Exploring ideas of embeddedness

Text throughout this chapter has been reproduced with permission from Ward et al.146 This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text.

Introduction

As noted in Chapter 1, and in line with the growing interest in knowledge co-production explored in Chapter 2, there has been a recent surge of interest in embedded approaches to research, particularly within health care. These have tended to focus on developing more productive ongoing relationships and increased social interaction between researchers and those in organisations. Examples include the incorporation of evidence-generating organisations into the wider health service delivery system,147,148 research–practice partnerships149 and local participatory research initiatives.150

An increasingly popular form of embedded research involves physically locating researchers in non-academic organisations. In this incarnation, embeddedness refers to researchers being ‘in residence’ in the organisation,47,151 and ‘research’ is used to denote at least three things: the knowledge and expertise that researchers bring with them, the research-based knowledge that they broker into the organisation, and the new insights that are developed from data gathered and interpreted in situ. The negotiation of expertise, the contextualising of external knowledge and the co-production of new understandings are often key tenets of this type of initiative, leading to its comparison with the notion of ‘engaged scholarship’.65,152,153 This is perceived to lead to greater organisational ownership of the knowledge being produced, ultimately leading to its incorporation into the work of the organisation.65,154

A growing literature has started to highlight the multiple challenges that face embedded researchers and those with whom they work.155,156 These include the challenges of establishing and maintaining relationships in the face of busy work schedules and tightly controlled service delivery spaces, defining and adapting the scope of the knowledge production work being undertaken, and maintaining an academic identity.65 The literature has also started to highlight the aspects of an embedded research initiative that facilitate change, including trusting relationships, shared-decision-making, clear communication about the focus and function of the embedded researcher’s role and negotiating the different understandings that those in the organisation may have of the researcher’s role.152

This growing literature largely focuses on descriptions of individual initiatives and/or the experiences of embedded researchers themselves, taking only an overview of the principles of embedded research. Reading across this literature, there are signs that embedded research initiatives are expressed and conducted very differently. However, there has been relatively little in the way of analysis of this diversity. This has resulted in a lack of understanding about what initiatives look like in practice, how and why they are designed as they are, and the implications of different variants. Workstreams 1 and 2 aimed to address such gaps.

Here we present the results of the second literature review carried out under workstream 1, identifying and analysing the published literature on embedded research initiatives as they have been put into operation. These findings are then combined with the scoping work of workstream 2, which sought to identify and analyse extant embedded schemes in health-related settings in the UK. In combing insights from the published literature and practical UK experience in health care, we have been able to outline 10 themes that encapsulate the key features of embedded research initiatives. These form a practical framework to understand the design features of embedded research initiatives.

Methods

This work comprised three parts spread across workstreams 1 and 2. The first was a review of the theoretical and empirical literatures on embedded research across different disciplines and settings. The articles included for analysis are listed in full in Report Supplementary Material 2. The second was a scoping exercise of embedded research initiatives in operation specifically in health settings across the UK. The third was a co-production workshop with embedded researchers and their managers. The literature review and scoping exercise ran in parallel, being mutually informative; the workshop was an integral part of the engagement strategy (workstream 4) and allowed refinement and some face validation of the emergent findings.

Assembling the published literature

For our review of the embedded research literature, we used a modified CLUSTER (Citations, Lead authors, Unpublished materials, Google Scholar, Theories, Early examples and Related projects) method.157 This approach to systematic reviews of complex interventions was developed as a way of providing both contextual thickness (an adequate description of the intervention and its context) and conceptual richness (the theoretical and conceptual development that explains how an intervention is supposed to work). The developers of the method argue that this level of detail is unlikely to be present in a single publication, but may be present in a ‘cluster’ of related publications and materials. We reasoned that this method would help us better understand the intent, structures and processes underpinning embedded research initiatives. The aspects of the method that we used are outlined in Figure 4, adapted from Booth et al.157

FIGURE 4 Aspects of the CLUSTER method used in our study. This figure was created using the logic and approach as laid out in Booth et al.157 Pearl citation, a key paper on an identifiable initiative that acts as a retrieval point for related outputs that may help to explicate theory or understand context; cluster search, a systematic attempt using a variety of search techniques to identify papers or other research outputs that relate to a pearl citation. (Figure not reproduced here; see the original article.)

We began by assembling a database of 45 potential ‘pearl’ citations (papers focusing on an identifiable embedded research initiative; see Figure 4) from different disciplines including education, health and urban development. These citations were sourced from a review conducted by members of the wider team in 2015,158 from database searches between that review and January 2018, and through personal contact with key informants.

We discarded those citations that did not focus on a specific embedded research initiative, and then grouped together those that focused on the same initiative and/or involved the same authors. This resulted in 26 distinct ‘clusters’ of papers. We then used forwards and backwards citation-tracing and author searches to identify related materials to add depth to each cluster. This resulted in a total of 47 papers across the 26 clusters.

Scoping extant schemes in health and health care

For our scoping exercise (workstream 2), we focused on embedded research initiatives in operation in health settings across the UK. These settings included public, private and voluntary sector organisations with a role to play in commissioning and/or delivering health services. We used our network of contacts; requests via mailing lists such as the NHS Contact, Help, Advice and Information Network (CHAIN); and posts on Twitter to identify potential embedded research initiatives. We kept the definition broad at this stage to capture initiatives described as embedded and researchers who defined themselves as embedded.

We identified a total of 90 potential embedded research initiatives. We then used three criteria to determine which were of most interest and relevance to this study. These focused on identity (were the researchers in the initiative trained and/or experienced in research and were they seen as a researcher by those in the health setting?), knowledge production (was the initiative designed to produce knowledge that would have direct relevance and application to the organisation?) and immersion (were the researchers physically located in the health setting for a significant portion of their working week?). These enabled us to narrow our focus to 45 initiatives, a summary of which can be seen in Tables 3 and 4.

For each initiative, we gathered publicly available information if possible (e.g. from websites). Each initiative was asked to share internal documents including role descriptions, strategy documents and reports. In this way, we constructed a database of documentation on each of these schemes (a total of 236 source items). To deepen our understanding of the varying types of initiatives, we also conducted telephone interviews with individuals from 12 initiatives, selected on the basis of diversity, taking into account their setting, longevity, structural features and overall purpose. When possible, we interviewed both an embedded researcher and the manager or instigator of the initiative, conducting 17 interviews in total. Interviews focused on adding depth to our understanding of the intent, structure and processes associated with embedded research initiatives, with the interview guide being developed from the evolving literature analysis.

Analysing the assembled materials

We used an inductive and iterative analysis process to bring together the embedded research literature and scoping materials. We began with a detailed reading of the clusters identified during the literature review, concentrating on extracting definitions, concepts and working theories associated with each cluster. Through ongoing discussion between team members, we developed provisional and emergent themes. Next, we applied these themes to materials gathered during the scoping exercise, using them to produce detailed analytical descriptions of each initiative. During this process, we sometimes identified additional themes or merged or disaggregated others (going back to the literature clusters as necessary), until the analytic descriptions gradually stabilised. Finally, we coded the interview data using the same themes, while being alert to the identification of further themes or destabilisation of existing ones. Throughout the analysis process, we compared and discussed the coded materials and descriptions, with repeated and intensive discussion across a core group (VW, TT, BR and HD) and broader sense-testing across the whole project team. Over time, we settled on a set of 10 themes, and a finer-grained set of subthemes, that seemed to represent the key features of embedded research initiatives.

Testing the emergent findings with embedded research actors

The third and final part of this study involved testing and validating the themes and putting them into an overarching framework. We held a day-long co-production workshop with embedded researchers and their managers (n = 18) that made use of a range of creative activities and was facilitated by an experienced team of researchers in design and health (see Acknowledgements). Activities included commenting and adding thoughts to postcards representing each of the themes, discussing the relative priority of each theme, and building physical metaphor models of the themes and their interconnections. Workshop participants confirmed and validated the importance and relevance of all 10 themes and suggested ways of linking the themes in a single metaphor for an embedded research initiative. This was used subsequently to derive practical guidance and web-based tools and resources for those designing or analysing embedded initiatives (see Chapters 6 and 7).

Findings

The themes and subthemes are summarised in Table 5, grouped into three categories: intent, structure and processes. Although there are some overlaps, resonances and implications that run across the themes, they have proved robust in conversations within and beyond the research team, and have survived repeated testing against the source materials.

In the following sections, we describe each theme and associated subthemes in some detail, providing evidence from the various source materials (specific initiatives have been disguised by using coded names; see Table 4 for brief information on each initiative).

The intent of embedded research initiatives

Across the data, we were able to identify two themes relating to the underlying intent of embedded research initiatives: the intended outcomes and the nature of the power dynamics. The first of these is often to the fore in discussions about embedded research, whereas the latter often remains obscured. These are now explored in turn.

Intended outcomes

The primary explicit focus, or intent, for many initiatives was to produce knowledge that would be beneficial within the health-care organisation. This knowledge included both local insights (generated through local service evaluation, service improvement or practice development activities) and more generalisable knowledge (generated through larger-scale, formalised research activities and aimed at wider peer-reviewed promulgation). Some initiatives aimed to produce both forms of knowledge across a portfolio of different projects:

We just call it research with a big R or research with a small r. So, research with a big R is probably funded . . . The small-r stuff is more clinician generated . . . I don’t see it as a hierarchy, I almost see it as a journey, a pathway.

Many initiatives also intended to bring about outcomes related to the capacity and capability of the individuals and organisations involved. These included the capacity to produce knowledge, to deliver services and to generate income:

The RiR [researcher-in-residence] role supports scale-up and spread of good practice, in order to share benefits of activity improvements.

The role is expected to result in:

The building of a culture in the locality which values the contribution of participatory evaluation of complex improvement programmes.

The building of local capacity and capability for critical evaluation.

Interestingly, the focus of such capacity-building activity was predominantly on the health service setting, rather than the academics and their organisations.

Some initiatives focused additionally on the reputational benefits of embedded research.159 These included access to and involvement in large-scale change or research projects, the number of publications arising from an initiative, and increased or continuing funding for research and/or service delivery (which could stem from being seen to be involved in an initiative or from the knowledge being generated by an initiative):

They have used every bit [of evidence] that we’ve generated, and all of the documents that we’ve produced sit proudly in the CEO’s [chief executive officer’s] office and they’re given out at all of the events. So they do really value this as a, almost like a commodity . . . It raises the profile of the organisation.

Power dynamics

As with many schemes that focus on the persistent gap between research and practice, embedded research initiatives often addressed power dynamics, sometimes explicitly and proactively or, perhaps more often, implicitly and reactively. Duggan155 speaks to this tension when he cites Cheek:160 ‘Taking money from a sponsor is not a neutral activity; it links the researcher and research inexorably with the values of that funder.’. From our reading of the source materials, two aspects of power (who and what) seemed to be attached to three different facets of the initiative (control, contribution and gain). The concerns, then, were often about who is in control of the initiative, and what aspects of it are they in control of; who contributes to the initiative, and what do they contribute; and who benefits or gains from the initiative, and what are these benefits?

The first part (i.e. who is in control, contributes and gains?) tended to be reflected in the structural arrangements of an initiative, but was rarely discussed openly by our interviewees or in the literature. Those involved in initiatives appeared to be more cognisant of the second part of these power-related subthemes (i.e. what is being controlled, contributed and gained):

Successful research–practice partnerships require co-contribution of resources if the partnerships are to endure . . . financial and in-kind contributions made by both parties . . . demonstrated commitment to the partnership and the value of its outcomes.

A further way in which power dynamics played out was in relation to the intended effect of the initiative on the traditional roles ascribed to academia and practice, whereby academics were conceived as knowledge producers, and practitioners as knowledge consumers. Many initiatives sought to influence not only these epistemic positions, but also those found in health-care practice itself (e.g. between different groups of health-care professionals):

One of the things that I’ve ended up being is this kind of weirdly passionate advocate revolutionary on behalf of nurses – because I just think that they’re treated like shit basically. And clinical teams talk a big game about being this great high-functioning team, but they don’t really mean it – they don’t really treat nurses’ perspectives or admin[istrators’] perspectives, or anyone who’s not a consultant’s perspective as [being as] valid as their own. And I’ve ended up fighting for that.

Or as Cunliffe and Scaratti153 noted:

While the Board might have invited the researchers in as ‘experts’, the researchers were keen to renegotiate that power relationship by acknowledging the expertise and situated knowledge of all participants.

However, actively disrupting power dynamics was rarely the explicit intention of initiatives. Although some sought to challenge power dynamics by bringing epistemic differences and other inequalities into focus, others sought to rebalance them by blurring roles and boundaries (e.g. by involving health-care staff in collecting and analysing data). Still others sought to maintain or bolster traditional roles and relationships, or simply left these unaddressed. In fact, many of our interviewees were reluctant to discuss power dynamics, or explicitly downplayed their relevance, and often seemed to have given these concerns little or no consideration:

The main driver especially for my managers is just improving clinical services . . . I don’t think [the power dynamics] really comes into anyone’s thought processes.

Our workshop participants, in contrast, suggested that power dynamics were an emotive and often painful issue for those involved in embedded research initiatives, using words such as ‘emotion fuelled’, ‘tension’ and ‘frustrating’ when reflecting on this theme. Such feelings were also evident in the literature, such as when Hackett and Rhoten161 reflect on their ability (or lack thereof) to speak of their findings. Further discussion revealed that it was precisely when power dynamics were hidden or unacknowledged that significant disruption and frustration were experienced by those involved in the initiative.

The structure of embedded research initiatives

As outlined in Tables 3 and 4, the on-the-ground initiatives that we identified were located in different institutional settings and structured in diverse ways; such structural diversity was also seen in the literature. We were able to draw out four themes that represented the various structural features of embedded research initiatives: scale, involvement, proximity and belonging.

Scale

The scale at which embedded research initiatives were operating was a notable structural feature across the data. This comprised the scale of the work undertaken, the timescale of the initiative, and the size and composition of the embedded research team.

Early examples of embedded research initiatives in health-care settings tended to be relatively small in scale and short lived,151 often focusing on well-defined projects such as service evaluations.64 Although we found examples of such single-focus, time-limited initiatives, many of those uncovered more recently had wider interests and/or a much longer time frame (over one-quarter had endured for ≥ 5 years; see Table 3). Moreover, some initiatives comprised a portfolio of defined projects, whereas others were more emergent:

This document will not establish the scope of the work and specific project areas . . . This may enable the role to be deployed in a range of settings, meeting the demands and needs of front-line services.

Much of the embedded research literature focuses on the challenges associated with performing the role of an embedded researcher and the need for ongoing support and mentoring.63,155,156 Many of these observations stem from initiatives comprising an individual researcher working in a health services setting. Although our scoping exercise found examples of such initiatives, it also identified instances of embedded teams of researchers.162,163 Our workshop participants suggested that multidisciplinary embedded research teams were particularly important for addressing the complex issues and problems that face health-care organisations.

Involvement

Another important structural feature of embedded research was the involvement of various actors within the initiative. We sought to establish whether or not embedded research initiatives involved people other than those researchers and health service staff working within them (e.g. going wider to include patients and members of the public) and, if so, how their involvement was facilitated and managed. From this, we developed four subthemes: who is involved in the embedded research initiative, the scale and location of their involvement, the activities they are involved in and the mechanisms for their involvement.

Relatively few initiatives were clear about the involvement of patients and members of the public in their work, and published accounts sometimes point to dissonance between intended and actual patient involvement.64,150,153 Of those that did discuss this aspect, the majority limited involvement to the specific knowledge work being undertaken in the initiative (e.g. a well-bounded service evaluation or improvement project), rather than involving people in the design or operation of the embedded research initiative itself:

We recruited a service user partner to the evaluation team . . . If I’m going to be honest, I don’t think I would describe her as being involved in my role – more on the project.

Although rarely involving patients and members of the public, some initiatives did involve a wider range of stakeholders in activities, such as advisory groups. As with patients and members of the public, however, activities were also more likely to relate to the work being undertaken by the embedded researchers, rather than the conceptualisation or conduct of the initiative as a whole.

Proximity

Given the focus on researcher immersion as one selection criterion for initiatives, and the importance placed on this in the literature, we identified researcher proximity as a key structural feature. We did, however, identify three somewhat distinct ways in which immersion or proximity could play out in practice: through physical location, intensity and visibility.

Although seen as a key enabler of embedded research, the physical location of the researcher varied across initiatives and was not always a straightforward decision for many. Initiatives that comprised a portfolio of projects, or were more emergent in nature, faced decisions about where and with whom the researchers should be located, what spaces they would have access to and whether they would be working at a single location or across multiple spaces:

I am evaluating the [area-wide multispecialty] programme, a partnership of six organisations representing health, social and voluntary care . . . Challenges include: where am I embedded? In a team? Or in the space between strategy and delivery?

The intensity of contact between the researcher and those in the health-care setting was also variable across initiatives. Although documents from many initiatives showed a clear expectation about the proportion of researcher time to be spent in the health-care setting, these proportions ranged from 20% to 100%. Regardless of these documented expectations, the intensity of contact between researchers and those in the health-care setting tended to vary over time, with researchers often reporting a need for greater intensity towards the start of an initiative as relationships were being formed and expectations agreed.

The visibility of the researcher(s) was related both to their physical location and to the intensity of contact, but was not merely the result of these structural features. Visibility was instead more nuanced, and spoke to the profile of the researcher(s) and their embedded research work and the extent to which they were known and well regarded within the health-care organisation and further afield:

My role has changed quite a bit, so I’m becoming more visible . . . a lot of introductions from more senior members of staff.

Visibility, then, is a function of the informal, relational work carried out by the researcher and the formal, structural features of an initiative, as well as the import or impact of their activities.

Belonging

Embedded research initiatives can be thought of as a mechanism for bringing together the worlds of research and practice. As such, we identified a number of structural features related to belonging (or otherwise) to these different worlds, and how this was facilitated in embedded research initiatives.

Both the literature and the people we interviewed emphasised the often precarious nature of working in an embedded role, and the sense of liminality that could arise from the need to work across (and between) multiple boundaries.156,164,165 These included the epistemic and functional boundaries between academia and health-care settings, and those that arose between different organisations, professions, teams and priorities in each of those settings:

If I’m really honest, this has tested me to breaking point almost, because it’s not easy. The university were interested, then they weren’t, and then they were – I don’t belong to the teaching fraternity, I don’t belong to the research fraternity.

Embedded research initiatives often made use of a variety of formal, contractual arrangements to enable researchers to belong to the worlds of research and practice and to manage the boundaries between these. Contrary to earlier literature on embedded research,158 the embedded research initiatives we uncovered rarely made use of joint contracts of employment between academic and health service organisations (see Table 3). Instead, expectations and agreements about how researchers would formally belong to these settings were often documented in a memorandum of understanding (MoU), a funding agreement and job descriptions:

This MoU defines the relationship between the parties and sets out roles and responsibilities within this; it sets out how the group will be governed, the duration of the arrangement, principles of working together and agreed terms and conditions.

In addition to formal, contractual arrangements, initiatives also made use of a range of more informal arrangements to enable researchers to belong to different worlds. These included support networks, mentors and champions. Although some initiatives built such arrangements into their structures, it was often researchers themselves who created these, or sought them out and nurtured them:

There were times when I started that I felt a bit isolated from academia . . .. And other than [my manager] I was the only person with a PhD [Doctor of Philosophy], so yeah, I did find that a bit isolating; so that’s why I went out and asked the senior lecturer at [university] to be my academic mentor, and they have agreed that I can go and sit in their department.

Researchers who were wholly located and employed in a health-care setting and lacked formal, contractual links with academia often sought to maintain a connection by participating in academic activities such as conferences. These researchers highlighted the importance of being given permission and encouragement to engage in these activities:

I think it’s really, really important that I make sure I keep those links with academia . . . I think that’s one of the biggest challenges, that if I left and someone else took up this post, I think that they would have to somehow find that academic support . . .. It doesn’t come naturally with this, you have to find it yourself.

The many and varied structural aspects discussed above often get ‘baked in’ as embedded research initiatives become established. More fluidly expressed, however, are the processes by which such initiatives operate, and it is to these that we now turn.

The processes of embedded research initiatives

Just as the embedded research initiatives we identified were structured in different ways, they also made use of a wide range of processes. We were able to categorise these into four themes that represented the ways in which initiatives played out day to day: functional activities, researcher skill and expertise, relational roles and learning mechanisms.

Functional activities

We found that a wide range of actions were being undertaken within embedded research initiatives, and that researchers were often expected to carry out a plethora of different activities.166 These included relational activities (such as attending meetings and facilitating relationships), knowledge-creation activities (such as collecting and analysing data), educational activities (such as facilitating a journal club and arranging seminars) and project management activities (such as planning, managing and leading individual projects). In practice, although job descriptions suggested that likely activities were relatively tightly defined, many interviewees suggested that they were instead fluid and emergent, with new opportunities presenting themselves throughout the initiative:

[The researcher] was attached to long-term conditions group, which was a group that had many, many challenges and many problems, and constant changing of leads. Once she was sitting in on this group, [initially] she couldn’t figure out what she was going to do that was going to be helpful for them.

The literature and the data from extant schemes suggested that there was a tendency for those leading initiatives to be overambitious about the activities that researchers should carry out.162 This could lead to ‘role strain’ and contribute to difficulties in managing boundaries. Our interviewees and workshop participants suggested that focusing on the purpose of activities was an important way of combating this.

The ‘training and support’ subtheme was informed especially by discussions with our workshop participants and with some interviewees. They suggested that training and support would enable researchers to carry out the range of activities required by an embedded research initiative and that this should be considered at the design stage of the initiative. We found relatively few examples of such training and support for functional activities being provided to embedded researchers, although some researchers accessed these via their informal arrangements for belonging:

Embedded brokers benefited from allies, champions and ‘chaperones’ located throughout the host organisations, who . . . developed the brokers’ skills and knowledge in research (management fellows) or commissioning (researchers-in-residence).

Researcher skill and expertise

The necessary skills and expertise of embedded researchers were a frequent preoccupation across the literature and the initiatives we identified; these came in three broad types: topic-specific skills and expertise, methodological skills and expertise, and interpersonal skills and expertise.

Topic-specific skills related to the particular clinical or practice-related issue that the embedded research initiative focused on, such as diabetes, neurorehabilitation or childhood obesity. Although many initiatives sought researchers with such specific content knowledge, some (particularly those working at larger scales, comprising a portfolio of projects or a team of embedded researchers) prioritised other, more generic, forms of skill and expertise:

Because we’ve got such a diverse trust, we have to not be too precious about what subject area we work in. However, I think we all have our own expertise in terms of skill set rather than subject.

Methodological skills supported the ways in which knowledge was created within the initiative, and included the skills needed to define and refine the focus of the knowledge-creation activity, how to collect and analyse data and how to produce knowledge of different kinds. In many initiatives, this type of research ‘know-how’ was seen as particularly valuable, over and above any topic-specific skills and expertise.166

Interpersonal skills and expertise were seen as highly valuable across the initiatives we identified. All role descriptions for embedded researchers required a range of interpersonal skills. These included facilitation skills, communication skills, relationship-building skills and emotional intelligence, and chimed with the emphasis in much of the literature on the social skills and dispositions of embedded researchers:151,154

And I think in essence, that sense of genuinely brokering is being able to . . . have a meaningful dialogue.

Researcher expertise and skill often then received explicit attention in embedded research initiatives. But how the different types of expertise and the softer interpersonal skills were channelled depended, in part, on the relational roles envisaged in the particular embedded initiative.

Relational roles

Although all embedded research initiatives aimed to bring research and practice into a closer relationship, we found that the type of role that researchers might play demonstrated a number of characteristics. These were the level of interdependence between researcher and health organisation, their relational stance and the type of input each provides.

Researchers in the initiatives we identified had varying levels of interdependence with the organisation in which they were embedded. This was expressed in the extent to which they viewed themselves (or were viewed by others) as insiders or outsiders in the health setting, the degree of flexibility and control they had over their work (including disseminating findings) and the extent to which they were able to access spaces (literal and figurative) within the health organisation. Their level of interdependence was often related to (and reflected in) contractual and informal arrangements for belonging, and was closely tied to power dynamics. Although we identified varying levels of interdependence across the initiatives, the challenge of managing the boundary between insider and outsider was a common theme:

Occupying these different spaces with people at various levels meant that I was forced to adopt multiple positions. This meant that I sometimes felt like an outsider, at other times, an insider, while sometimes both or neither simultaneously . . . This constant shifting and flux was unsettling.

Researchers adopted a variety of relational stances towards the health setting in which they were embedded and towards those working in it. The literature frequently highlights the role of an embedded researcher as a ‘critical friend’ and the importance of maintaining a critical stance towards the health setting.151,158 This is usually related to the maintenance of academic professional identity that depends on a researcher’s ability to maintain a critical distance.65 Researchers working in some initiatives, however, adopted roles as advocates and supporters, seeking to produce knowledge and operate in ways that would support, rather than challenge, the organisation. These choices were strongly related to the underlying intent of the initiative:

A critical friend needs to be, first of all, a friend. And it’s easy to assume the role of a critical friend where actually your voice is seen as the voice of an outsider. And in reality, it doesn’t have weight, because you’re seen as someone from the outside looking in and guiding, and instructing, and criticising, and telling. Whereas if you’re fundamentally part of the team, and you’re seen to be part of them when they’re in the trenches, you’re there with them . . . and that’s why you’ve got to get the right person because it’s not every researcher who can be an embedded researcher.

The types of input provided by embedded researchers also varied across initiatives. Some researchers provided the health organisation with a fresh pair of eyes and a new way of seeing things, bringing insights that could help to catalyse change.152 Other researchers provided an additional pair of hands, producing knowledge and evidence to drive the organisation’s processes and activities. Still others focused on providing specialist or expert advice (methodological or topic specific) in a more hands-off fashion. In line with our observations about functional activities, many initiatives also expected more than one type of input from researchers.

Learning mechanisms

Embedded research initiatives made use of a variety of mechanisms to assess how things were going and whether they were achieving their intended outcomes.

Those wholly based in NHS or other health service organisations tended to make use of performance monitoring mechanisms, including key performance indicators and annual performance reviews (typically for the embedded researchers). These mechanisms seemed to be used because they fitted into wider organisational governance arrangements that often focused on maintaining funding levels and controlling resource allocation:

I have to report my team’s work quite frequently to the board of trustees through my CEO.

Initiatives that were funded or controlled by organisations with a strong research focus (e.g. university departments, national research funders, academic–practice partnerships) tended to make use of formal evaluations. These were usually focused on producing an in-depth understanding of how and why the initiative was (or was not) working and made use of formal evaluation methodologies. Both summative and formative approaches were used, and these often resulted in academic publications (a literature that we have drawn on heavily as part of this work):

Research methods were applied to understand, inform, adapt and assess [the KM (knowledge mobilisation) team’s] impact. This paper draws on multiple sources including brokers’ logs, reflective essays and exit interviews; whole team workshops; and independent evaluations of the KM team.

Some initiatives made use of more informal mechanisms for learning and reflection. These were usually understood to be developmental and formative in nature. Informal mechanisms included group or individual supervision, team meetings, workshops and learning sets. The main participants in such activities tended to be embedded researchers themselves, however, and there was relatively little involvement from those leading or managing the initiative.

Concluding remarks

The work described in this chapter (primarily the second literature review of workstream 1 and the scoping study of workstream 2, but also drawing on some of the engagement activities of workstream 4) provides a detailed and grounded analysis of embedded research initiatives, both as they are conceptualised and articulated in the academic literature and as they are playing out in UK health-related settings.

The underpinning logic of these schemes (outlined in Chapter 1) lies in a wide literature developed over decades,167,168 one that sees effective knowledge production and ‘research use’ as a social, situated and contextually mediated process.4,9 In that sense, embedded research initiatives have a robust and persuasive logic that underpins their conception. They are, however, diversely enacted and much in need of more systematic and evaluative enquiry.

Through this work, we have drawn out and described 10 major themes with multiple subthemes, grouped under the categories of intent, structure and processes of embedded research initiatives. Each of these was clearly seen, but variably expressed, in both the wider literature and the data sources that we gathered about extant health-related schemes. Each theme exposed a degree of complexity and nuance that often remained hidden when proponents (or critics) talked of embedded research as though it were clearly understood and homogeneous. The themes have necessarily been presented as discrete categories, but overlaps and interconnections were legion.

To date, the literature on embedded research has tended to focus on individual initiatives and (especially) on the experiences of embedded researchers. We have lacked both descriptive and evaluative comparisons of embedded research initiatives. One reason for this was the absence of transparent, detailed and consistent reporting of initiatives. When reviewing the literature, for instance, we found scant description of the functional activities performed by embedded researchers, how belonging was managed and facilitated, or how various actors (beyond the researchers) were involved. Those involved in initiatives, however, had much to say about these and other aspects during e-mail exchanges, in interviews and in our workshop. This lack of detail in the published literature made it difficult to adequately compare initiatives and begin to understand how they worked and whether or not they were effective. We suggest that our themes could inform the reporting of initiatives at both an individual and collective level to enable further description and evaluation. For example, the themes naturally lend themselves to the assembly of categories of ‘similarly designed’ embedded research initiatives, thus contributing to the emergence of scheme typologies.

In sum then, the literature review and associated scoping work (workstreams 1 and 2) showed that embedded research initiatives come in a wide variety of shapes and forms. Despite being varied in terms of their intent, structure and processes, we were able to identify 10 themes that characterise their features, and then disaggregate these themes to reveal further layers of nuance. Making use of these themes is likely to bring about much needed clarity and transparency both within and between initiatives, enabling further in-depth understanding and comparison of the potential value of embedded research.

Subsequent ‘drilling down’ in specific schemes (the case studies explored in workstream 3) was able to use and build on this framework. That work is described in Chapters 4 and 5. Additional work through our engagement strategy (workstream 4) allowed these themes, and the insights gained from the case studies, to be further developed into visual metaphors and practical resources to aid dialogue about the design and management of embedded research initiatives. That practitioner-facing work is elaborated on in Chapters 6 and 7.