Balancing exploration and exploitation in transferring...

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Original citation: Oborn, Eivor, Barrett, Michael, Prince, Karl and Racko, Girts. (2013) Balancing exploration and exploitation in transferring research into practice : a comparison of five knowledge translation entity archetypes. Implementation Science, Volume 8 (Number 1). Article number 104. ISSN 1748-5908 Permanent WRAP url: http://wrap.warwick.ac.uk/58462 Copyright and reuse: The Warwick Research Archive Portal (WRAP) makes this work of researchers of the University of Warwick available open access under the following conditions. This article is made available under the Creative Commons Attribution 2.0 Generic (CC BY 2.0) license and may be reused according to the conditions of the license. For more details see: http://creativecommons.org/licenses/by/2.0/ A note on versions: The version presented in WRAP is the published version, or, version of record, and may be cited as it appears here. For more information, please contact the WRAP Team at: [email protected]

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Oborn et al. Implementation Science 2013, 8:104http://www.implementationscience.com/content/8/1/104

RESEARCH Open Access

Balancing exploration and exploitation intransferring research into practice: a comparisonof five knowledge translation entity archetypesEivor Oborn1*, Michael Barrett2, Karl Prince2 and Girts Racko1

Abstract

Background: Translating knowledge from research into clinical practice has emerged as a practice of increasingimportance. This has led to the creation of new organizational entities designed to bridge knowledge betweenresearch and practice. Within the UK, the Collaborations for Leadership in Applied Health Research and Care(CLAHRC) have been introduced to ensure that emphasis is placed in ensuring research is more effectivelytranslated and implemented in clinical practice. Knowledge translation (KT) can be accomplished in various waysand is affected by the structures, activities, and coordination practices of organizations. We draw on concepts in theinnovation literature—namely exploration, exploitation, and ambidexterity—to examine these structures andactivities as well as the ensuing tensions between research and implementation.

Methods: Using a qualitative research approach, the study was based on 106 semi-structured, in-depth interviewswith the directors, theme leads and managers, key professionals involved in research and implementation in nineCLAHRCs. Data was also collected from intensive focus group workshops.

Results: In this article we develop five archetypes for organizing KT. The results show how the various CLAHRCentities work through partnerships to create explorative research and deliver exploitative implementation. Thedifferent archetypes highlight a range of structures that can achieve ambidextrous balance as they organize activityand coordinate practice on a continuum of exploration and exploitation.

Conclusion: This work suggests that KT entities aim to reach their goals through a balance between explorationand exploitation in the support of generating new research and ensuring knowledge implementation. We highlightdifferent organizational archetypes that support various ways to maintain ambidexterity, where both explorationand exploitation are supported in an attempt to narrow the knowledge gaps. The KT entity archetypes offerinsights on strategies in structuring collaboration to facilitate an effective balance of exploration and exploitationlearning in the KT process.

Keywords: Knowledge translation, Exploration, Exploitation, Ambidexterity, Collaboration, Research implementation,Absorptive capacity, Innovation

* Correspondence: [email protected] Business School, The University of Warwick, Coventry CV4 7AL, UKFull list of author information is available at the end of the article

© 2013 Oborn et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.

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BackgroundIn recent years, the practice of translating knowledge fromresearch into clinical practice has emerged to be of signifi-cant importance [1-5]. The rapid pace of innovation andresearch in the health and medical field heightens the im-perative of minimizing this ‘knowledge gap’ with fundingagencies allocating significant resources to close the gap.This has led to the development of new organizationsthat promote knowledge translation (KT) research andactivity [4,6,7]. In the United Kingdom (UK), the arrivalof Collaborations for Leadership in Applied HealthResearch and Care (CLAHRC) is one such importantinitiative with nine loosely coupled organizations inpartnership receiving approximately £10 M new fundingover a five-year duration from 2008 to 2013. Funded bythe National Institute for Health Research (NIHR), thestated mission of the CLAHRCs is ‘to undertake high-quality applied health research focused on the needs ofpatients and to support the translation of researchevidence into practice in the NHS (National HealthService)’ [8]. Each of the nine CLAHRCs is a regionally-based, NHS-led consortia pulling in external moniesalongside matched funds from local partners. The exactstructure of each CLAHRC emerged from the localpartnership arrangements, and in particular the aca-demic partners, that has led to the natural diversity inorganizational form. There was an explicit need to equip‘the NHS to harness better the capacity of higher educa-tion to support initiatives to enhance the effectivenessand efficiency of clinical care’ [9]. Member organizationswithin the partnership have unique skills, knowledge, re-sources, and capabilities; these are salient for conductingresearch, training, and changing current health serviceprovision through implementation activities.The majority of research into KT activity focuses on

efforts by health providers to enable KT within theirorganizational context, or within specific clinical areas,such as oncology [10,11] or mental health delivery [12].There are also many health service studies that describeand examine barriers and facilitators of evidence adop-tion across a range of policy areas [13-15]. A handful ofstudies have examined designated KT entities, notablythe Genetics Parks established in the UK to develop thehealthcare services in the area of genetics [16]. Similarly,‘SEARCH Canada’ was established to support region-wide KT activity in the healthcare sector and focused ondeveloping a strong educational and social networkingcomponent. In addition, a number of studies havereported on the activities and challenges associated withspecific CLAHRC entities, focusing on a micro level ofpractice [17-19]. Tensions that work to maintain the KTgap have been shown to include the contrasting re-searcher and provider cultures, knowledge domains,timelines, and incentive structures [20-26].

Yet, there has been little comparative study of multipleKT entities and their capabilities as they work to trans-late research knowledge into practice and accommodatethe tensions inherent in coordinating research and im-plementation activities [6,24]. We suggest that this is animportant lacuna to fill, as governments are increasinglyinvesting in translational entities and leaders wouldbenefit from exploring the different models in practiceto inform investment options and leadership challengesassociated with the different models. In particular it isimportant to examine different ways of organizingresearch activities that are exploratory in nature andconjoining these with implementation activities thatfocus on the exploitation of knowledge.In this paper we draw on a comparative case study of

nine KT entities in the development of five KT arche-types. Our cross-sectional comparative study of nineCLAHRCs provides insight into diverse organizinglogics that enable KT. We highlight, in particular, thecoordination and capacity development of exploratoryand exploitative dimensions of the KT entities. In thefollowing section we review the health service researchliterature on the challenges associated with KT. Further,we develop insights from the innovation literature thatexamines knowledge exploration associated with re-search activity, and knowledge exploitation associatedwith implementing existing knowledge to increaseknowledge application and organizational effectiveness.

Challenges of implementing KTThe complexity and challenge inherent in KT is widelyacknowledged [5,7,27,28]. As such, a number of distinctways to accomplish KT have proliferated, including ap-proaches that seek to render knowledge more explicit interms of systematic synthesis and guidelines, improvingsocial interaction and sustaining relationships betweenresearchers and decision makers as well as emphasizingorganizational readiness and contextual features asso-ciated with KT [29]. Entities explicitly developed to fa-cilitate KT activity may draw on all these approaches toachieve knowledge utilization.An important underpinning challenge in enabling KT

stems from the knowledge boundaries between stake-holder groups; knowledge boundaries that may befounded in contrasting meanings ascribed to particularknowledge claims, or more fundamental political dif-ferences in priorities held by the groups involved[25,30,31]. Managing knowledge flows across thesediverse boundaries is difficult, whether the context sur-rounding the anticipated translation is to enhance theuptake of research [32], new product innovation [31,33]or multidisciplinary collaboration [34]. As recentlysummarized [35], a number of strategies have been de-veloped to help leaders facilitate the translation of


knowledge across stakeholder boundaries, including theuse of knowledge brokers (e.g., opinion leaders), boun-dary spanners (e.g., practitioner researchers), and sys-tematically integrative boundary activities (e.g., regularengagement events) [24-26,35].Three critical capabilities need to be enabled and

sustained by KT entities such as CLAHRC’s, namely:improving research capacity among service providers;producing relevant research findings; and changing ser-vice provision in accordance with research knowledge[6,21,24]. The first KT capability relates to the difficultyfor practitioners to understand and assimilate the tech-nical complexity of research and their need to developresearch literacy so that the new knowledge can beabsorbed. The KT term ‘absorptive capacity’ [36,37] hasbeen increasingly used in the health service literature[38] to emphasize the need for examining, appraisingand assimilating. E.g., among paediatric occupationaltherapists, Lyons et al. found that frontline staff heldpositive attitudes towards research and were willing toaccess research information, but lacked confidence indoing so [39]. Engaging more clinicians and service pro-viders in the production of research has been suggestedas an important way of increasing research absorptivecapacity, as practitioners become more familiar with re-search methods, language, and interpretation [40] andcan inform researchers on strategies for rendering theirfindings accessible.The second KT capability is producing research. It is,

however, important that research findings and outputs arerelevant to service providers; the seeming irrelevance ofthe research questions studied has been cited as a reasonfor low research utilization [40,41]. Participation of practi-tioners in the research process can make the researchquestions more relevant and grounded in current con-cerns [42]. Sustaining the interest of service providers ishindered by the length of time required for conductingresearch and in making conclusive findings [17]. Theco-creation of research between academics and serviceprovider staff points towards the importance of changingthe culture of research to be more inclusive. Researchwithin CLAHRCs, e.g., explicitly acknowledges the im-portance of active participation of different stakeholdersin the research process [5,17,24,43,44], which represents ashift away from a passive view of non-researcher partici-pants such as service providers [45]. An important focusand concern has been how lay service users and patientrepresentatives might adequately participate in the know-ledge generation [20,43]. Given the historical autonomyheld by academics over the research process, and theincentive structure of the academic tenure system thathinges foremost on high impact publications, it is difficultto impose significant changes on the research process,which can alienate elite and highly-qualified academics.

On the other hand, in order to legitimize this new area oftranslational applied research as being of high standardand worthy of publication, it is important to engage topresearchers and secure their ownership in the process.The third capability associated with KT is being able to

sustain behavior changes in service delivery for prolongedperiods, until the new practices become implemented[46]. As emphasized in the abovementioned capability,making research more relevant by engaging more stake-holders with the research question and the researchprocess can be an important means to facilitate and sup-port adoption and behavior change at the level of servicedelivery [24,38]. Further, these processes of engagementwith service leaders or local champions are important [47]in developing long-term commitment and relationships,which plays an important role in embedding sustainedbehavior changes [48-51]. Further, a stream of implemen-tation research has foregrounded the importance of con-sidering local contexts to promote sustained changes. E.g.,Wensing et al. [52] argue for the importance of tailoringnew research knowledge for specific contexts to enableimplementation. They suggest that systematic tailoring en-tails three key steps: identification of the determinants ofhealthcare practice (that is, those factors that might pre-vent or enable improvement), designing implementationinterventions appropriate to the determinants, and appli-cation and assessment of implementation interventionsthat are tailored to the identified determinants.

Understanding KT challenges through exploration andexploitationConsistent with the renewed UK government focus oninnovation [53,54], we explicitly link KT activities inapplied health research with the process of innovation.We draw specifically on key concepts of the innovationliterature, namely exploration and exploitation, to exa-mine diverse ways of organizing KT as well as a thirdconcept, ambidexterity, which refers to achieving abalance between exploration and exploitation.In essence, exploration underpins the knowledge

generation processes of health research—and thus doingresearch—while exploitation underpins service improve-ment and implementation activities, being explicitlyconcerned with applying new knowledge to changecurrent practices [55]. These two dimensions of theinnovation process can provide further insight into thetensions and challenges of leveraging research to deliversuccessful improvements in health service delivery,thereby achieving ambidextrous balance between crea-ting and using knowledge. March [55] suggests that theessence of exploration is experimentation to developradically new ideas while exploitation is centered onrefining and extending existing competencies and tech-nologies for more proximate gain. Kang et al. [56]


elaborate that exploratory processes, which necessarilyinvolve knowledge creation and thus includes researchprocesses, are needed in order to find new and betterways of providing services or new products. New know-ledge is necessarily characterized as having initial uncer-tain relevance, as the outcome of doing research ordeveloping new products is by definition not known; theproduct may fail or the research may be inconclusive.Yet, it offers high potential for benefits, though at theexpense of high costs in terms of its generation. Explora-tive activity is supported by an ability to value, under-stand, and apply new external knowledge, commonlyreferred to as absorptive capacity [57], a term now in-creasingly used in public health contexts [36-38]. Asnew ideas and forms of knowledge are combined, tested,and developed, novel findings emerge, e.g., as is typicalof research outputs. Innovation research has shown thathigh levels of external control negatively impacts oninnovation outputs, as creativity and novelty are bestsupported by open processes and high levels of workerautonomy [58,59].Exploitative innovation processes focus on imple-

menting and refining existing knowledge and practices—such as using a new product, device, or technology. Ex-ploitative innovation can also include implementing anew pathway or process that has been shown to beeffective elsewhere into a novel context—e.g., a new userregistration system or new tracking process for medicinespreviously used in another organization. Exploitativeinnovation has been associated with quality improvementtechniques [59] and increased levels of centralized control[60] as they seek to minimize variation and obtain align-ment across an organization domain. Exploitative pro-cesses are more certain due to their incremental naturethus resulting in more certain outcomes—e.g., when it isalready known that the tracking device or new medicineworks based on implementation elsewhere, or publishedreports. While the scope for benefits is limited—e.g., newpatents will not be produced and radically new ideas arenot anticipated—costs are more predictable. March [61]notes, ‘exploiting interesting ideas often thrives on com-mitment more than thoughtfulness, narrowness morethan breadth, cohesiveness more than openness’.A challenge frequently highlighted in the innovation

literature is the competing demands entailed in organi-zing for both explorative and exploitative learning asthese activities are fundamentally different, requiring dif-ferent coordination mechanisms, levels of control, andresourcing [62]. One way of organizing for innovation isto develop organizations or collaborations that are ambi-dextrous—able to perform both types of activities simul-taneously [59]. An alternative mode of organizing forexplorative and exploitative activities is to create a balanceby alternating periods of exploitation and exploration [62].

This mitigates the need to balance the coordinationbetween both types of activities. Through these alternatingperiods implementation teams, e.g., can focus on delive-ring exploitative innovation through continuous processimprovements, reducing variability and increased efficien-cies and control [59].KT, as a general process of transferring research into

practice, can be regarded as constituting both explora-tive innovation found in research domains and the moreexploitative innovation in the implementation domains.Absorptive capacity [37,57], which we argued earlier wasa core capability sought after by KT organizations ingeneral (as well as CLAHRC entities in particular), is arelevant and important concept in understanding bothexploration and exploitation. The exploration activitiesof researchers are reliant on the ability to recognize andassimilate new knowledge, but ultimately they need tobe directed at application as an outcome of a KT entity’soperation, resulting in behavior changes at service deli-very levels. As pointed out previously, in order to engagetop researchers, it is important to understand the impactof constraining the autonomy of exploratory processesto the extent that the research is no longer of interest.Given the often competing timeframes of researchproduction and immediate service provision demands,research within what is sometimes referred to as a KTcollaborative is generally pre-designated as ‘appliedhealth research’ and may be designed to be less explora-tory or radical than other health-related research, suchas laboratory medicine. On the other hand, while serviceproviders may concentrate their activities in exploitingresearch for more practical application, they also have toensure that they are able to, when needed, recognize anddraw on relevant knowledge bases generated by research,which requires absorptive capacity. Through increasedparticipation in explorative research processes, practi-tioners can engage in the production of research aidingtheir understanding of research outputs and contributingto the relevance of research questions. Whereas re-searchers, through exploitative dimensions of innovation,are able to consider the ways in which the research can beused in service provider practice.We draw on the role of exploration and exploitation

in the innovation and KT processes to compare andcontrast CLAHRC KT entities. We address the followingresearch question: ‘What are the ambidextrous strategiesemployed by the CLAHRC entities in translating know-ledge from research into practice?’ Our comparative ana-lysis unpacks different archetypes that characterize howCLAHRCs sought to balance the competing demands ofexploration and exploitation, how these organizationalforms differed in structure, and the nature of innovationthey enabled. In presenting our findings of our fivearchetypes, we discuss the implications for translating


knowledge across the research to practice ‘gap’ and con-clude with practical suggestions for leaders engaged inKT activities. First, we present our research methods.

MethodsCLAHRCs were set up in 2008 in England as a pilotprogram by the Department of Health (DoH) to bridgethe research to practice knowledge gap. Each new partner-ship was given flexibility as to how to organize, with verylittle guidance from the DoH. The primary reporting re-quirement was an annual document that detailed the out-puts and impact of the respective CLARHC. CLAHRCsorganized themselves into research and implementationthemes with designated theme leads overseeing the pro-jects; they developed governance mechanisms that en-abled organizations to bridge and coordinate the efforts ofacademics across different departments, and provider or-ganizations. Most of the partnerships involved more thanone university department, as well as health (e.g., NHS)and social service providers and other stakeholdergroups (such as business sector or public and patientrepresentatives). Each of the CLAHRCs developed novelapproaches to bridging the research to practice gap inthis context of a natural ‘experiment’.The research team obtained ethics approval from each

of the NHS provider organizations involved in theCLAHRCs as well as each of the directors of the KTentities. Some members of the research team were alsoinvolved in a specific KT entity, which further attuned thefieldworkers to the salient issues, challenges and remit ofthe CLAHRCs. The NIHR Service Delivery Organisation(SDO) funded project was explicitly not seeking to rankthe CLAHRCs or their respective outputs, but rather toprovide feedback on the overall CLAHRC process in acomparative manner.The study is based on the qualitative analysis of 106

semi-structured in-depth interviews with the directors,theme leads and managers, key professionals involved inresearch and implementation from all nine CLAHRCs[9,63]. Most of the interviews were conducted in person,with a small number being carried out over the phone.Data were also collected from intensive focus group typeworkshops conducted with the key members of fiveCLAHRCs. Focus group workshops were conducted incollaboration with the colleagues from the RANDCorporationa; each workshop included between eightand 23 participants. Interviews and workshops generallylasted for one and three hours respectively. They weredigitally recorded and transcribed by a professionaltranscription service. Researchers also attended a num-ber of meetings in association with CLAHRC organiza-tions, including seven theme leaders’ meetings in threedifferent CLAHRCs, one CLAHRC directors’ meeting,four CLAHRC cross theme learning activities, three

feedback sessions, and three CLAHRC-wide eventsorganized by the central funding agency. During thesemeetings and events, detailed notes were taking regar-ding challenges, CLAHRC structure, KT processes, andperceived leadership challenges.The interview protocol included questions focusing on

the goals of the CLAHRC; process and mechanisms be-hind their adoption; organization of the theme or researchprojects; vision for KT; activities (e.g., projects, collabora-tions) used to attain KT goals; key challenges encountered;breadth of stakeholder involvement across the spectrumof activities; and relationships between research andimplementation themes. The interview protocol was alsoadapted to the specific expertise of an interviewee. Forexample, senior managers (e.g., directors, deputy directors)were able to provide a more generalized understanding ofthe goals and means of the CLAHRC. In comparison, rep-resentatives of research implementation themes provideda more nuanced understanding of the practical challengesfaced in the execution of KT goals or networking patternsacross research and implementation themes.Data analysis and KT model development occurred in

three stages. In the first stage, data from the first 52 in-terviews—approximately six from each CLAHRCconducted in the second year of operation—was qualita-tively analyzed and coded using Atlas.ti. This yieldedbroad themes of similarities and differences in ap-proaches used by CLAHRCs in developing their earlyKT vision and coordination across partnerships. Themeswere further refined by using tables and graphs to dis-play and organize findings [64]. We then re-analyzed thetranscripts for perceptions regarding the strengths andweaknesses of KT within and between CLAHRCs andsought to link these to the differing approaches used tocoordinate KT activity. Because our focus was a cross-sectional comparison across CLAHRC entities, we didnot emphasize the ongoing changes in structure asCLAHRC entities learned from each other during laterstages of CLAHRC programs.In the second stage, we developed written narratives of

contrasting KT models, highlighting the strengths andchallenges associated with each. We used these discur-sive scripts to engage and discuss with at least one se-nior member from each of the CLAHRCs regardingtheir perceptions of their CLAHRC KT model and getfeedback on our insights. From this we developed sche-matic representations of archetypes for organizing KTactivities found within and across the CLAHRCs. Wethen went back through the further set of uncoded 54interview transcripts—conducted in the third and fourthyear of operation—as well as focus group meeting tran-scripts to examine the fit of the typologies with the data.In the third stage of analysis, we further developed the

validity of our schematic diagrams by presenting our


findings to three separate groups of CLAHRC stake-holders. Two groups represented eight to ten senior stake-holders, including the directors and deputy directors,involved in one respective CLAHRC who were given thefive models as part of a formative evaluation process oftheir own KT approach (in consideration of their reappli-cation bid). The third group was more eclectic, incorpo-rating 80 individuals representing all nine CLAHRCs andwho spanned across the hierarchy in terms of seniority.The schematic models were presented in a workshop for-mat to solicit feedback on archetypes from the diversestakeholders. Schematic models were then further refinedusing the feedback from these groups. While there was astrong sense in which the models reflected the CLAHRCorganizing structure, a key point of feedback was regar-ding how patient and public involvement fit into therespective modelsb. Importantly, we highlight in this finalstage that the models are not representative of all thecharacteristics of one CLAHRC partnership, but rather asynthesis of distinctive strategies used by CLAHRCentities into an archetype. As has been previouslyhighlighted regarding such ideal archetypes of organiza-tions [65], real organizations seldom, if ever, reflect all thefeatures of an ideal type, but rather different aspects andvarying degrees of these features. Rather archetypes are aset of structures and processes that reflect a single inter-pretive scheme that orders everyday practices [65,66].

ResultsIn the following section, we organize our findings aroundfive KT archetypes that became evident in the comparativeanalysis across CLAHRCs. Though CLAHRCs generally

Table 1 Archetype A

KT archetype& organizinglogic

Explorative dimension Exploitative dimension

Archetype A Research governancemaintained by academics yetthey are accountable to a widergroup of stakeholders; this canincrease researcher absorptivecapacity of service providervalues and concerns.

Exploitation supportedseeking to shift the culturresearch to integrate broaset of perspectives andstakeholders.

Multi-stakeholderresearch toengage awide range ofperspectives

High exploratory focusmaintains academic autonomy.

Wider research engagemeenables research to be mrelevant to users and incrtheir absorptive capacitybeing more aware of reseprocess.

Wider research agendapromotes research intoimplementation processes frommultiple perspectives.

Engaging practitioners anhealth service providers inresearch increases their leownership, supporting thimplementation of researfindings; yet implementatprocess not formally cont

organized their KT approach predominantly around oneof the archetypes, CLAHRCs drew on features fromseveral models. Thus, while our descriptions are based onthe empirical cases, our purpose is not to delineate therelationship of particular CLAHRCs to specific archetypes,but rather to reveal the breadth of KT approaches thatdeveloped in this ‘natural experiment’ of a unified con-text, unified goals, and where organizational approachesemerged independently. A number of similarities wereevident across all CLAHRCs. Key similarities that fea-tured across multiple levels and stakeholders withinCLAHRCs were the temporal challenge of integratingresearch and implementation activities, including thetimeframe of managing the ethics process, differentpriorities of academic and provider organizations, mea-suring empirical impact, perceived difficulties in pub-lishing highly contextualized research, on-going healthand social care reorganizations, and finding adequatemeans of integrating patient and public concerns intoresearch and implementation processes.

Archetype A: involving a broad array of stakeholders in amultidisciplinary research processOne way to organize KT activities entailed the pur-poseful integration of multiple stakeholder groups intothe research process, so as to address research questionsconcerning highly complex problems from novel per-spectives. This could include researchers from multipleacademic backgrounds, patients and service users, aswell as practitioners and managers from diverse organi-zations—see Table 1 and Figure 1 for a diagrammaticrepresentation. KT entities organized around Archetype

Strengths Leadership challenges

bye ofder

Increased stakeholderinvolvement enablesintegration of perspectives,thus suited to researchingcomplex multidimensionalproblems.

Complexity of research andintegration of (shifting)stakeholder agendas canincrease the time needed togenerate research outputs.

ntoreeases,arch

Research includes the KTprocess, which may be donefrom multiple perspectives.

Brokering and negotiationneeded across multiplestakeholder groups.

d

vel ofechionrolled.

New culture of inclusive andmultidisciplinary research cangenerate wider genre ofresearch, beyond medicalparadigm.

Risk of alienation and retreat toinstitutionalized silos of activityif boundaries are not activelymanaged, rather than sustainingnew culture of multi-stakeholderresearch.

Figure 1 Archetype A: Multidisciplinary research.


A maintained exploration as a focus but with a newinclusive culture of research being enabled as new stake-holders, such as patients or health service providers,became involved in research supported by a knowledge-brokering process. The expanded groups of stakeholdersbecame involved in designing the research question,collecting data and receiving on-going feedback on re-search progress and early findings, restructuring in somepart how explorative research was conducted to make itmore relevant to implementation. An important em-phasis in this approach, therefore, is to alter the cultureof research from uni-disciplinary silo activity to accom-modate more diversity; an aim is to improve researchrelevance, as well as gain broader ownership, enablingthe knowledge produced to be more easily exploited‘downstream,’ and promote ambidexterity. Research ac-tivity in this context focused on complex multifacetedproblems that by their nature require multiple perspec-tives to address. This archetype emphasizes rigor in theresearch process but in doing so, seeks to adapt the po-tential relevance of the research output as well as widenthe stakeholder ownership among entities who may sub-sequently exploit findings in healthcare deliveryc. Fromthe perspective of the researchers and practitioners in-volved, this model of KT radically alters the process ofexploring and generating new knowledge and was seenas uncomfortable because researchers needed to accom-modate the advice of non-academic stakeholders (e.g.,service providers and practitioner researchers) and in-clude them in the research activities:

‘This is the most radical thing the NIHR has everdone. I have never done research like this before … itis completely different.’ (Academic lead)

‘We used to stand outside and look in at [the researchprocess] but now you have opened up the windowsand let us in … [it is great] to participate in theresearch [process].’ (Senior manager, service provider)

In the context of the CLAHRCs, this model alsoemphasizes doing research on KT as a process andscience of implementation, including how patients andpublic might be involved in knowledge generationd;implementation themes may draw on the multiplestakeholder perspective to explore the dynamics of im-plementation itself. Thus, a core output of this modelis to generate conceptual and systematic knowledgeregarding implementation and KT and ultimately fa-cilitate exploitation practices:

‘Our approach in the implementation themes isnot about going into the hospitals and telling thenurses and doctors what to do, but to engagewith these and other stakeholders to understandimplementation [challenges] better. We areacademics … we don’t have [the] jurisdiction togo into hospitals or social services and tell themwhat to do. But we can develop knowledgethat will help facilitate the process.’(Implementation Theme lead)


A strength of this KT model is its lack of com-promise on the rigor of research as researchers retainhigh levels of autonomy over the exploratory process,with the potential for the new knowledge to be radi-cally innovative given its multidisciplinary breadth, aswell as its potential to address complex problems in asystematic manner:

‘Ours is very research orientated, it’s very, verymuch so… ours is very academic based which isgood; it just takes a bit longer to get thingsgoing… But I think in terms of sustainability theway we do it is much more sustainable because weare producing the evidence that should besustainable.’ (Director)

‘A strength of our CLAHRC is its [multidisciplinarity]….e.g., our business school does research thatdevelops the science of moving knowledge around asystem.’ (Director)

Allowing high levels of researcher autonomy can enableresearch teams to adjust and renegotiate their projects tofit with the needs and emergent context of stakeholdersinvolved; however, this level of co-production is de-pendent on adequate flexibility in the exploratory researchdesign as well as researchers’ mind set. Sustaining broadresearch engagement and stakeholder facilitation is an im-portant role of the central management.Organizing KT activity in this manner relies on high

levels of collaboration and mutuality; breakdown acrossstakeholder boundaries is difficult to manage and liable tomake existing groups retreat back into silos and comfortzones of historical relationships (of non-integration). Tomaintain a generative exploratory KT process with ongoingco-production, central management leaders would need tomaintain loose coupling across the diverse agendas andnot be seen to favour one stakeholder group above another,to avoid alienation and return to compartmentalization:

‘In principle collaborating across departments is agreat idea. But we have issues of data ownership,which type of research publications to focus on, andhow to work together…. In the first two years we usedto work more closely with other themes … but it ishard… and now we are farther apart. I notice thisacross the board that sustained engagement is[difficult].’ (Theme lead)

Our analysis found fundamentally sustained changesassociated with widening the stakeholders engaged withthe knowledge exploration; the successful implementa-tion of this model is associated with the nature of theresearch process itself becoming more inclusive and

using multiple perspectives in ongoing co-production,including both social science and medical worldviews.Exploitative functions are enabled through ownership byway of co-production and general increases in providerabsorptive capacity through participation in researchactivities. The breadth of stakeholder perspectives accom-modated within the research process also enables exploi-tation because the research questions are more relevant tocurrent provider concerns and take account of the com-plexity of service delivery contexts.

Archetype B: loosely autonomous research streams withdesignated knowledge brokersKT activity can also be organized around loosely struc-tured collaborative research projects that have a numberof designated knowledge brokers attached to each pro-ject—see Table 2 and Figure 2 for a diagrammaticrepresentation. The emphasis is on structuring the im-plementation processes within specific service pro-viders. Explorative research activities remain largelyunchanged, although they accommodate brokeringagents who contribute contextual insight and retainownership of the exploitation activities. Knowledgebrokering agents have the responsibility to exploit theknowledge being developed by researchers. As know-ledge brokers work across two distinct stakeholdergroups, having managers who are familiar with front-line care delivery and thus implementation issuesseconded to work within the CLAHRC for a designatedportion of their week enables dialogue and integrationof explorative and exploitative activities promotingambidexterity. In this way, research activity can beorganized and controlled by university researcherse, yetthe research questions can be negotiated with the desig-nated knowledge brokers, who have critical knowledge ofprovider issues and have established relationships with theresearch team. Balance between exploration and exploi-tation can be maintained, supporting both research andimplementation—see Table 2:

‘[My role was about] ensuring that the projects …linked into the NHS through [designated brokers] andthings like that and the engagement theme was aboutengaging with wide stakeholders like members of thepublic and patients.’ (Implementation theme lead)

The ideal type of this KT model requires brokers withvarying levels of time commitment and seniority withinprovider organizations, to balance their ability to brokerwith relevant target audiences across the spectrum ofprovider services:

‘We are trying to fully integrate [knowledge brokers]into our [research] team so that they know what stage

Table 2 Archetype B

KTarchetypeandorganizinglogic

Explorative dimension Exploitative dimension Strengths Leadership challenges

Archetype B Research governancemaintained by academics,including process andquestions; yet select KBs areinvited to interact with researchteams.

Exploitation supported by KBsin accordance to KB jurisdiction.

Research capacity withinservice providers is developedthrough KBs.

Difficulty appointing KBs at theright level of seniority to effectand resource service change.

Designatedknowledgebrokers(KBs)

High exploratory focusmaintains academicautonomy.

Central management organizeand support KBs.

Researchers can developsustained dialogue withprovider representatives tofacilitate on-going relationshipfollowing project completion.

There is a risk researchers canfocus on exploration anddisregard concerns of serviceorientated KBs and knowledgeexploitation, given no formalaccountability betweenacademics and service providers.

KBs receive formal training inbrokering techniques and skills,increasing individual and systemlevel absorptive capacity todraw on research knowledge toinfluence service delivery.

KBs are aware of researchagenda and nature of likelyfindings, thus able to developimplementation goals early inresearch process.

KBs responsible for embeddingfindings in local services, beingaccountable to local services.

Designated KBs haveownership for supporting KTinto specific service contexts.


we are at with the research. They helped write theimplementation component for each of our proposalsand we also have used an implementation contact towork alongside our [knowledge broker], so they do abit of education and teaching and support with the[knowledge broker].’ (Theme leader)

As each provider organization has a unique contextand each research theme have their own particular

Figure 2 Archetype B: Designated knowledge brokers.

dynamics, having designated individuals charged withbrokering the boundary across these domains allowsthem to develop locally suitable ways of integrating KTprocesses. Individuals can work to their strengths andnest activities into the unique contextf, making the newboundary dynamics sustainable through long-term re-lationships. The implementation activities of brokers,helps create conduits between the diverse groups thusbringing synergy across the different projects.


An important feature of this model is its potential todevelop absorptive capacity within provider organiza-tions. Knowledge brokers can be trained and given skillsin interpreting research methodologies and managingchange processes within their organization. Trainingprograms designed by central management integrateacross diverse stakeholder worldviews and can be tai-lored to the profile of provider organizations and partici-pant experience:

‘The dissemination team committee which meetsregularly, … the committee [is] trying to run allthese … classes so economics classes e.g., [and]sociology of networks for the [knowledge brokers].’(senior manager)

Importantly, as the designated brokers and boundaryspanners originate from provider, rather than researcher,organizations, they retain ownership of the exploitationprocess. Given the designated brokers’ breadth of con-tacts, they can access and draw in a range of resources ifthey have sufficient status within their host organization:

‘[Designated brokers] are located in the NHS and aredesigned to link clinical and/or managerial problemsinto CLAHRCs so the CLAHRC can offer expertiseand assistance and help doing either research or doingsome of the knowledge generation that isn’t researchto help them address that. So it is a way of ensuringthat ownership of some of these issues remains withthe NHS.’ (Senior manager)

Yet an ongoing challenge in the KT model is the tensioninherent in integrating traditional research activities withongoing engagement with stakeholders so as to facilitateexploitation. Researchers are likely to divert their attentionand interest in knowledge exploitation activities towardsthe production of interesting and publishable findings:

‘There is this continuing tension as you probablyknow between them running off with their projectsand the rest of us saying ‘hang on, this is aboutknowledge transfer, this is not just about stroke.... butthere are tensions because they are the people that aretrying to sell dissemination and [knowledgebrokering] …and it is quite clear that the PIs andsome of the Research Fellows aren’t terribly interestedin that.’ (Implementation Lead)

Similarly, in the current fiscal climate of healthcareproviders, it remains a challenge for providers to con-tinue releasing the designated knowledge brokers andboundary spanners away from their normal activities.Pressing matters frequently draw them back into their

former routines, as the priority of research can pale inthe face of current crises:

‘There has been a lot of effort to try and release these[designated knowledge brokers], but other key peoplehave not been released from their time even thoughyou could argue that the Department of Health andthe other contributors of funding feel that they havebeen charged for it.’ (Research theme lead)

Archetype C: independent research and implementationactivitiesAnother typology for organizing KT activity entailed theseparation of research and implementation activities,maintaining them in parallel as independent modularfunctions—see Table 3 and Figure 3 for a diagrammaticrepresentation. Ambidexterity is achieved through sepa-ration rather than integration. Given the distinct temporaldynamics of research and implementation activities, non-integration enables focus on exploratory research activitiesby academic researchers working on topics they chooseand know can be published. The research themes maybroaden their concerns to consider the practical relevanceof their work, but this is not their focus. Patient and publicinvolvement can be incorporated within the researchprocess as per existing guidance available from the centralfunding agency, but is likely to be more problematic toincorporate within the implementation processes as fewstandards exist to guide their involvement and the pro-cesses are kept separate:

‘We are not trying to do research in a different wayfundamentally, I mean the mechanics of research, butwe want the research to be more aware of some of thecontextual issues that then tend to change people’sthinking about how they do it.’ (Deputy Director)

Implementation activities focus on exploiting all existinghealth research available in published literature. Ratherthan integrating with exploratory knowledge productionactivities, this modular organization of parallel activitydevelops service providers’ knowledge regarding relevantevidence already published. Given the wealth of well-established research and best practice guidelines, thismodel of implementation is efficient since it incorporatesan already available corpus of research knowledge intoservice improvement processes rather than spending re-sources and time producing more knowledgeg. Hence ser-vice improvement is primarily informed by searching foralready existing external knowledge rather than creatingnew knowledge internally:

‘Other CLAHRCs have these very clear things, youknow, … teach management to researchers … plus the

Table 3 Archetype C

KT archetypeandorganizinglogic

Explorative dimension Exploitative dimension Strengths Leadership challenges

Archetype C Research governancemaintained by academicswho determine researchquestions and process.

Exploitation supported bydevelopment ofimplementation skills, asorganized by centralmanagement.

Quick start to implementation processas not waiting for new researchfindings to be produced.

Boundary betweenimplementation andresearch themes, stymieingintegration between theirefforts.

Modularindependence

Highly autonomousexploration with no explicitneed to accommodate newsignificant stakeholdergroups.

Existing external knowledgeused, such as systematicreviews and other publishedaccounts of research outputs.

Autonomous research processattractive to highly qualifiedacademics who are not needing tochange their research practice; thisincreases likelihood of high impactgeneralizable findings.

Low co-production ofresearch topic risksknowledge outputs havinglow relevance to localstakeholders.

Exploratory focus maintainsacademic autonomy.

No explicit link with in-houseresearch process.

Increases absorptive capacitythrough acquired skills inidentifying and appraisingresearch evidence and reviews.


implementation guys understanding how thosecomponents actually go together to create a situationwhere the two can speak to each other. We have notdone that in any form.’ (Director)

An important advantage of this KT model is the speedby which implementation activities can ramp up. Ratherthan waiting for the end of a lengthy research study,change agents can develop local capacity within serviceproviders and influence practice more quickly usingexisting knowledge outputs. Once networks are esta-blished to influence health service practice, these can

Figure 3 Archetype C: Modular independence.

later be used to mobilize findings from the organiza-tions’ own research program:

‘The implementation people having got such a head ofsteam and worked hard to create this momentum andmovement for change, they don’t want to be checkedin the process by research slowing them down.’(Deputy Director)

The slow temporal rhythm of research, as comparedto service provider environments was a consistent causeof strain across all CLAHRCs; while research production


and knowledge creation is a slow and meticulous process,NHS clinicians and managers were being confronted dailywith making decisions in contexts where sufficientinformation was elusive. By separating the implementationactivity in a modular fashion, focus could be kept onexploiting relevant knowledge and evidence from existingresearch in a co-production manner focused on currentprovider concerns. Supported by central management, thisimplementation activity entailed building research literacyamong service providers, teaching them sustainable waysof finding relevant research to address their current needs,an important means of developing absorptive capacity.This model enables a focus on research rigor, through

the maintenance of researcher autonomy, ensuring thatnew knowledge within the funding constraints of ‘appliedhealth research’ is produced and published in a traditionalfashion. Given that broad stakeholder involvement andmultidisciplinary collaboration is slow and resource inten-sive [34], a KT model that allows researchers to focus onthe complexity of the research task can be more efficientin developing knowledge outputs, as compared to Arche-type A; Archetype C may be particularly relevant forstraight forward clinical questions that require less con-textual embedding so as to enable eventual exploitation:

‘As a research team our goals are very muchincentivized by the researchers, universities and theREF. Working here you cannot escape your targets …If you don’t publish then forget it. So 90% of oureffort has been making sure that our findings arepublished.’ (Researcher)

The activities of the implementation themes can beclosely coordinated with the current priorities and

Table 4 Archetype D



ArchetypeD

Governance of research processshared between academics andservice providers.

Exploitation supported hilevels of trust that facilitateemergent connections betwresearch and implementatio

Building onexistingnetworks

Academics and service providersinvolved in research process;existing relationships form thebasis for the collaboration,relinquishing some academicautonomy.

Efforts to balance research aimplementation goals in thphases are assisted by existstructures and informalmechanism rather than cenmanagement.

Research questions heavilyinfluenced by local providerconcerns.

Absorptive capacity enablincreased practitioner involvin research.

knowledge needs of provider organizations. Given thenovelty of CLAHRC entities and the ambiguity of theirrole in relation to provider organizations, closely aligningthe implementation process with provider priorities wasan important means of gaining stakeholder commitmentand support.Yet the limited relationship that develops between

research and implementation theme activities remains.While the intention might be for exploratory researchthemes to draw on the exploitation expertise of imple-mentation themes to disseminate their eventual outputs,this exchange was difficult accomplish in practice:

‘I don’t think there is a model of knowledge transfer[between research and implementation themes]. Ithink we know that we are not doing a very well onthat… I don’t think over the three or four years thatwe have been together [that] we have quiteunderstood each other and we have certainly notworked together.’ (Theme lead)

Archetype D: collaborating through loose networksOrganizing logic of KT activity in this archetype isthrough loosely coupled and regionally embedded net-works as shown in Table 4 and Figure 4. This model ofKT takes advantage of existing informal structures andbuilds organically from existing relationships betweenservice providers, researchers and other stakeholders.This emphasis is particularly important in a contextsuch as medicine where a number of academics are alsopracticing clinicians in provider organizations, withexisting social ties to draw upon. Recognizing the know-ledge exploration and exploitation activity occurs in acontext where existing collaborations are already taking


gh

eenn.

Low levels of inertia toovercome at early stages,as individuals alreadyhave connections andgoodwill ties.

Cliques and silos can arise fromunconnected groups withinnetwork as no designated brokersare accountable or assigned.

nde earlying

tral

High levels of possibleintegration and tailoringof research projects withlocal provider needs.

Informal governance is difficult tohold to account.

ed byement

Strengthening existingties enables solid basis forlegacy to remain oncefunding for overallinitiative ceases.

Difficult to extend the networkbeyond certain size when workingmore informally as this is notcentrally managed and more adhoc; ICTs can help facilitate this.

Figure 4 Archetype D: Building on existing networks.


place, this model seeks foremost to develop and extendcurrent organic activity in pursing ambidexterity:

‘Much of the [early CLAHRC] work was done by theinformal collaborations that we already had going.There would often be clinicians, academics and so onworking together.’ (Director)

‘There was an historical context within which webegan that was partly because it is a relatively smallpatch and so there were a lot of personal relationshipsthat had already been established.’ (Director)

This archetype was used in contexts where multiple alli-ances between researchers and health providers (and otherkey stakeholders such as industry) were strong and wherehierarchy between research and providers was not empha-sized. Existing relationships of trust and goodwill can pro-vide a basis for building partnership projects and a meansfor arbitrating between competing organizational prior-ities and goals. In this way, governance structures set bycentral management can be more informal, guided by mu-tual goodwill. Networked project groups can also incorp-orate public and patient participation and their respectivesocial networksh. Similarly, other stakeholders, such as so-cial services, charities, or industry can also be accommo-dated within specific project groups, as enabled by projectgoals and local relationships:

‘To put this another way - we are taking about acollaboration here, and what you are saying is thatthere was already an extant collaboration in placewhich you could draw on. … There was this chunk ofgood will to work from.’ (Director)

A feature of this model is the early efficiency gains thatcan come from cooperative decision making and existinggoodwill. Having established means for working to-gether, existing relations can provide structure for howto organize new projects and set joint goals:

‘This is not about transferring knowledge from thosewho have it to those who don’t and almost semi-accidentally we have produced a system wherebecause we actively try to find where the problem lieswithin the system, and it is not about us providingknowledge, it is about us working with the people forwhom it is a problem to try and create somethingtogether.’ (Deputy Director)

For example, while the challenge of overcoming themultiple hurdles for research governance were high-lighted repeatedly by CLAHRC organizations, using thisinformal network efficiency can enable new projects toinitiate quickly. By seeking to organically embed explor-ation activities within provider concerns, genuine en-gagement is possible between providers and academicresearchers (and other stakeholders), as neither is able tocarry out the networked activity without adequate par-ticipation and engagement with the other:

‘You are trying to move from the NHS being a passiverecipient of, or purchaser of, or commissioner ofresearch, to being a partner in generating knowledge.’(Director)

As knowledge brokers are organically nurtured, ratherthan centrally controlled or appointed, an organizationalchallenge entails the need to further develop brokers


who can span between project groups and build scalebeyond the initial collaboration level. While research-based institutions such as universities have establishedstructures for scaling and promoting knowledge explo-ration, embedding exploratory processes within providerorganizations can limit scaling processes, particularlywithin a context of reorganization and austerity. Thus, anetwork-centric orientation to KT activities relies onknowledge brokers to take initiative:

‘We started with a theory that we needed to have[brokers] within the CLAHRC who were very clearlyseen as having their primary label, allegiance, realityas being within the NHS.’ (Director)

Organic development of new project ideas, building newrelationships and translating knowledge around the widerhealth system can be facilitated through established rela-tionships, often in a manner that appeals to the collegialethos built into academic and medical professionals:

‘We have a relatively open agenda, although there isalways a requirement that it needs to be research thatis going to be of some applied use to promotingevidence based practice, but the agenda is not pre-digested. We can generate it ourselves and we cangenerate it from colleagues in the service and that isvery refreshing because increasingly, and especially aswe said at national level, the research agenda hasbecome quite heavily bureaucratized.’ (Research lead)

Yet, brokers need to be strategically located in orderto maximize their network impact and broker acrossunconnected groups or network entities. In addition,

Table 5 Archetype E



Archetype E Research explicitly managedby central controls, whohold governance oversight.

Exploitation supported by sapproaches to quality manageensuring consistency.

Centralmanagementcontrol

Research directly influencedor determined by localprovider concerns, thus lowacademic autonomy.

Strong central governance aorganization.

Exploration is moreincremental.

High likelihood of researchimplementation due to centrmanagement control and higcontextualized improvement-research.

Central managementsystematically collects andcollates research findings.

Absorptive capacity aboutimplementation processes andimprovement developed.

brokers are likely to need strategic placement in order tominimize clique formation or isolated groups in the net-work. Without adequate brokers organized to enableknowledge flows, it is difficult to strategically scale thenetwork systematically:

‘What has been more difficult, much more difficult,has been to get beyond that network of fifty, sixty,seventy people, to get beyond that.’ (Director)

A challenge to any informal network is the non-hierarchical leadership and governance process, as it re-mains by definition loosely coupled and implicit. Hence,accountability mechanisms are difficult to monitor, relyingheavily on relational trust and goodwill. A summary ofthese challenges as well as the strengths of Archetype Dorganizing forms is provided in Table 4 and Figure 4.

Archetype E: centrally controlled service improvementprojectsThis model of organizing KT, shown in Table 5 andFigure 5, is managerially focused retaining control overboth research and implementation activities through on-going accountability mechanisms and formalized struc-tures to monitor projects. Mechanisms for exercisingcontrol include centralized budget management and for-mal accountability metrics in accordance with centralmanagement priorities, which together enable ambi-dexterity. This model for organizing KT places a veryhigh emphasis on knowledge exploitation for improvedservice improvement:

‘Well I suppose the guiding philosophy for the wholeCLAHRC is that we actually want to make a


ystematicment,

Project level control bycentral managementenables high levels ofaccountability.

Low levels of research autonomyrisks alienation of high calibreacademics.

nd Sustained investmentin local serviceimprovement.

Incremental nature of serviceorientated research and alienationof academics decreases likelihoodof high impact publications.

alhlyorientated

Integrates into cultureand goals of ahierarchical healthservice system.

service

Figure 5 Archetype E: Central management control.


difference, this isn’t just research, so in terms of whatwe are about it should be about making it better forpatients and then making it better for staff. … If weknow we don’t [deliver a service] terribly well, how dowe learn from that and change it into something wedo do well.’ (Senior manager of CLAHRC)

One strength of this archetype is the horizontal, system-atic approach to knowledge exploitation (i.e., collaborativeresearch design, evaluation, and implementation) embed-ded at the project level drawing on quality managementtechniques, and improving absorptive capacity of serviceimprovement techniques. As these projects necessarilyinvolve highly integrated service provider and researcherrelationships, this enables learning and knowledge transferas well as social relationships among project teamsi.Central management takes responsibility for organizingevents, workshops, and regular cross boundary activitiesin order to promote learning and integration of researchknowledge into specific service contexts; this system isdeveloped so research can be consistently exploited:

‘There are a number of sort of managementstructures that the core team have developed …obviously the projects by themselves are a series ofclinical projects, but to be more than a series ofclinical projects the CLAHRC core team hasdeveloped these vehicles to spread and transfer theknowledge out.’ (Evaluation theme lead)

Having a centralized hierarchy structures project find-ings and enables accountability for service impact; fre-quent updates on the status of the work as well asrequested research outcomes can be ordered. Rather

than letting project teams work autonomously as self-organizing co-production activities, accountability for spe-cified project outcomes is monitored. New interventionscan then be recommended by central management, asthey control the research process from a distance:

‘Every week we have to feed back our statistics tocentral management through this database. We needto do this in order to get the funding. So they arealways checking on us.’ (Project team member)

‘We are probably slightly different to the otherCLAHRCs in that we have sort of direct contact withour projects on a weekly basis … and we can thenlook at that data to see if it has made a difference.’(Central manager)

In order for research to fit into predetermined metricsand categories, the new knowledge is limited to being in-cremental and predicable. Project teams are instrumen-tal in executing project activities and learning, howeverthe overarching plan is held centrally and thus neitherlocally emergent nor reconfigured without sanction frommanagement:

‘So we do have timelines and we do haveaccountability and we do have governance, you know,we can change some of those things if there is goodevidence that we are doing things wrong, but basicallywe have a plan and we are trying to work to thatplan.’ (Deputy Director)

In order to be exploitative, research projects aim tomeet current provider needs, with specified outcomes


written in to project deliverables. Instead of researchersexploring areas of interest or novelty, projects are de-fined in relation to exploiting current service providerconcerns. Centralizing the interactions ensures thatthese are spread out across relevant stakeholders:

‘We did a lot of groundwork by going out to seevarious chief executives and various other medicaldirectors on the patch in both primary and secondarycare… we [asked] a whole variety of people, cliniciansand researchers … basically looking for them to giveus ideas about what projects to put forward becausewe wanted things that were on the shelf but also thatultimately fitted our final brief.‘ (Deputy Director)

A high proportion of the project members and eventleaders are not research academics, but individualsinvolved in service provision or part time consultantshired for the job of exploiting research findings and get-ting change implemented. As commented by one projectmanager whose role encompassed engaging the newClinical Commissioning General Practitioner leads:

‘It takes a lot of time, I am out there on the beat,meeting people, calling people… sometimes they don’tshow up or cancel. But slowly we are making animpact.’ (Project manager)

As many of those participating in CLAHRC activitiesare from health service providers, they will be accus-tomed to the more rigid control and hierarchy culturecommon in provider organizations and project manage-ment teams.This model of organizing KT is less likely to produce

radically novel findings; research-intensive academicsmay also avoid the seeming instrumental control ofmanagement and it may therefore be difficult to attractthese researchers to participate. Overall, research out-puts are likely to be incremental, according to the trans-ference of research findings from the innovation field onexploitation learning [59,62] and thus at risk of havinglow levels of publication impact, though local serviceimprovements would be expected to be significant[59,62,67]. While concern for local service improvementis of interest to local providers of that specific service,its highly contextual nature limits the broad gene-ralizability of findings. Hence exploration is highly con-strained in order to favour exploitation as summarizedin Table 5 and Figure 5.

DiscussionOur study identified five archetypes of KT that weredrawn on by the CLAHRCs. We found that each ofthese typologies organized KT activity by emphasizing

different organizing logics for managing knowledgeacross the multiple boundaries. Each sought to addressthe KT gap by coordinating exploration and exploitationactivities in distinctive ways and by achieving an ambi-dextrous balance of these innovation processes.Organizations are products of their administrative

heritage [68], which leads to path-dependency that rein-forces existing patterns of behavior [69]. Research orga-nizations therefore, will continue to be fundamentallyinclined to focus on exploration activities while organi-zations involved in implementation will essentially be fo-cused on exploitation. At the same time, however, thereare numerous and diverse ways in which the CLAHRCsas KT entities adopted unique strategies in balancingexplorative learning within exploitative processes.KT entities organized around Archetype A maintain

exploration as a priority, but with a new inclusiveculture of research that engages directly with serviceprovider stakeholders in order to influence the researchcontent and process, while improving its practical rele-vance. The ambidextrous balance is enhanced throughexplorative research of implementation processes, whichincreases absorptive capacity concerning new perspec-tives in research. Thus, the explorative outputs entailapplied health knowledge in areas that are complex andmultifaceted, as well as knowledge concerning how theknowledge gap between research and practice might bebridged. The relationships between stakeholders arenewly established and relatively weak and unstructuredin comparison to other archetypes; as highlighted in theinnovation literature [56], these loose connections bet-ween previously unconnected groups favors and sup-ports exploratory learning as many new perspectivesand stocks of knowledge are combined. A risk of theweaker links between stakeholder groups is the poten-tial for domination by certain groups and the alienationof others, which may lead to groups returning to theirinstitutional silos where strong relationships alreadyexist. Previous research has highlighted the need forstructured coordination across diverse communities[19,34], which points to a role for leaders and centralmanagement to facilitate brokering and to limit domi-nation of particular groups [70], ensuring that stake-holder groups are adequately represented and broadownership is facilitated [17,35,70,71].KT entities based on Archetype B, organized around a

logic of using designated knowledge brokers workingwithin loosely autonomous research streams, achieveambidexterity through the development of the absorptivecapacity of numerous brokers who now have a betterunderstanding of explorative processes [72]. Though theexploratory research process is not explicitly designed tochange—as in archetype A—the sustained presence ofknowledge brokers from service provider domains may


nonetheless influence the research process and dynamics.Informing service providers and implementation leadsregarding the rigor and process of research can support itsutilization through improved ownership and awareness[42,73]. Given the key role of knowledge brokers ininfluencing both exploration and exploitation in Arche-type B, it is important to ensure that they have sufficientability to engage with researchers as well as steer theimplementation processes. Thus, the level of power andseniority of the knowledge broker as well as their abilityto develop and sustain relationships is an essentialconsideration.Archetype C, involving independent research and im-

plementation streams, is unique in its organizing logic ofmodular research and implementation as parallel acti-vities. Unlike other ambidextrous strategies, there is littlecross over and fertilization of ideas or organizationalprocesses between exploratory research and exploitativeimplementation, a strategy that the innovation literaturehas highlighted as particularly efficient to coordinate[62]. In the language of systems design, exploration canbe pursued in one module of a modular system while ex-ploitation is pursued in another, in which case conflictsover resources, mindsets, and organizational routinesand timeframes are less problematic [62,69]. The absorp-tive capacity of provider organization staff in having theskills to search for, recognize, and assess relevantresearch to exploit knowledge is key to sustaining ambi-dexterity and is of central importance for implementa-tion leaders. As such, Archetype C’s model enablesambidexterity through the dynamic capability of both in-creasing the efficiency of knowledge search (e.g., beingable to find good evidence) and supporting the assimila-tion of information to specific problems within the im-mediate service provider context [56,59].In Archetype D, the organizing logic is collaborating

through loose networks. Ambidexterity is facilitated bycapitalizing on the existing relationships and buildingcapacity concerning each other’s work context. The rela-tively informal mechanisms of central governance overprojects can lead to considerable variation in explorativeand exploitative scope, leading to a loosely structuredambidexterity approach, as well as novel ways of inte-grating patients into the networks. The literature onsocial networks and social capital suggests that strongand dense social connections are efficient at sharingfine-grained and in-depth knowledge for exploitativelearning [72]. For example, the more frequently em-ployees interact with particular parties, the more oppor-tunities they have to recognize and access the parties’idiosyncratic knowledge [73,74] and mediate trust rela-tionships. The relationships between research andimplementation partners promote exploitation as itmay enable the implementation requirements to be

incorporated into the research design. A potentiallynegative consequence of strong relationships suggestedin the literature is the formation of cliques and silos, es-pecially when certain groups become unconnected inthe wider network [75]. Since the Archetype D isdependent on informal links it is necessary for theleaders and central management to nurture integrativerelationships across the entire network to facilitateknowledge flows [75].KT entities organized around Archetype E logic, invol-

ving centrally controlled service improvement projects,are strongly focused on exploitation processes in addres-sing the KT gap. These entities achieve ambidexteritythrough centralized and tightly coupled managementstructures and diffuse knowledge through monitored net-works [56]. Managed routines facilitate knowledge flowsin very specific knowledge domains that are highly suitedto incremental innovation and pursuing well-defined solu-tions [76]. Thus, the innovation emphasis is on refiningand deepening existing knowledge so as to expand or en-rich service provision. Within the implementation sciencedomain, this approach has been characterized as syste-matic tailoring of interventions [52] and has a strong focuson overcoming barriers for change and implementation[11]. Ambidexterity is shaped by exploring how to exploitany knowledge generated; the ambidextrous capabilityemphasizes proximate gain for more certain outcomeswith significant potential to influence the practice of ser-vice providers. The capability developed around learningto implement and evaluate services—an important area ofabsorptive capacity development—contributes directly toservice improvement.In this study, we do not attempt to assess whether a

particular archetype is ‘better’ than another in terms ofdelivering KT outcomes. Each type can be managed andled more or less effectively, present different challenges,and are more suited to certain contexts. KT implemen-ters of each of the archetypes have various ways to ac-complish translation; the archetype selection is likely tobe influenced by factors such as partners’ organizationalstructure, current capabilities of the various partners,and the legacy of collaborative relationships, as well asthe nature of KT required or envisioned. The archetypesA to E uncovered by our research of the nine CLAHRCsshould be considered as being on a continuum ofexploration and exploitation. Archetypes A, B, and Cmaintain relatively high levels of exploration and know-ledge generation and, to varying degrees, can support re-search autonomy. We contend that these KT entities arelikely to produce more generalizable knowledge that haspotential to contribute to addressing the KT gap in thewider healthcare system. The weaker and non-redundantsocial connections found in Archetypes A and B arelikely to provide individuals (from research and service


provider contexts) with opportunities to identify andutilize novel knowledge from a variety of sources and,thus, encourage exploratory learning. Archetypes D andE center their focus on exploitation in order to facilitateand tailor implementation in local contexts, though withdiffering levels of central control. In these KT entitiesknowledge production is more contextually based andspecifically targeted at generating value at the local level[11,52], with greater potential to influence the practiceof service providers and in so doing effectively span theKT gap.We suggest that understanding and clarifying the

organizing logic underpinning KT collaborations is im-portant for two reasons. First, a clear organizing vision isimportant to enable leaders to unite multiple stake-holders and enable effective communication of commongoals. Given the multiple challenges, as evidenced in thisstudy and echoed in the innovation literature, an over-arching vision is an essential leadership task to engageand orientate people. Without adequate clarity of pur-pose and focus, the bundles of activity may seem chaoticand disjointed rather than integrated. Second, a clearvision enables leaders to develop and articulate a clearstrategy for achieving KT goals. Each archetype presentsunique challenges and requires particular attention fromleaders to sustain performance. A clear strategy enablesleaders and central management to focus their resourceson developing appropriate synergy so as to maximizethe distinct strengths of their KT archetype.Based on our analysis of the five archetypes, we sug-

gest a few practical implications. Leaders of archetype Aand B KT entities need to ensure that the various groupsremain connected and that brokering and negotiationroles and tasks are assigned to suitable individuals. Fur-thermore, selected staff need sufficient time outside oftheir traditional full-time roles to perform the knowledgebrokering roles effectively. In Archetype C KT entitiesthe leaders should ensure that service providers respon-sible for implementation have the requisite training tobe able to find, access and assess relevant research.Those implementing Archetype D KT entities need toensure that networking is facilitated and managed, whilerecognizing that network governance is seldom enabledthrough traditional hierarchy and control. Leaders could,e.g., ensure there are opportunities for individuals tomeet, engage, and exchange knowledge and use IT sys-tems to facilitate communication within and beyond thenetworks. Archetype E KT entities require a strong pro-ject management team supported by a hierarchical workculture, to ensure that the KT entity maintains its focuson ensuring effective implementation. Further, the im-plementation and use of an effective IT system will pro-vide support and focus on performance metrics at aservice level.

ConclusionOur paper contributes an understanding of five differentmodels for organizing KT. We have shown how learningand coordination practices are different when conductingexplorative or exploitative activities [56,62,69] and howthese differing orientations can be approached within thevarious archetypes. Each archetype has its own uniquestrengths and also presents unique challenges whichdirectors should pay particular attention to in order toimprove the performance of their own CLAHRC. Ad-ditionally, we have provided support for previous researchon the CLAHRCs, in particular the central role of know-ledge brokering arrangements in managing and nego-tiating the research-practice boundary [18,21] and therelevance of social networks in influencing research aswell as the stakeholders involved [77].We suggest that our work on developing KT arche-

types opens a number of productive research areas forthe future. First, whie this research examined KT entitiesat one point in time, it is important to understand howKT models change and adapt over time. As some chal-lenges, such as improved levels of absorptive capacity,may be overcome, new challenges may arise. Additio-nally new models for organizing may arise as leadersreflect on and evolve their organizing structure and cul-ture. Second, further work is needed to better under-stand which brokering roles are more effective and whatthe implications of different forms of governance andaccountability for improved KT are. In addition, futurework should develop ways of evaluating and assessingthe effectiveness and performance of KT activity thatinclude but go beyond ‘tick-the-box’ metrics to suggestqualitative assessment of effective knowledge brokering.Finally, an emerging area of increasing importance inKT research is to understand how the advent of newpolicies, such as academic health science and otherclinical networks influence the evolution of KT entitiesand their activities, thereby shaping the innovation land-scape in healthcare.

Endnotesahttp://www.rand.org/ The RAND Corporation is a

non-profit institution that helps improve policy anddecision making through research and analysis.

bA number of CLAHRC directors and senior teammembers subsequently drew on these models to reflect onrevising their organizing structure in the CLAHRC 2 re-application bid, thereby further highlighting the practicalusefulness of the models.

cThis might include bringing engineering, architectureor sociology departments into the research process, orincluding a police member in the stakeholder team.

dAn example of patient involvement might includepatients or their representatives examining their own

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role in the research process, and providing feedback onengagement processes to the ‘research team.’

eWhich may be run in a similar way to a programgrant, yet have more outside influence from brokers.

fFor example, a broker who might have a role asmanager of a stroke service would have a different abilityto influence and broker the research process than anurse or doctor involved in the stroke service.

gFor example, if systematic reviews or reputable guide-lines exist for diabetes’ community pathways, these canform the basis of the implementation focus, as they turntheir attention to getting the guidelines used.

hFor example, patients or public who have been in-volved with research teams, or who have strong ties toprovider organizations through advocacy groups can be-come centrally involved in project groups.

iFor example, a ward may seek to improve their dis-charge compliance having seen successful examples ofthis elsewhere.

AbbreviationsCLAHRC: Collaborations for leadership in applied health research and care;DoH: Department of health; NIHR: National institute for health research;NHS: National health service; KT: Knowledge translation.

Competing interestsThe authors declare they have no competing interests.

Authors’ contributionsEO, MB, and GR collected and analyzed the data. EO, MB and KP drafted themanuscript. All authors contributed to the development of the models. Allauthors read and approved the final manuscript.

AcknowledgementsThis work was funded by the National Institute for Health Research (NIHR)Service Delivery Organisation (SDO) Program (SDO 09/1809/1073) and alsopartly funded by the CLAHRC for Cambridgeshire and Peterborough. Thispaper presents independent research funded by the National Institute forHealth Research (NIHR). The views expressed are those of the authors andnot necessarily those of the NHS, the NIHR or the Department of Health.

Author details1Warwick Business School, The University of Warwick, Coventry CV4 7AL, UK.2Judge Business School, University of Cambridge, Cambridge CB2 1AG, UK.

Received: 22 April 2013 Accepted: 22 August 2013Published: 5 September 2013

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doi:10.1186/1748-5908-8-104Cite this article as: Oborn et al.: Balancing exploration and exploitationin transferring research into practice: a comparison of five knowledgetranslation entity archetypes. Implementation Science 2013 8:104.

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