1.Guide for defining roles

and tasks in partnershipresearch projects

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arrangements, or working together to build an information technology platform tofacilitate data collection (McDonald and Viehbeck, 2007).

Overall, the literature characterized R-PPs mostly in terms of the objectives,function, or the main activities of the partnership (King et al., 2008; Mendel et al., 2009;Mold and Peterson, 2005). R-PPs have also been characterized in terms of theproductivity of the partnerships as regards products, tools or deliverables, such aspublications or grants (King et al., 2008; Gold and Taylor, 2007), or in terms of impact.For many, a dual objective is to contribute to both resolving practical problems andproducing generalizable knowledge. However, there are different conceptions of how toassess the effectiveness and impact of the partnership, and these include lastingchange (Waterman et al., 2001), measurable change in clinical practice (processmeasures, cost savings or other organizational impacts, or improvements in patients’health), or the degree of spread (Gold and Taylor, 2007).

Defining “R-PPs”Drawing on our literature review, interviews and discussions, we propose the followingcriteria to differentiate R-PPs from other ways of conducting research:

. researchers contribute to actions taken by practitioners or community membersacting on or at one or more levels of a health system;

. studies are intended to produce quickly and directly actionable findings, but alsoto be published in peer-reviewed scientific journals;

. studies involve both researchers and practitioners in defining the researchquestions and interpreting the findings;

. studies involve a “significant” amount of time or other contributions (such as adata gathering system) from both researchers and practitioners; and

. a formulated description of the partnership approach has been published, withaims and methods, and there are published empirical studies showing theapproach as applied (i.e. not just a conceptual description of a possible approachwithout examples).

A guide that we developed to help future partnership researchers and practitionersdefine roles at different stages of the project is given in Figure 1. The goal of this guideis to increase the likelihood of those interested creating a substantive R-PP rather thanthe superficial “involvement” that characterizes many collaborations. The guide hasnot been formally validated as a tool; it is intended to stimulate discussion amongresearchers and practitioners before undertaking a project, so that the parties morefully understand what is involved and agree upon roles at different stages of theventure. We are not presenting recommendations about where a partnership should beplaced on this matrix, as there is insufficient evidence for this and because it may welldepend on the purpose of the partnership and its objectives. Another guide we founduseful is CACSH (2013).

Implications for research-practice partnership programsAs regards VA research or UK CLAHRCs, our overview of the literature did not reveal apartnership typology that adequately characterized or categorized the research we hadreviewed or which was useful for the future. In the VA, several partnership approacheshave been, or are being, used, including PBRNs (Frayne et al., 2013), practice-based quality

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improvement research (Rubenstein et al., 2010), and action research. Similarly, there are arange of collaborative research approaches used in UK CLAHRCs and elsewhere.

Within the VA setting, and as part of an evaluation of the VA Quality EnhancementResearch Initiative (QUERI), we are currently assessing the degree to which fundedQUERI projects include “partnered work”. Based on the significant conceptual overlap inthe various partnership approaches above, our strategy for completing this evaluationwill be less concept-driven and more empirical, focusing on characterizing theindividuals or organizational entities involved in the partnership, the partnershipactivities that were proposed compared to what happened, and the various outputs fromthe partnership. This approach may be suitable for reviewing or evaluating or otherpartnerships, such as the UK CLAHRCs and/or for planning their future development.

Of note, King et al. (2008) provide a categorization of partnerships that could beadapted for use by QUERI and other programs. This categorization includes fourpartnership types:

(1) In King’s “clinician-researcher skill development model”, researchers provideconsultation and advice to clinicians who are interested in pursuing researchprojects. Although not identical to what King describes, QUERI, together withthe VA Health Services Research and Development (HSR&D) service, does offermentored career development awards for nascent clinician researchers as wellas PhD-trained non-clinicians seeking careers in health services research (VAHealth Services Research and Development, 2013a, c).

(2) In the “clinician and researcher program evaluation model,” researchers supportclinicians and managers to evaluate specific clinical services. Similarly, QUERIresearchers partner with practitioners in certain VA program offices to helpevaluate activities within the VA operations. These include advanced diseasemanagement, prevention of hospital-acquired pressure ulcers, and “eConsults,”,which allow primary care providers to obtain specialist input on patientmanagement without the specialist seeing the patient face-to-face.

(3) In the “researcher-led knowledge generation model”, the focus is on generatingnew knowledge, but in collaboration with other stakeholders, includingclinicians and patients. In the VA, QUERI seeks to fund investigator-initiatedinterventions, conducted in collaboration with practitioners, that will generatenew knowledge about effective implementation strategies. Our evaluation ofQUERI will determine to what degree this has been achieved.

(4) In the “knowledge conduit model,” the focus is on researchers synthesizingknowledge that can be shared with stakeholders within and outside theorganization. Similarly, the HSR&D/QUERI Evidence Synthesis Programsynthesizes knowledge in a useful form for practitioners (VA Health ServicesResearch and Development, 2013b).

ConclusionOur review of published reports about research-practice partnerships revealed a widerange of understandings and conceptualizations of R-PPs in healthcare. The detailsabout the partnership arrangements were often not described, unlike the intermediateoutcomes of partnerships such as scientific publications. It was possible, however, todefine a distinct set of approaches with substantive collaboration, which we classify

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here as R-PPs and for which we define criteria so as to distinguish them from manythat are only partnerships in name but not in substance.

We found the King et al. (2008) categorization a useful starting point for definingdifferent approaches, but this categorization did not describe a number of partnershipsreported in research, or which we had observed or experienced in the VA and UKCLAHRCs. To characterize these, we find the guide which we developed and presentedin Figure 1 more useful. We offer this guide for others to try when describing to othersa particular type of partnership being used, or when choosing an approach. or to helpto see how the partnership might be developed and to develop one type into anothertype of partnership.

Ultimately, the impact of the partnership should be assessed, but the mostappropriate approach to measurement remains to be shown. An important question forfuture research is for which objectives R-PPs are more effective than “conventionalresearch” for producing actionable research, or for enabling research to be applied inpractice for improvement.

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Author affiliationsJohn Ovretveit is at the Medical Management Center (MMC), Karolinska Institutet, Stockholm,Sweden.

Susanne Hempel is at the RAND Corporation, Santa Monica, California, USA.Jennifer L. Magnabosco is at the VA QUERI California Mental Health Services Authority, Los

Angeles, California, USA and Yo San University of Traditional Chinese Medicine, Los Angeles,California, USA.

Brian S. Mittman is at the VA Greater Los Angeles Healthcare System, Los Angeles,California, USA, VA QUERI Center for Implementation Practice and Research Support,Sepulveda, California, USA, and Kaiser Permanente Southern California Department of Researchand Evaluation, Oakland, California, USA.

Lisa V. Rubenstein and David A. Ganz are at the VA Greater Los Angeles Healthcare System,Los Angeles, California, USA, VA QUERI Center for Implementation Practice and ResearchSupport, Sepulveda, California, USA, David Geffen School of Medicine, University of CaliforniaLos Angeles, California, Los Angeles, USA and RAND Corporation, Santa Monica, California,USA.

Corresponding authorJohn Ovretveit can be contacted at: jovret@aol.com

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