Resource needs at the initial stages of research uptake
During the initial stages of research uptake, (i.e., at the discovery of and consideration of new research evidence) organizational culture were identified as important:
'I think organizational culture [is most critical in the beginning]. If ... particular organizations weren't open to partnering, even having the right people in the right places and the latitude to work on it within their positions, we wouldn't have moved [forward].' -- Researcher, FCS
'... I think the organizational culture recognized the value of research to practice. And they were given the opportunity to participate in decision making opportunities, like being part of working groups, the forum, being invited to the forum, and being as participants.' -- Policy maker, RSS
'The organization values, the leadership, the access, the exposure, are really pro-research, and we need to embark on this project because it is very important and our organization supports that.' -- Practitioner, RSS
Aspects of organizational culture that were perceived to initiate and support research use included the accessibility of research evidence, the presence of policies/infrastructure to support research use, and the belief in the benefits of research use:
'The organization invests in research-related articles, partly due to the affiliation with the [University].' -- Policy maker, RSS
'Opportunities do exist to foster learning and development of research skills.' -- Practioner, RSS
'I think there was more a feeling of freedom of moving between the political and the administrative sides of the organization.' -- Practitioner, RSS
'[Capacity building efforts were focused on] education and skills development versus addressing the root causes and looking at policy and system's change.' - Researcher, FCS
As evident from the above quotes, participants identified the need for investment in infrastructure and activities to support research use. Although the overall categories of resources identified were consistent across participants, some differences emerged in the types of resources that were identified as playing a prominent role in the initial stages of research uptake. Policy makers tended to emphasize the importance of flexibility within the organizational structure to make changes as new research evidence emerges. Competing demands and the need for equal distribution of resources were often reported to be a barrier to research uptake:
'In rural Nova Scotia, it is a struggle for resources. When you have limited resources, you have to be equitable about where to allocate funds. Do you put it here or there? Do you take it from here or there?' -- Policy maker, RSS
Practitioners tended to emphasize the need for sufficient time for advancing research use activities:
'Their [management] contributions and support would have been in the way of providing staff time to go to meeting and providing openings within their departmental meetings.' -- Practitioner, RSS
Researchers emphasized the importance of a new organizational receptivity to research use:
'There is an openness in the departments to hear about [research]. They are aware of it now. We went to a Policy Advisory Committee and presented it. And there is more and more with the [government] strategy.' -- Researcher, UB
Resource needs at the implementation stage of research uptake
During the implementation stage of research uptake (i.e., once the decision has been made to act on research evidence), both human resources (e.g., champions, skilled staff who make a commitment sustain change) and economic resources (e.g., available resources, flexibility to reallocate economic resources) were reported as prominent themes in the uptake of research evidence. In particular, the presence of a champion or facilitator was considered to be among the most valuable resources in seeking the support of others for evidence-based change:
'One of the reasons that our work has been successful is that we've had some real champions leading the work.' -- Policy maker, FCS
'Under human resources, I think what was really key is now they have champions identified, with actually high respect in our organization. [Examples include a medical doctor and a stroke navigator].' -- Researcher, RSS
There were a few champions, I'll say, within the organization that were motivated and energized to help make some stroke care improvements.' -- Policy maker, RSS
'Having people in place to implement best practices: That was most important later on ... but to get there, you need the support of the organization.' -- Practitioner, RSS
Participants acknowledged that organizational culture is inextricably linked to characteristics of the individuals within the organization; most notably, the extent to which individuals are receptive to research/innovation, possess a research use orientation, and hold shared beliefs with others in the organization, and openness to collaboration (e.g., between researchers, decision makers, and practitioners):
'...Certainly in terms of readiness to proceed with trying out some of the best practices and the recommendations in the document, [our organization] was way far ahead of some of the [organizations in] other districts.' -- Policy maker, UB
'There are individuals in the organization who were really motivated and willing to adapt to change, and were really key players.' -- Researcher, UB
Aspects of economic resources that were reported to facilitate research uptake during the implementation stage included dedicated funds or the flexibility within the budget to reallocate funds. It was noted that change should occur with the realization of potential benefits and efficiencies from implementing new research evidence:
'Economic resources, I think there was definitely a realization that in order to improve stroke care to the recommended levels that were in the stroke strategy document, that money was going to be required. Not that is wasn't known all the way along, but I think they were thinking more in terms of what exactly do we need. Is it two OTs [occupational therapists] or three, or three speech pathologists, or what exactly is it? And starting to think about what dollars would have to go along with that.' -- Policy maker, RSS
Participants' comments illustrate the importance of time to establish and foster relationships between researchers, policy makers, and practitioners to effect change. Consequently, short-term collaborations may have limited impact if major systems change is required.
Resource needs at the later stages of research uptake
During the later stages of sustaining newly implemented policies and/or practices, human resources and economic resources were considered to be essential for sustaining any changes to policy and/or practice resulting from research evidence:
'[We] need the resources to do it ...ultimately, dollars and human resources.' -- Researcher, RSS
Dedicated staff with a flexible workload to engage in change efforts were thought to play an important role in sustaining policy and/or practice changes in the later stages of research uptake. Economic resources including funds to sustain new policies and/or practices as well as a financially supportive system were considered to be increasingly important at this stage of research uptake, particularly when the changes were brought about through the course of a limited term funded research project.
COR-KT theme two: The threat of loss leads to the protection of assets
A central component of COR theory is the notion that the threat of resource loss results in the guarding of existing resources and risk aversion (i.e., pushback on research use). The fear of resource loss over potential benefits was documented in the four cases. All participants expressed some hesitation or resistance to engage in research use activities; however concerns differed among policy makers, practitioners, and researchers.
Policy makers were primarily concerned with the impact of dedicating resources to change policy and/or practice in one area to the detriment of other programs.:
'There was a fear that money would be taken away from other programs to be able to do this...' -- Policy maker, RSS
Practitioner concerns stemmed from having an unmanageable workload, decreased time, and role confusion:
'I am only one person! I was quite overwhelmed...where do you put your time and how do you make those decisions?' -- Practitioner, RSS
Concerns were expressed about the availability of health system support for the sustainability of a change that was being tested. However the concerns about loss varied as a function of stages in the KT pipeline. In the early stages:
'There were concerns about becoming involved because previous experience with research had left them unsatisfied [and led to a breakdown in trust]' -- Researcher, DRS
'Before you put the time and effort into it...is it sustainable? How are people going to respond to it? What directions will they be given? And will we be prepared for the potential outcomes in terms of resource allocation and capacity to respond.' - Policy maker, DRS
The later stages of a grant, termination of grant funding, and the coordination that comes with it, contributed to concerns about the sustainability of engaging in research use activities:
'All of a sudden, it was the end of the project, and the money was gone, the person was gone ... so a sense of disappointment that we didn't accomplish what we had hoped to ...' -- Community partner, DRS
'But what happened when the project ends is you no longer have that overarching coordination...[we] saw the differences ... it fell back to the provinces to implement and sustain the activity on a provincial basis because you lost that coordination.' -- Policy maker, DRS
'So if anything, after the money was done, all of these things became more strained.' -- Practitioner, DRS
In summary, worries over potential resource loss were heightened if participants had prior negative experiences with research. This issue was particularly salient if past research collaborations had resulted in losing a champion or losing skilled staff. Negative experiences with past research initiatives served to exacerbate resistance to research use and increased the scepticism concerning the benefits of changing practice and/or policy.
There were several marked differences between long-term and short-term projects involving research use. The salience of resource loss over the potential gains of research use was particularly strong among the participants in short-term projects. Participants conveyed a sense that there was insufficient time to develop a strong university-community partnership. Projects that received only short-term funding suffered from the lack of a strong research or policy champion. Participants reported that trust was not well-established between policy makers, community partners, and researchers. Limited communication between partners was perceived to decrease confidence in the recommended policy changes that resulted from the research. Interestingly, confidence in the research evidence was largely intertwined with the relationships between researchers, policy makers, practitioners, and community partners.
Involvement in long-term projects that connected directly to the development of health system changes seemed to build confidence among the service providers, allayed fears of resource loss, and increased capacity to act on research evidence. Participants in long-term projects reported that there was sufficient time to conduct the research, translate the findings, and facilitate system changes. Time, coupled with additional money and further involvement in partnerships appeared to generate greater receptivity to using evidence.
COR-KT theme three: Resources must be optimized for adaptation
All participants identified strategies that maximized the use of existing resources to gain buy-in. In particular, participants reported the value of a champion to create momentum among staff and buy in among decision makers:
'A champion makes all the difference in the world [in gaining buy-in and involvement].' -- Researcher, RSS
Ongoing education and training opportunities about the issue and approaches to addressing it, capitalizing on existing partnerships and collaborations served to bolster confidence in the ability to act on research evidence:
'[The principal investigator] had a history and a reputation for working in the area of food security ... provided credibility.'-- Researcher, FCS
'They encouraged...They allowed us, as clinicians, to go to the forum. And certainly several of us going involved with working groups.' -- Practitioner, RSS
'All new projects that are being built are being built to accommodate bicyclists as well. So if we are re-building a roadway, an existing roadway, if the opportunity exists, we widen the roadway to incorporate bike lanes ... bikeway projects would be tacked onto existing pre-planned, much larger roadway building projects.' -- Policy maker, UB
Together, these engagement strategies empowered individuals and teams within health systems and cultivated efficacy to enact evidence based change. Receptivity to research use was bolstered with confidence that improvements to service would result. Participants' comments reflect the importance of leveraging an existing resource -- even through a seemingly small act such as encouraging staff participation at a scheduled event -- and serves to create a culture shift and momentum towards implementing changes based on evidence. It appears that resource optimization occurs when threat of resource loss is countered with perceived benefits are associated with the outcomes of research use. In many cases, participants expressed excitement for resulting changes and reported an eagerness to engage in future research use activities:
'Benefits include the prevention of strokes among those who might otherwise have had strokes, potential for earlier and more effective treatment, and improved potential for quality of healthcare across the spectrum ... from prevention to rehabilitation.' -- Policy maker, RSS
'I think that we are going to gain a healthier population, a healthier future, a healthier environment. Not that we have gained it. These are long term things [that we will continue to act on].'-- Researcher, FCS
Although organizational resources can be optimized to enhance research uptake, there appears to be a threshold to optimization. Participants suggested that it is not as simple as 'making do with existing resources.' The provision of financial resources from the province that supported improvements to stroke care at the regional level helped to sustain momentum:
'Because of the money, we received equipment that enabled us to do a better job, increase our human resources, and become a more integrated team moving forward' -- Researcher, RSS
'So now that the province has awarded funding for the stroke program, I think there is excitement and commitment. And actually having resources really gives people an opportunity to do a lot of brainstorming and that kind of thing.' -- Policy maker, RSS
'If the Heart and Stroke Foundation hadn't pushed for the funding to go with it, the project might have been at the same place -- ending with no sustainability ... serendipitous.' -- Researcher, RSS
As evident from the multiple case study, there is some variation in how the COR-KT themes play out across the four cases. However, the four cases were consistent in providing evidence that the three COR-KT themes manifest in the health systems context and at varying stages of research uptake: Resources are required for research uptake; threat of resource loss leads to the protection of assets; and resources must be optimized for adaptation.