Background: Getting research into policy and practice in healthcare is a recognised, world-wide concern. As an attempt to bridge the gap between research and practice, research funders are requesting more interdisciplinary and collaborative research, while actual experiences of such processes have been less studied. Accordingly, the purpose of this study was to gain more knowledge on the interdisciplinary, collaborative and partnership research process by investigating researchers’ experiences of and approaches to the process, based on their participation in an inventive national research programme. The programme aimed to boost collaborative and partnership research and build learning structures, while improving ways to lead, manage and develop practices in Swedish health and social services. Methods: Interviews conducted with project leaders and/or lead researchers and documentation from 20 projects were analysed using directed and conventional content analysis. Results: Collaborative approaches were achieved by design, e.g. action research, or by involving practitioners from several levels of the healthcare system in various parts of the research process. The use of dual roles as researcher/ clinician or practitioner/PhD student or the use of education designed especially for practitioners or ‘student researchers’ were other approaches. The collaborative process constituted the area for the main lessons learned as well as the main problems. Difficulties concerned handling complexity and conflicts between different expectations and demands in the practitioner’s and researcher’s contexts, and dealing with human resource issues and group interactions when forming collaborative and interdisciplinary research teams. The handling of such challenges required time, resources, knowledge, interactive learning and skilled project management. Conclusions: Collaborative approaches are important in the study of complex phenomena. Results from this study show that allocated time, arenas for interactions and skills in project management and communication are needed during research collaboration to ensure support and build trust and understanding with involved practitioners at several levels in the healthcare system. For researchers, dealing with this complexity takes time and energy from the scientific process. For practitioners, this puts demands on understanding a research process and how it fits with on- going organisational agendas and activities and allocating time. Some of the identified factors may be overlooked by funders and involved stakeholders when designing, performing and evaluating interdisciplinary, collaborative and partnership research. Keywords: Collaborative research, co-production, integrated knowledge translation, partnership research, quality improvement, healthcare, social services * Correspondence: firstname.lastname@example.org Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, SE 171 77 Stockholm, Sweden Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, SE 901 87 Umeå, Sweden Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Nyström et al. Health Research Policy and Systems (2018) 16:46 Page 2 of 17 Background Funding organisations have started to request research Healthcare organisations are complex and knowledge proposals to include researcher–decision-maker partner- intensive, with patients often taking for granted that care ships in collaborative research teams with representatives of providers use the best available knowledge on diagnosis industry, local communities and professional organisations and treatment. Evidence-based medicine and practice (e.g. [23, 24]). The increased focus on research-use is also ensure that the best available knowledge is used systematic- mirrored in research funders’ strategies (e.g. ). Some ex- ally in clinical care (e.g. ). Nevertheless, the gap between amples of collaborative initiatives are the Partnership pro- research and practice in healthcare is well-known and a jects and Centres financed by the National Health and recognised concern (e.g. [2, 3]), where failures to translate Medical Research Council in Australia, the Dutch Academic research into practical actions contribute to health inequi- Collaborative Centres for Public Health in the Netherlands, ties [4, 5]. The process from research-produced knowledge and The Collaborations for Leadership in Applied Health to its use in healthcare practices can take considerable time Research and Care in the United Kingdom (e.g. ), as well (e.g. ). The estimated lack of research use in the United as the practice-based research networks and structured use States and the Netherlands has suggested that 30–40% of of practice facilitators [27, 28] and the Integrated Delivery patients do not receive care complying with current Systems Research Network programme to foster public–pri- research evidence . The required increase in the speed vate collaboration between health service researchers and of uptake of evidence-based clinical practice guidelines has healthcare delivery systems in the United States . There been frequently discussed (e.g. ) and factors influencing are three main strategies that research funding agencies their adoption have been extensively studied (e.g. [9, 10]). might use to enhance knowledge translation – push, pull, or Getting research into policy and practice in healthcare is a linkage and exchange. The push–pull strategies distinguish recognised, world-wide concern (e.g. ). between mechanisms driven by science (push) and those Several research areas deal with aspects related to the driven by the demands of practitioners or policy-makers transfer of knowledge and use of research findings for (pull) . The linkage and exchange model is based on improving healthcare. The view of research production co-construction of applied knowledge and the relevance of as separate from the use of research findings initially in- applied research to both practitioners and researchers . spired research on diffusion and implementation pro- In a recent review of the ways research funding agencies cesses [12, 13], mainly focusing on the later stages of the support science integration into policy and practice in the research process with variable emphasis on a division field of health , most of the 13 agencies investigated between knowledge production and its implementation. used one or two of these strategies. The large heterogeneity The shortcomings of the traditional ‘linear’ model of of users and how this may affect the use of various mecha- research-into-practice have become more evident . Van nisms for research initiation, development and dissemin- de Venand Johnson suggest that the problem may be ation was highlighted in this review. one of methods for knowledge production rather than Collaboration has been addressed for some time in knowledge transfer or knowledge translation. To enhance a community-based participatory research regarding public faster and more systematic use of knowledge, collaborative health and social issues in society (e.g. [32, 33]), for ex- and interdisciplinary research approaches have been asked ample, on how to achieve policy level collaboration (e.g. for as well as more useful research [15–17]. Research [24, 34]) and evidence-informed policy-making (e.g. ). collaboration is assumed to enable and enhance both the Nevertheless, there is a need for more empirical research use of research and increase the amount of research on the actual processes, conditions and outcomes of the relevant to end users. more recent collaborative and partnership research initia- Research on knowledge transfer and exchange describes tives in healthcare [36, 37] and, to date, there are few em- an interactive exchange of knowledge between research pirical studies on researchers’ approaches and experiences users and researcher producers [18, 19]. Knowledge trans- of the combination of interdisciplinary and collaborative fer and exchange interaction between researchers and and partnership research, including the actual effect of such practitioners can take place from the on-set of the re- programme or project calls. Less explored is also research search process and involve more long-standing relation- partnership aiming to respond to the challenges and prior- ships. Several approaches to knowledge transfer have been ities of the health system and much research has been described, focusing, for example, on systematic synthesis based on assumptions of researcher-driven initiatives with and guidelines, social interaction between researchers and newly established collaborations . decision-makers, contextual features and organisational readiness . The Canadian Institute of Health Research Collaborative and partnership research uses the term ‘integrated knowledge translation’ to de- Approaches, strategies and roles scribe projects where the knowledge users are involved as Collaboration and partnerships are two concepts used to equal partners during the entire research process [21, 22]. describe the involvement of people and groups from Nyström et al. Health Research Policy and Systems (2018) 16:46 Page 3 of 17 different contexts and with different experiences, take part in defining the research question and interpret perspectives and agendas in research and development. findings; significant time and contributions from both re- Accordingly, collaborative research contains social rela- searchers and practitioners; and an extensive formulated tions and a variation of potential roles for those involved description of the partnership approach. during the research process. In earlier research, means for collaboration were described in the form of ‘linkage mechanisms’ between researcher and user contexts, i.e. Challenges and enabling features the presence of intermediaries (boundary spanners); for- One challenge for collaborative and partnership research mal and informal contacts with users during studies; in- concerns the variation of views on the production and use volvement of users during data collection; and interim of knowledge and on the relationship between researcher feedback . The boundary-spanning role of knowledge and practitioner, spanning from top-down to bottom-up or brokers has been brought forward as a bridge between from linear to interactive and multidimensional (e.g. [39, research and practice (e.g. ). Knowledge brokering 47]). Depending on research tradition and/or experiences, has been defined as “all the activity that links decision- basic assumptions regarding knowledge and learning can makers with researchers, facilitating their interaction so vary among researchers, but also among stakeholders (e.g. that they are able to better understand each other’s goals ). Sibbald et al.  identified challenges such as role and professional cultures, influence each other’s work, clarity, organisational change and cultural differences forge new partnerships, and promote the use of research- regarding expectations on research output and (positive) based evidence in decision-making” (, p. 131). Indi- effects on actual practice and found that role ambiguity, viduals, teams or organisations can all play the role of multiple roles and role conflicts could hamper social rela- knowledge brokers [41, 42]. Michaels  describes six tionships. Factors facilitating collaboration were already primary brokering strategies that span from more pas- established relationships, the alignments of goals/objec- sive dissemination of information, interaction by seeking tives, skilled and experienced researchers, and the use of and using expert’s advice and linking different actors, to regular, multi-modal communication. active engagements and close collaborative relations with Another influence on collaboration, mainly from the healthcare actors, and which aim to inform, consult, researcher context, is the variety of research paradigms match-make, engage, collaborate and build capacity. A and areas and related basic assumptions. One approach recent study highlights the importance of effective ‘rela- to be expected is action research, where knowledge cre- tionship brokering’ in researcher-health system partner- ation is combined with practice development. There are ship for establishing a meaningful collaboration . a variety of action research approaches depending on, A detailed road map on research collaboration is of- for example, how the collaborative element is organised fered by Martin  in his description of five approaches . The interactive research approach builds on action to co-production of research. Depending on the chosen research and emphasises the common learning and approach, stakeholders can be more or less involved in knowledge creation for both practitioners and phases of the research process, from study design, data researchers during the complete process . Both ap- collection and analyses, to dissemination, while the proaches involve a number of different roles for the re- degree of academic independence of the researcher/s searcher to enact . and the utilisation of the research results may vary. Con- Based on a realist evaluation, Rycroft-Malone et al. sequently, practitioners can play the role of informants,  list features of research collaboration likely to en- recipients, endorsers, commissioners or co-researchers. hance knowledge use, namely attention to communica- On programme level, King et al.  describe four re- tion mechanisms, setting intermediate/outcome goals, search programme operating models used in a collaborative providing time and space for the development and im- approach to enhance research-informed practice in plementation of plans, making the choice of topic with community-based clinical service organisations. The resonance and relevance, close proximity between part- models describe the types of partnership involved such as ners, re-balancing and sharing power, and allowing time the ‘clinician-researcher skills development model,’ ‘clinician to develop mutual trust and respect. These features put and researcher evaluation model,’ ‘researcher-led evaluation other demands on the planning and execution of re- model,a ’ nd the ‘knowledge-conduit model’. To differentiate search than a traditional approach when research has research-practice partnerships from other ways of conduct- precedence over practice. ing research, Øvretveit et al.  suggest five criteria for Sibbald et al.  present a model describing the research partnership research, namely research that contributes to partnership process, with enablers, facilitators, challenges actions taken by actors within a health system; studies and impact, and identify three partnership types based on intended to produce quick and actionable findings as well an empirical study as token, asymmetric or egalitarian part- as scientific publications; both researchers and practitioners nerships. In Fig. 1, features of the research partnership Nyström et al. Health Research Policy and Systems (2018) 16:46 Page 4 of 17 Fig. 1 Model over the research partnership process (adopted after Sibbald et al.  and Rycroft Malone et al. ) process are presented, grounded on aspects highlighted by The empirical base of the present study is an example of Sibbald et al.  and Rycroft Malone et al. . a collaborative and interdisciplinary research initiative – a Collaborative and partnership research poses spe- national research programme seeking to boost collabora- cific demands regarding project management. Accord- tive and partnership research to improve health and social ing to a review , collaborative research can be services in Sweden. The purpose of the study was to gain characterised by heterogeneity of actors, collective re- more knowledge on the interdisciplinary, collaborative sponsibilities, demands for applicability in addition to and partnership research process by investigating re- scientific requirements, and by being funded by public searchers’ experiences based on their participation in this agencies with specific agendas. Project management national programme. We have studied the experiences of in collaborative projects usually involves three para- researchers in all 20 research projects funded by the doxes : programme during the period 2008–2014, focusing on three themes – complexity in collaboration, collaborative 1) To reach expected results, both freedom and procedures, and challenges, obstacles and lessons learned. flexibility to handle the uncertainty in research is The research questions posed were (1) what types of re- needed, as well as a tight and managed firm project search approaches, research focus and partners/actors structure. were involved in the projects? (2) How was collaborative 2) The necessary integration of different views of the and partnership research achieved, according to the re- actors involved may also lead to intercultural, searchers? (3) What were the challenges and obstacles to interorganisational and interdisciplinary problems interdisciplinary, collaborative and partnership research that need to be managed. encountered, and what main lessons were learned? 3) The limited formal authority of the project manager is in contrast with the demands for integrative Methods managing of results, commitment and involvement This study is based on analyses of interviews and arch- of all parties. ival data. The interviews were performed during the final stages of the projects and the documents covered the Thus, collaborative and partnership research may entire project period. have the potential to enhance the use of knowledge in practice and thereby improve healthcare and social Empirical setting – the national research programme services, but also to challenge the practitioners’ and The Vinnvård research programme was financed by a researchers’ views, assumptions and roles. consortium of research funders, including the Ministry Nyström et al. Health Research Policy and Systems (2018) 16:46 Page 5 of 17 of Health and Social Welfare, Sweden’s innovation project leader. The semi-structured interviews had the agency VINNOVA, Vårdalstiftelsen and the Swedish Asso- aim of following up on the main goals and lessons learned ciation of Local Authorities and Regions. It was the first within the projects and covered the characters of the pro- major attempt by research funders in Sweden to address jects with its overall contributions, roles taken in projects, the challenges of the ‘quality chasm’ in health and social collaborations, and participating or studied organisations services focusing on organisational aspects, with clear as- and institutional levels. Questions followed five themes for pirations to bridge research and practice, stimulate inter- each one of the four programme goals, namely interpreta- disciplinary research and enhance research collaboration tions of the goal, the importance it was given, how it was between universities/research institutions and healthcare/ fulfilled, how the project had worked to reach the goal, social service organisations. In addition, new research and and results related to the goal. Practical examples of the learning infrastructures were expected to emerge. The re- last two themes were requested. The last part of the inter- quirements and evaluation criteria for the applications view covered how the four goals were integrated, any ex- reflected these aspirations and documented active cooper- pected or unexpected insights, difficulties experienced, ation between practitioners, researchers and other public and emphasised and miscellaneous findings. In a few actors was asked for. Moreover, applications had to in- cases, interviews were complemented by the respondents clude an interdisciplinary approach, a common vision for with written comments or documents. Interviews lasted all parties involved and documented approaches for secur- 40 to 120 min, with longer interviews with respondents ing participation and dissemination of research and/or de- representing two projects. The respondents received the velopment results. Both researchers and practitioners/ questions a week in advance. Each interview was recorded public institutions could apply for funding. Non- and transcribed verbatim. researchers were part of the peer-review panel in both Archival data were gathered in May 2015 and con- calls. The programme’s broad approach was new, both to sisted of the projects’ final reports and, for one project the funding agencies and the research community. With a not yet finished, a progress report (same structure as the focus on health and social services, the programme aimed final reports, but without a popular science description to (1) increase the use of research-based knowledge and financial report). The report template had the fol- (bridge research and practice), (2) develop innovative ways lowing headings: introduction; short summary on how of organising work, (3) stimulate the development of insti- the project had worked to fulfil the research pro- tutional learning structures with a focus on how to lead, gramme’s goals (with subheadings for each of the four manage and develop practices in organisations, and (4) goals); publication list; participation in national and establish more research on how to lead, manage and de- international conferences/workshops; PhD students; de- velop practices in health and social services organisations scription of potential problems encountered; description at Swedish universities. of the most important lessons learned; popular science The subsequent aims (3 and 4) had a more long-term description; references; and financial accounting. Reports character than the preceding ones (aims 1 and 2) and varied in length from 4 to 42 pages, with an average of can be seen as a means to build long-lasting support for 19 pages; yet the four-page report came from the project these. During the period studied (2008–2013) there were not yet finished. A total of 386 pages were analysed. two calls for projects lasting up to 4 years each. A total of 20 projects were funded, 9 in 2008–2011 and 11 in Data analysis 2009–2013, all of which are included in the present Qualitative data in interviews and documents were scruti- study. All projects were on-going when the interviews nised in several steps, first by using a mix between directed were conducted and all except one had ended when the (guided by the research questions) and conventional con- archival data was gathered in May 2015. tent analysis . Theentirematerialwas read throughto get a sense of the whole and then analysed to identify rele- Data collection vant text related to the research questions. Both data Interviews were conducted between September and No- sources were then further used for determining themes, vember 2011, when most projects were in their later categories and overall patterns. Finally, a summative con- stages. In total, 17 respondents with an equal gender dis- tent analysis  was applied to get a sense of variation by tribution were chosen based on their overall project in- identifying how many projects provided information in the volvement. Four respondents were responsible for two identified categories. Three researchers performed the ana- projects each and one project was represented by two lyses, first individually and through meetings held to discuss respondents. All 20 projects were covered. All respon- and validate interpretations. dents held a PhD and were intensely involved in the pro- Document analysis focused on information related to jects, either as project leaders, principal investigators, or the three research questions, namely (1) system level as the most important researcher, as judged by the actors involved (care recipient, unit/clinic/ward, Nyström et al. Health Research Policy and Systems (2018) 16:46 Page 6 of 17 organisation, region/county council, and/or national served as important bridges between the two contexts. level) and basic project information; (2) descriptions of or Five main categories were identified to cover the various activities and strategies for research collaboration, includ- ways collaborations were described. In Fig. 2, the num- ing with which actors; and (3) obstacles/problems encoun- ber and proportion of the projects providing descrip- tered and main lessons learnt. A fourth category (Other) tions in each of these categories is provided. was used in order not to miss important aspects. De- scribed collaborations and process reflections (i.e. obsta- Collaboration as described by the overall research and cles/problems and lessons learnt) were the main development design categories used to sort the material for questions 2 and 3. Seventeen projects (85%) clearly described an interactive In a second iterative step for these questions, subcategor- research design that either involved healthcare practi- ies were identified, tested, revised and defined. The cat- tioners, managers, politicians, patients, next-of-kin or a egory definitions were then used in a third step for a final mixture of those. Seven projects used the term ‘action text classification of data. research’ or ‘action-oriented research’, two used the term As the interviews were performed when the projects ‘interactive research model’, and one used the term ‘par- were still ongoing, they were used to complement, add ticipatory design’, all of which imply a close interaction details, provide examples and validate information found between researchers and practitioners. Examples of in documents. Moreover, they also added a more per- statements are “the project’s action research approach sonal perspective on the results based on the experience has involved a continuous and iterative collaboration of the main researchers. that has both fed into and questioned on-going [change and learning] processes” and “we used a participatory de- Results sign where the young people actively participated in the Project overviews and the complexity of the creation of what to study, that is the effects of using a collaborations web-based instrument”. Four projects developed infor- Of the 20 projects, 14 included three or more stake- mation and communication technology-based solutions holder levels, indicating an elaborated multilevel or sys- in close collaboration with practitioners. The terms ‘co- tem view. Five projects actively involved care recipients design’ or ‘co-creator’ were often used in two projects (and sometimes their next-of-kin) in design of solutions involving patients and their next-of-kin and in a project or interactive co-production. Two projects had a sole focusing on mixed learning networks with researchers, clinical focus (screening for atrial fibrillation and im- patients and other actors. proving methods for stroke care), but such foci were present in several projects’ sub-studies. Four projects Collaborative involvement of practitioners in different (three geographical sites) had a deliberate strategy to stages of the research process build learning structures that involved university level Interactive forms were described as being used during the education at undergraduate and/or master’s levels, but following stages: (1) mapping of the research problem and education was included in several projects, sometimes as its manifestation in practice, and formulation of research distance learning or continuing education for profes- questions; (2) planning, creation of interventions and sionals. All projects except two involved PhD students, choices of design; (3) investigation, test, follow-up and im- with a total of 72 for the programme overall. Most pro- plementation processes; (4) analyses, reflection and learn- jects (n = 16) clearly stated that their research group was ing; and (5) reporting on and dissemination of results, interdisciplinary and some discussed the benefits and including further implementation of studied intervention. obstacles encountered due to this. A total of 203 articles Nineteen projects (95%) described an interactive approach in scientific journals (including submitted manuscripts) in at least one of these stages. Collaboration or interaction were reported to have been produced during the 6-year was most common during follow-ups and feedback pro- period. The widespread target groups and involved or- cesses (Stage 3 and 5), and less interaction was described ganisational levels in the projects’ research activities are during the formulation of the research problem and dur- illustrated in Table 1. More information on the projects ing analyses (Stage 1 and 4). Statements like “conducting is provided in Additional file 1. research with practitioners, not on practitioners” and “pa- tients have participated in the mapping [of the current Descriptions of collaborative procedures situation]” are examples of Stage 1. Stage 2 is exemplified Descriptions of the research collaboration varied – from by the statements “practitioners participated during the describing a more or less interactive research design to construction of the interview [manual]”.Statementssuch more explicit descriptions of when and how practi- as “the researchers and contact persons [from the health- tioners were involved during the research process. Prac- care organisations] have met 1–2 times a year to discuss titioner’s and researcher’s boundary-spanning roles and reconcile research questions, data collections and Nyström et al. Health Research Policy and Systems (2018) 16:46 Page 7 of 17 Table 1 System/organisational levels where research was performed and levels where support was needed in order to establish the projects and keep them going; the summary provides an overview for comparison Project Levels where research was performed Levels where support Summary of levels was established 2008–2011 1 ACTION – partnership for Homebased health and social care Municipality officers Reg., Org, Unit, increased care and quality Meetings with patients and next-of- Municipality collaboration Care recipient kin National networks for IT support 2 Bridging the gaps Micro system (i.e. patient-care provider Micro system, Clinical Dep., Nat., Reg., Org, interaction), Clinical Dep., Diagnosis Region, National level IT Unit, Care recipient cohorts, Patient - web support (quality reg.), Municipality IT network (quality reg.) 3 Chronical health Diagnosis cohort Multiple clinical dep. (several Nat., Unit, Specialist (MD) cohort regions) Care recipient National level IT (quality reg.) 4 Innovation systems for Clinical Dep. Clinical Dep. Reg., Org., Unit better health Hospital or organisation, Region Hospital or organisation, Region 5 Sustainability in innovation Patient cohort, Clinical Dep. Hospital or organisation Reg., Org., Unit and organisation learning Hospital or organisation, Region, Region in healthcare County County 6 NDR – Better use of the Diagnosis cohort, Specialist National level information Nat., Org, Unit national diabetes registry (Medical Doctor) cohort, technology (quality reg.) (a national quality registry) Clinical Dep. Hospital or organisation, National level IT 7 Knowledge, management and Clinical Dep. Clinical Dep. Reg., Org value creation in geriatric care County County County top management 8 Increased participation/access to society for Meetings with patients and Municipality Reg., Unit, Care people with psychiatric conditions next-of-kin, Diagnosis cohort, Region, National, Non-governmental recipient Region, National organisation 9 QIHREA - Quality improvement Patient, Clinical Dep., Hospital, Micro system Internat., Nat., in healthcare, a research and Region, Region based Clinical Dep. Reg., Org. education agenda management network Hospital, Region 2009–2013 10 Bridging the gaps 2 – Patients Micro system Micro system Reg., Org, Unit, as active co-creators in care National level IT (quality reg.) National level IT (quality reg.) Care recipient processes Region-based management network 11 Care chain – From emergency Meetings with patients and Clinical Dep. Reg., Unit care to home next-of-kin, Clinical Dep., Hospital (management) Hospital management, Municipality (management), Municipality management Region 12 Learning on patient safety Clinical Dep. Clinical Dep. Nat., Reg., Unit 13 FLIP – Atrial fibrillation in Diagnosis cohort – Reg., Unit, primary care Specialist (MD) cohort 14 Nat. guidelines for health Clinical Dep. Clinical Dep., Professional Nat., Reg., Unit promotion – from evidence Professional cohorts in care cohorts in care, County, to clinical practice County, National, Government National body Government body 15 Lean and agile Hospital National research cohort Org., Unit County 16 INTEGRAL Hospital management Hospital management Reg., Unit University management 17 P-Inn – The patient’s Patient cohorts National level IT (quality reg.) Nat., Unit, innovation system National level IT (quality reg.) Care recipient 18 Patient choice system in Regional Regional Nat., Reg. primary care National Nyström et al. Health Research Policy and Systems (2018) 16:46 Page 8 of 17 Table 1 System/organisational levels where research was performed and levels where support was needed in order to establish the projects and keep them going; the summary provides an overview for comparison (Continued) Project Levels where research was performed Levels where support Summary of levels was established 19 InOut Clinical Dep., Hospital Clinical Dep., Hospital, National Internat., Nat., National, International level IT, National patient organisation, Reg., Unit, European Stroke Organisation 20 FELLOW – Fellowship program Clinical Dep. Clinical Dep. Reg., Unit University management dep. Department, Internat. international organisation, Nat. national organisation, Reg. regional organisation, Org. local organisation, Unit clinical department or other organisational unit, Care recipient individual patient (incl. next-of-kin) results from different sub-projects” represent several stages researchers. This dual role of being involved in both (Stage 1, 2, 3 and 5). Involving practitioners directly in practical work and research was more common for analyses (Stage 4) was not explicitly mentioned, but clinicians performing research in the area of their ex- the described interactive sessions could involve the pertise, e.g. in projects and sub-cases with a clinical discussion and validation of results. Statements such focus. This can be exemplified by statements such as as “the researchers regularly fed back their observa- “we areconductingresearchwithactivelyserving tions and analyses to the hospital management and practitioners and clinicians” or as a statement made hospital unit representatives”; “we had several formal by a clinician project leader “improvement work for and informal feedback sessions and this feedback has increased quality in healthcare is best performed dir- been further used”;or “the feedback and the action re- ectly in connection to the meeting between patients search approach have given researchers an opportunity and professional care-givers”.Inone case,inthe Clin- to stimulate reflection and contribute with knowledge ical Innovation Fellowship programme, teams of prac- on implementation, learning and change” can repre- titioners were trained as action researchers for 2 sent situations when practitioners participated in the months (fellows) and spent 6 months working in clin- interpretation of results and that this had effects on ical quality improvement in healthcare, sometimes in both research and practice. Thus, if researchers in the collaboration with students working on their masters research teams holding dual roles are not accounted or bachelor thesis. Examples on practitioners’ dual for, no project involved non-researchers in the entire role were described as “some healthcare staff became research process. PhD students and thereby gained a double bridge- building role” (e.g. conducting research within their Collaboration enhanced by the dual role of practitioners organisation). The role of translating knowledge as and/or researchers part of the dual role was exemplified as “we have in- Ten projects (50%) described a dual, boundary- volved healthcare staff as interpreters”.Nofurther de- spanning role held by either the practitioners or the tails on what this actually meant were provided. Fig. 2 Number and proportion of projects (n = 20) providing descriptions in the different subcategories of collaboration Nyström et al. Health Research Policy and Systems (2018) 16:46 Page 9 of 17 Three projects described that their research team conduct single randomised controlled trial (RCT) studies consisted of both researchers and practitioners. using their own measurements. Collaboration via education Challenges, obstacles encountered and the main lessons Seven projects (35%) described interactive processes learned from the research collaborations linked to educational activities, either designed for en- Seventeen projects (85%) provided detailed descriptions of hancing learning and (sustained) interaction between re- problems encountered and a meta-reflection of lessons searchers, practitioners and their organisations, or designed learned. The others reported no problems or none that for students to participate in and study development initia- could not be dealt with and/or interpreted the question tives while learning together with practitioners. Some in- on lessons learned as an opportunity to report on detailed volved the development of new programmes and courses project results. We could not find any patterns for the two where “experience-based education” was essential or where projects reporting no problems (19 and 20). Described networks of previous healthcare students (now as practi- problems were classified into six categories and similar tioners) were established as a resource. Some examples categories also summarise the lessons learnt, except for concerned the interaction between students and practi- ‘staff-related issues’, which was mentioned only as a prob- tioners exemplified by statements such as “collaboration lem. In Fig. 3, the number and proportion of the projects with students concerning knowledge on improvement, using providing descriptions in these categories is presented. a model for learning that involves multi-professional teams The most reported problem category concerned the col- with care professionals and students that together reflect on laborative and partnership research and development the potential improvements of the care practices”,or the in- process (with practitioners) followed by issues related to volvement of students in the development of healthcare the practitioners’ context and the research design and practices exemplified by one project’snew master’s methods used. Thus, most problems described were re- programme where conducting an improvement project in lated to the adaptation to or collaboration with practi- practice was a basic requirement for a master’s thesis. tioners and their organisations and the different agendas of and demands from the practitioners’ and researchers’ Collaboration by involving patients/next-of-kin context. It was sometimes difficult to maximise the fit be- Five projects (25%) described an active involvement of tween the project’s agenda, the research process and the patients in the research process. One project developed dynamic agendas and activities of the organisations and mixed learning networks with both patients and their their representatives. A third of the projects reported on next-of-kin in an active learning process. Another pro- problems within a single context or issues related to re- ject had “engaged patients, relatives and care profes- search staff or designs. Most of the lessons learned also sionals in the work of changing care practices” describing concerned the collaborative and partnership research patients as “co-creators, co-producers and co-evaluators”. process. Otherwise, lessons learned were more evenly Two projects had developed information and communi- spread, except for the staff category. cation technology solutions together with patients and Reported problems related to ‘the practitioner context’ one project had given patients the opportunity to concerned partner engagement, competing activities, Fig. 3 Number and proportion of projects (n = 20) providing descriptions in the subcategories of problems encountered and lessons learned Nyström et al. Health Research Policy and Systems (2018) 16:46 Page 10 of 17 economy, political decisions and organisational changes. contexts. Statements such as “the interactive research Examples of problems were “delays, organisational process takes more time to establish”, “output data were changes and changes in management teams that altered supposed to be generated and provided by the county the initial engagement in the project”; “other parallel de- council, we had to use whatever we could find when this velopment projects have taken time for our collaborating could not be done”, and “our organisational partners’ organisations” and “the development unit that was to co- need for quick results and tendency to change work ap- ordinate interventions within the county council was proaches towards the introduced intervention made it closed down”. The major lessons learned mirrored these hard to scientifically evaluate the results”. The lessons problems, acknowledging the anchoring, flexibility and learned described were related to insights concerning time needed to work with the practitioners’ (politically different views, contexts and efforts to handle dilemmas. governed) organisations. Examples of statements pro- Example of statements were, “research and practice are vided are “county councils and universities are large or- two systems with a different pace, demands on PhD stu- ganisations where change takes time and anchoring on dents delay analyses and cause delays in the feedback to several levels must be secured” or “changes in health and practitioners”, “practitioners sometimes have un-realistic social care occur quickly and are difficult to foresee and expectations on researchers”, and “the importance as a improvements have to adjust to this, and to document researcher to always be prepared to re-evaluate, be flex- such periods is both a challenge and an opportunity”. ible and adapt the project focus and time plan after the Reported problems related to ‘the researcher context’ dynamic situation of the empirical reality studied”. Some often concerned the PhD, master or bachelor level stu- important actors in the researcher context made this dents involved, where university demands caused delays, process difficult, exemplified by “the ethical board ap- frustration or extra work. Examples of statements were proving the project has demanded a clear distinction be- “writing applications to fully finance participating PhD tween research and improvement work”. students have taken a lot of time and energy”, “the full Problems related to conducting ‘inter-disciplinary re- student participation was delayed and affected the pro- search’ gave examples of paradigmatic differences in per- ject”, and “the choice to build a school for research stud- spectives, assumptions, experiences, methods and ways ies have delayed publications”. Learnings included the to report results. Examples of statements were “PhD stu- need to deal with such aspects and the demands this put dents struggled against time and felt fragmented and on the project management and the research group, ex- torn between their own research area and the demand emplified by “the research field is young and it has been for interdisciplinary research” and “to form such group central to build networks and cooperation with others” consisting of different disciplines takes a long time and and “to build research and education demands active the mixed methods approach demanded a period of and competent project management, not only an effective interactive learning for the interdisciplinary research administrative management but also an overarching re- group”. Lessons learned related to conducting interdis- search perspective, and this administration and research ciplinary research concerned insights into the process of overview is time demanding”. building interdisciplinary teams and benefits of several The category ‘staff-related concerns’ contained human perspectives, for example, “interdisciplinary research is resource management issues related to research group not easily or quickly established, it takes a long time for members (mainly researchers and PhD students) and no participants to build trust and understanding of each lessons learned related to these were recorded. Issues other’s perspectives and terminology, and to be attentive concerned interruptions or delays in the project process and responsive towards each other’s contributions” and due to recruitment of staff, leave due to sickness, paren- “the importance of a firmly grounded theoretical frame- tal leave or other changes in work situation. Example of work and the creation of instructions for the research ac- statements were, “one researcher was on leave for a long- tivities during an interactive process”. time due to sickness and this made us have to start all Problems connected to ‘the research focus’ were re- over again with analyses”, “the project leader was ported by one project and concerned the investigated assigned a mission by the government”, and “two of the health economic concept, which was new to the area project’s PhD students went on parental leave for a total and demanded a shift in perspective. Six projects period of 3 years, which delayed the project”. reflected on lessons learned connected to the research Problems related to ‘the collaborative and partnership focus, for example, “internet-based support and coaching research and development process’ concerned the time have provided coaches with increased insights into how and energy needed for the process, expectations on the large a disability individuals with neuropsychiatric dis- practitioner organisation, and differences in focus and abilities can actually have” and “the care structure is a pace of the more rigorous scientific process compared to central factor for improvement and the availability of the quicker decision-processes in the practitioners’ stroke units essential”. Nyström et al. Health Research Policy and Systems (2018) 16:46 Page 11 of 17 Problems related to the chosen ‘research design and of the organisation’s values and assumptions. This indicates methods’ concerned demands of specific methods and the need for researchers to have an in-depth understanding instruments, for example, “building a computer model not only of the involved practitioners as individuals or pro- and the inclusion in the RCT study has taken more time fessional groups but also of their organisations in order to than anticipated”, “the ethno-methodological observation enhance the use of research findings. method is time and resource consuming”, and “it was A majority of the projects addressed several levels of challenging to find data for follow-up studies and a lot of the involved healthcare organisations (or systems) imply- work studying patient journals”. The reported lessons ing several types of partners and stakeholders to interact learned concerned the chosen approach, design or with. Demands put on project management and the pro- spread of interventions exemplified by the following ject group corresponded with these multidimensional statements: “the meta-study has been important for syn- views and mixed approaches – providing variable room thesising and extracting knowledge”, “action research is and energy to support and adhere to demands related to an important method for gaining new knowledge and for collaboration and research use. The importance to stimulating participation in improvement initiatives”, understand and address the interaction and inter- and “the major lesson learned has been that the work to connection between system levels during development implement findings does not start or continue by itself, it efforts has been highlighted by several researchers [60, will demand large efforts and continuing economic 61]. The types of project management, research design resources”. and collaboration across the organisational system that are needed to get access, and to build, co-create and transfer knowledge in order to enhance development in Discussion organisations have been less discussed. Recently, the het- Addressing complex research areas in complex systems erogeneity among knowledge users and the need for re- affects the complexity of the collaboration lationship brokering in collaborative and partnership The research programme was set out to address problems research has been highlighted . related to the gap between research and practice in health and social services. Several projects reported putting large Different perceptions of interdisciplinary, collaborative efforts on addressing this broad and interdisciplinary con- and partnership research and on the roles and tent by trying to frame clinical and service activities within relationships of involved actors general organisational frameworks. Many projects focused Any empirical research process is characterised by inter- on how to organise care to achieve a more research-based action between the researcher and practitioner context, practice or to identify hindrances, contradictions or op- each one in a constant flux, continuously changing and re- portunities related to development. To study such com- structuring. The research process in itself also differs de- plex phenomena over several system levels often requires pending on the type of research and focus, for example, if longitudinal designs, interdisciplinary approaches and a there is an innovative or developmental component in- mix of methods , in combination with participatory volved to be tested and evaluated or if an on-going situ- approaches (e.g. ). A large variation of research and ation or phenomenon is investigated. Qualified methodological approaches, most of them very demand- practitioners, sometimes enrolled as PhD students, served ing, was used in the projects, from action research to as knowledge brokers interpreting results – in both direc- quasi-experimental studies and RCT designs. Single or tions – when understanding the practical phenomenon in multiple case studies using qualitative and mixed methods theoretical terms and when translating theories and were common. The use of a demanding research design models used into practical terms. Educational fora and and the lack of a research culture on behalf of practi- interactive learning approaches were a significant part of tioners and their organisation can act as a strong barrier many projects, often combined with active involvement of for research collaboration . practitioners. Involvement of patients and their next-of- Research use represents a specific form or knowledge kin, often during intervention design, was also described. utilisation [57, 58], where research findings support deci- Based on our findings, using the terms introduced by sions through a complex process enacted at a practical Sibbald et al. , two projects could be described as hav- level. Scott-Findlay and Golden-Biddle argue that un- ing a more researcher-dominant or token partnership, derstanding this process only at an individual level is mis- while eight projects involved non-researchers to some ex- guiding and should be complemented with an tent in an asymmetric partnership and ten projects had understanding of practitioners’ research use at an organisa- features that indicated a more egalitarian partnership. tional level. When making major changes in line with new The role of the researcher varied – from being deeply research knowledge the authors propose strategies involving and practically involved in a development process in the efforts to change organisational culture and consideration practitioner context, to more distant when studying the Nyström et al. Health Research Policy and Systems (2018) 16:46 Page 12 of 17 effects of different care choice models. Martin  listed to lead, manage and develop practices in health services the various roles of practitioners in research collabora- organisations might have aided this development, more so tions, but researchers are also able to enact different than traditional programme calls. roles, depending on opportunities, preferences and the Creating long-term relationships between researchers chosen research focus (explorative, descriptive, explana- and decision-makers might be a useful way for bridging tory, intervention and action oriented). An ability to de- research and practice. For such a strategy to become suc- scribe the nature of both the practitioners’ and cessful it has been argued that it must be complemented researchers’ roles may indicate the type of interaction, with strategies for involving researchers in decision- participation, involvement or influence that can be ex- making around policy and practice and with core funding pected from both parties. In Fig. 4, the potential roles of for building and upholding capacity for knowledge ex- practitioners  are displayed together with some sug- change . Maintaining such relationships for longer pe- gested potential roles for researchers to enact. Indica- riods often requires formal support or structure. The tions of egalitarian partnership were identified in national collaborative examples (e.g. practice-based re- projects that clearly described interactive research ap- search networks) described in the introduction can be one proaches, but otherwise our data did not provide much way to achieve this. Incentives for supporting and nourish- detail on the relationships and roles. For an in-depth ing such relationships are scarce in the research context study of the enactment of different roles over time, situ- where funding is often difficult to obtain and outcomes ation and context would provide more information on are measured in production of scientific publications. Sup- how the researcher–practitioner relations evolve over porting the costs associated with research involvement time, both initially and in long-term partnerships. (for both parts) can facilitate partnership with managers Interdisciplinary research, often across faculties, was en- and decision-makers . This is an important message to hanced, further developed and deepened in the majority research funders, who despite tasks to increase “research of the projects. There were several examples of clinical re- utilisation and interaction with society”, often support searchers working together with both social scientists and short-term projects with more limited scopes – astrategy scientists from technical faculties. Building trust and les- that is seen as insufficient for sustaining practitioner rela- sons learned concerning different perspectives and ways tionships and achieving goals of research utilisation . of conducting research were important. The programme’s Research collaboration between researchers and goals regarding the expected development of institutional decision-makers and other types of stakeholders can be learning structures and establishment of research on how ethically challenging, especially when members of the Fig. 4 The five types of potential roles of practitioners during a research process according to Martin , and some suggested potential roles for researchers to enact Nyström et al. Health Research Policy and Systems (2018) 16:46 Page 13 of 17 team are insiders or participants in a studied case. The innovative researchers tend to be more engaged in re- role of insiders needs to be clarified, for example, with search collaborations, both disciplinary and interdiscip- regards to access to raw data and ensuring anonymity linary, than adaptive researchers who prefer to work and confidentiality , but also a sensitivity on how to with well-established procedures within existing frame- handle organisational information as a researcher. Hof- works and in stable groups [69, 70]. Female scientists meyer et al.  recommend the use of self-reflection are also more engaged in interdisciplinary research, and ethical dialogues to enhance shared meanings and while years of research experience has been found to be understandings among researchers and decision-makers positively correlated with collaboration both within one’s – a practice that requires time, motivation and skills, own discipline and with researchers from other scientific and which could be highlighted in future programmes disciplines [70, 71]. aiming for collaborative and partnership research. Some of the problems and enablers experienced in the projects correspond to the enabling factors in the re- search partnership process as described by Sibbald et al. Experienced challenges, obstacles and enablers for  and Rycroft-Malone et al. . The described diffi- interdisciplinary collaborative, partnership research culties due to changes occurring in the partner organisa- There were indications of the tension between the demands tion, role problems due to ambiguous or conflicting from the practitioner versus the researcher contexts and demands, and different view and paces for knowledge the role of the researcher. Dilemmas occurred, for example, production and use between researcher and partner or- when adhering to conflicting demands for knowledge trans- ganisations correspond to the challenges described by lation and the different types of knowledge production , Sibbald et al.  (Fig. 1). Problems and lessons learned such as a curiosity-driven inquiry based on a positivist epis- related to time needed for development of mutual trust temology or a problem-solving epistemology with know- and respect, power issues, and planning and implement- ledge production in the context of application . ing change are in line with Rycroft-Malone et al.’s Collaboration in the projects’ research constellations observations (Fig. 1). Skilled project leaders and re- was mentioned both as an asset and a challenge, espe- searchers able to handle various perspectives and en- cially the interdisciplinary aspect where team members hance communication among involved actors and the might differ in views and ways to handle collaboration. establishment of infrastructures and long-term relation- That interdisciplinary research is challenging is not a ships, as in the sustainable collaborative structures initi- new insight (e.g. [65, 66]) and there are strategies to fa- ated or strengthened by the projects, are all considered cilitate such research, i.e. selective collaboration, cross- as enablers for research partnership . training, sustained relationships, good humour, partici- Ideally, there is room for a mixture of research ap- pation in peer review, declaring the place of one’s work, proaches in a programme, in line with current debates on and balancing dissemination of research between peer mixed methods where Gorard et al. advocate the develop- and other audiences . Past experience of interdiscip- ment of a research community where “all methods have a linary collaborations and an understanding of different role, and a key place in the full research cycle from the views on epistemology are foundations that can enhance generation of ideas to the rigorous testing of theories for collaborations. There were indications in some projects amelioration” (p. 162, ). Collaborative approaches that participating researchers did gain a deepened appre- are amendable to many different research topics, designs ciation of the need to join several paradigms in order to and disciplines, and the mixture of projects, research ap- understand the complexities of the issues at hand. The proaches and collaborations in the programme provides ‘inside’ clinical PhD students could act as door openers an example of this. It also shows the need to consider how and knowledge brokers  to the world and practice of to evaluate research applications when broader, complex health and social services for the social or technical sci- issues are the topics, as also highlighted by others . ences PhD students, and vice versa. Clinical researchers Assessment of the benefits and lessons learned through and PhD students were invited to new knowledge para- participating in the research process for individuals and digms by social scientists. Other practitioners involved partnership organisations, as well as of the sustainability as co-researchers in the projects could employ various of partnerships and joint interventions, might be a way brokering strategies, e.g. to engage, collaborate and build forward. capacity . The described challenges for these persons to adhere to expectations and demands from several Limitations of the study contexts in their in-between role and the conflicts that The study mainly represents project leaders’ and senior follow when demands are incompatible or role expecta- scientists’ views on the research programme and their tions are ambiguous have also been identified elsewhere own project’s efforts to bridge research and practice and (e.g. [40, 68]). Previous research has shown that initiate collaborative and partnership research. No Nyström et al. Health Research Policy and Systems (2018) 16:46 Page 14 of 17 representatives of the involved practitioners were inter- areas. Both interdisciplinary research teams and re- viewed and the reporting on impact and collaboration searcher–non-researcher teams can be challenging and with stakeholders was retrieved via project documents time-consuming per se. By mixing these two conditions and interviews with representatives of the projects. To the situation becomes exponentially complex, as every- expand the understanding of the entire process and all one has to learn about each other and adapt in various actors’ perspective on the acquired knowledge, the part- ways. The development of support from various ners’ views will need to be addressed. We also acknow- decision-makers and build trust and understanding with ledge that there might be information missing in final involved practitioners at several levels of a healthcare reports depending on the amount of text provided and system/organisation will need both skills in and arenas how questions in the report template were interpreted, as for communication and interaction. For the researchers, well as the potential bias introduced by providing ‘socially this takes time and energy from actual work with data accepted’ information to highlight the project’s benefits. collection, analyses and scientific writing. For the practi- We sought to reduce this bias by asking representatives tioners, this puts demands on understanding a research from all projects to read through the results of analyses process and how it fits with ongoing organisational and comment on any missing information or misunder- agendas and activities, and allocating enough time. standings – all projects provided answers and five of them Nevertheless, ensuring good relations (relationship bro- provided additional information or corrections. Frequen- kering) is an important precondition for establishing a cies and proportions were calculated to indicate trends research process and gaining access to high quality data, and overall patterns and should otherwise be interpreted especially on complex issues. with caution. Due to resources, it was no possible, but it Another process that might be overlooked is the for- would be interesting for future research, to address the ac- mation and building of research teams and the enact- tual impact of the collaborative and partnership projects ment of different roles in research intending to be both on healthcare practices, on further collaboration, and in interdisciplinary and collaborative. If collaboration is not terms of cultural change, research use and relevance of already established among researchers and involved part- the research conducted , despite the potential chal- ners, the experiences show that these processes need sig- lenges posed by the projects’ diversity. nificant time and effort on behalf of both researchers and practitioners. Such efforts must not be underesti- Conclusions mated if project agendas and schedules are to be realis- Using collaborative efforts to perform research on com- tic. The different roles and skills and the time required plex areas in complex systems requires a contextual un- by researchers to both conduct research and contribute derstanding, longitudinal efforts, collaboration on to the solving of complex problems in society by form- multiple system levels and often interdisciplinary designs. ing interdisciplinary research collaborations and collabo- Described problems, mirrored in the lessons learned, pro- rations with decision-makers and practitioners may be vided an indication on challenges to manage interdiscip- underestimated or simply ignored by involved stake- linary, collaborative and partnership research, enact holders. Many researchers (especially PhD students) are different roles and bridge several worlds as a researcher. not trained or experienced in working with interdiscip- Staffing, funding PhD students and paying attention to the linary research teams or in a collaborative way with work environment are some of the duties adhering to the practitioners. Practitioners, in turn, may lack experience tasks of an employer. Administrating and handling the and skills in research collaboration. Both these aspects project budget and monitoring its progress belong to the may have contributed to the problems encountered in role of a project leader/administrator. Possessing know- this study. The lessons expressed can thus provide input ledge on research designs and on the characteristics, de- for future collaborative or partnership research mands, etc. of several disciplines is important in initiatives. interdisciplinary, collaborative and partnership research. Research funders, as well as researchers and partners, Finally, skills in collaboration and communication are may also benefit from gaining an overall understanding needed, including a basic understanding of both the re- of the different types of research that can aid an under- searcher and the practitioner contexts, while not forget- standing of and support changes in health and social ser- ting any ethical concerns. Such demands and the often vices – from explanatory studies and experimental ambiguous roles and conflicting expectations make the re- research to explorative studies and case study research, search process challenging. as in this case, which focused on understanding larger Funders, as well as managers, practitioners and re- systems and more complex phenomena. Moreover, a searchers, might underestimate the complexity induced flexibility regarding content and schedule is necessary to and efforts needed to collaborate during a research meet the complex demands, particularly concerning the process, especially in multifaceted and complex research time and resources needed for project management. To Nyström et al. Health Research Policy and Systems (2018) 16:46 Page 15 of 17 avoid exhaustive situations for involved researchers and Additional file practitioners, such considerations need to be included in Additional file 1: Overview of the projects based on information in the agenda of the funding body. documents. (DOCX 19 kb) There is a need for more empirical studies on the con- ditions for researchers and practitioners in collaborative partnership and interdisciplinary research processes with Acknowledgements the aim to increase the capabilities in addressing com- We wish to thank the interview respondents for their participation, the research project leaders and representatives for reviewing results for plex questions and the ‘usefulness’ of research in prac- potential biases or misinterpretations, and Professor John Øvretveit who tice. An assessment of the efforts made to handle the provided helpful comments to improve the manuscript. different contexts and views of all involved actors in interdisciplinary, collaborative and partnership research Funding initiatives in greater detail would provide more infor- This work was mainly supported by the universities where the authors were mation on such processes and on their outcomes. Fu- situated (Karolinska Institutet and Jönköping University), with additional contribution from the Vinnvård research programme in Sweden 2014–15 [no ture studies could also address some remaining grant no provided]. The Vinnvård research programme management placed questions, including do the efforts to build interdis- no restrictions and had no influence on the research process. ciplinary, collaborative and partnership research lead to better uptake and use of research outcomes, or Availability of data and materials provide more useful outcomes for practitioners and The datasets used and/or analysed during the current study are available patients? Do they lead to deeper learning and under- from the corresponding author on reasonable request. It consists of transcripts from interviews and project documents (all in Swedish). Excerpts standing for researchers, and does the bilateral learn- from the data sources are presented in the article as citations (translated to ing process and integrated knowledge translation English and checked by multi-lingual persons). between practice and academia occur? Authors’ contributions MN, CK, JK and BA-G designed the study, MN collected the archival data, Comments on the results of the national programme and CK and JK conducted the interviews. MN, CK and JK performed the ana- lyses and MN drafted the manuscript. All authors read, contributed to and The programme’s goals can be considered as new and approved the final manuscript. innovative in the Swedish context. Further, the programme chose to fund less traditional research Ethics approval and consent to participate projects such as intervention studies, studies of nat- For the 20 investigated projects, regional Ethical Committees approved the ural experiments and the building of new infrastruc- studies according to Swedish regulations. The project documents and the tures. This approach may be risky with regards to Swedish report on the interview study (data used in the study) are openly displayed on the programme’s public website (http://www.vinnvard.se). results evaluation, but the rich variety of projects, Seeking ethical approval for this type of study is not required according to foci, new structures and lessons learned provided Swedish regulations. Participation in the original interview study was based more types of results than traditional ones (i.e. scien- on informed consent, also for open publication. For this study, the interviewed project leaders and senior researchers were given an additional tific presentations and publications), which fits rather opportunity to read and comment on the results of the analyses and to well with the initial broad aims of the programme. correct or add missing information and provide consent; they all provided Scientific production, measured through traditional answers, information and consent. metrics, was substantial. Other presented results were categorised into five areas of innovation (what to de- Competing interests velop) – a product/artefact, an approach when meet- The authors declare that they have no competing interests. ing patient/next-of-kin, routines and work procedures, administrative systems and structures, and increased Publisher’sNote organisational learning/competence. All projects re- Springer Nature remains neutral with regard to jurisdictional claims in ported results in at least two categories, and six pro- published maps and institutional affiliations. jects reported results in all categories. Some of these Author details were tangible, like employment of nurses in new Department of Learning, Informatics, Management and Ethics, Medical roles, education of hundreds of care providers, new Management Centre, Karolinska Institutet, SE 171 77 Stockholm, Sweden. IT systems, web portals, academic courses, and a de- Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, SE 901 87 Umeå, Sweden. Department of cision support used yearly in 25,000 patient meetings; Industrial Engineering and Management, School of Engineering, Jönköping some results were also very vulnerable. Quality in 4 University, P.O. Box 1026, SE 551 11 Jönköping, Sweden. Jönköping care processes can take long time to develop, espe- International Business School, Jönköping University, P.O. Box 1026, SE 551 11 5 6 Jönköping, Sweden. Futurum, Region Jönköping County, Sweden. The cially when many actors and interests are involved, Jönköping Academy for Improvement of Health and Welfare, School of but might be destroyed by one major politically Health Sciences, Jönköping University, P.O. Box 1026, SE 55111 Jönköping, decided organisational change. Sweden. Nyström et al. Health Research Policy and Systems (2018) 16:46 Page 16 of 17 Received: 29 August 2017 Accepted: 4 May 2018 partnerships: a realistic evaluation of the Collaborations for Leadership in Applied Health Research and Care (CLAHRC). Implement Sci. 2011;6:74. https://doi.org/10.1186/1748-5908-6-74. 27. DeVoe JE, Likumahuwa S, Eiff MP, Nelson CA, Carroll JE, Hill CN, Gold R, Kullberg References PA. Lessons learned and challenges ahead: report from the OCHIN Safety Net West 1. 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