Implementation and development of an embedded researcher program driven by rural health services: a qualitative exploratory case study

Abstract

Background

Embedding researchers in healthcare settings is a strategy used to close the gap between research and practice. Existing research pays little attention to the factors related to the implementation, development, and outcomes of embedded researcher programs in rural healthcare settings. There are additional challenges to embedding research in rural health practice, including enduring workforce shortages and limited research resources.

This case study aimed to describe the implementation, development, and the types of outcomes of a rural and regional embedded researcher program, comprising three research translation coordinator (RTC) roles implemented in rural health services by an academic health science centre (AHSC).

Methods

This exploratory case study was informed by multiple data sources: the RTCs (n = 4; 100%); their employing health service chief executive officers (n = 3; 100%), and the implementing AHSC’s executive officers (n = 2; 100%). Data were gathered via semi-structured interviews, RTCs’ written activity reports, and impact case examples developed by the RTCs. Data were analysed using a team-based five stage framework approach.

Results

Data collected included eight semi-structured interviews, fifteen activity reports and six impact case examples. Analysis of these data informed three themes and sub-themes: (1) Enabling and challenging implementation factors coded to two sub-themes (Rural health service ownership and Region-wide implementation) (2), Development of the rural embedded research translation coordinator role, comprising three sub-themes (Emerging and responsive to health service needs; Supporting translation of research, and Engaging strategic partners, and (3) Types of outcomes of the rural embedded research translation coordinator program at four levels (Rural clinician-researcher; Rural RTC; Organisation, and Region-wide or AHSC-levels).

Conclusions

The rural embedded researcher program represents an evolving, yet ostensibly successful initiative implemented across a large rural and regional area. The RTCs were employed by and accountable to a rural health service, and worked as a team while simultaneously collaborating with partner regional health services and universities. This rural health-service driven embedded researcher program operated within a collectivist framework to produce different types of outcomes for clinicians and researchers, health services, and the region. These findings will inform policymakers and organisations concerned with improving research and practice in rural and other resource-constrained health settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-025-13336-x.

Background

Efforts to embed practice and policy translation research in healthcare delivery settings have increased over the last two decades [1, 2]. Strategies to reduce the gap between research knowledge and translation into practice often involves promoting partnerships and collaboration between organisations delivering healthcare services (health services) and academic institutions producing research knowledge [1, 3]. Effective tailored strategies to increase the uptake and sustained translation of research into practice in rural and regional areas, where the communities and populations they serve experience poorer health outcomes remain poorly defined [4]. Challenges specific to the rural and regional (rural hereafter) health service context include enduring workforce shortages, higher comparative rates of chronic and complex health conditions, and the challenges associated with access to health services due to the geographic distances between communities and services [4, 5]. Rurally based health research is needed to generate evidence to address these contextually nuanced challenges and health and healthcare inequities, however, place-based rural health is underrepresented in the literature [5, 6]. This is due to underdeveloped research infrastructure in rural health settings, fewer partnerships with universities and research institutes, less access to experienced researchers for support and mentoring [7], and comparatively less funding allocated to rural health research [8]. Moreover, rural health researchers tend to be geographically and professionally isolated [9, 10].

Building the capacity and capability of health service staff and academic researchers to translate research into practice has attracted much attention. In a recent systematic scoping review of the literature, it was found that the common strategies to build research translation capacity in health settings were targeted training and education, research-practice partnerships, and embedded researcher roles [11]. Embedded researchers are individuals with research experience employed in a research or research support role within a practice setting, such as a health service [12, 13]. These roles represent a tangible and operational research capacity building strategy of health service and academic institution partnerships [1]. Embedded researchers often serve as a conduit between these organisations, co-producing research evidence and ensuring it is relevant to practice [14–17]. Embedded researchers’ physical presence in their health organisation is central to their effectiveness. Being immersed in the healthcare delivery environment enables them to thoroughly understand the context, the challenges within, and the current priorities [18]. Research translation support roles also known as knowledge brokers are often employed as co-located embedded researchers [1, 15].

There are numerous embedded researcher programs and roles in place in rural settings in Australia. In Queensland, Australia, for example, the Health Practitioner Research Fellow program was established in 2008 [4, 19] and in Victoria, Australia, the University Department of Rural Health implemented embedded clinician-researchers [4]. Researchers have previously explored the individual characteristics of embedded researchers [16], the features of embedded researcher initiatives [1], components of embedded researcher roles [20], mechanisms embedded researchers use to support research translation [13, 18], the enablers and barriers of embedded research models [15], and the outcomes and impacts of these roles [19, 21]. The outcomes typically measured include published papers, grant funding attained, number of projects approved by ethics offices, conference presentations or posters, research student supervision [16, 21] participation in quality and research translation activities, changes in attitudes towards evidence-based practice among clinicians who have been engaged with the embedded researcher [21], clinical service changes and research collaborations [19]. The research to date on embedded researchers pays little attention to the geographic and resource context within which the embedded researchers are situated. Specifically, there remains a lack of evidence related to the factors influencing the implementation and development of rural health service embedded researcher roles. This multisite case study research seeks to address this gap by exploring the implementation, development, and the types of outcomes achieved by a rural embedded researcher program developed using a coordinated regional approach to enable research and translation support for health services of different sizes. This evidence is needed to inform and guide the implementation and development of effective and sustainable approaches to implementing research capacity building initiatives in rural areas [4].

Study aims and research questions.

This study aimed to describe the implementation, development, and the types of outcomes achieved by a rural and regional health service embedded Research Translation Coordinator (RTC) program developed and delivered in rural health services by an academic health science centre (AHSC). Drawing on the perspectives of multiple stakeholder groups, this study sought to answer the following research questions:

1. What enabling and challenging factors influenced the implementation the rural RTC program?

2. How was the rural RTC role developed over the initial implementation period?

3. What are the types of outcomes reported in the first three years of the rural RTC program?

The terms implementation and development mean different things in different contexts. For the purposes of this research, implementation refers to the process of initially putting the RTC program in place, whereas development refers to the evolution of the RTC role over time.

Methods

Context and study population

This study was conducted in Victoria, Australia, where the health system operates in a devolved governance model. Under this model, individual health services are responsible for developing and delivering the health programs and services that best meet the needs of the communities they serve [22]. The AHSC responsible for development and implementation of the rural RTC program covers two large regions in Victoria, comprising a mix of small rural and larger regional towns and communities. The towns vary with respect to population profiles and their distance from major cities, with towns categorised according to the Modified Monash (MM) Model as regional centres (MM2), large (MM3), medium (MM4), and small rural town (MM5), with one area categorised as a major city (MM1) [23].

The AHSC operates as a not-for-profit company funded by its member health organisations [24]. When the rural RTC program was initially implemented, the AHSC had 12 member organisations: six regional, sub-regional, and local publicly funded health services, three privately funded rural and regional hospitals, two universities, and one primary health network. The central objective of the AHSC was to promote the capability and capacity of its members to conduct research relevant to rural and regional health and to support the translation of research findings into health practice and local policy. The AHSC’s member organisations (health services) identified their perceived support needs to enable their research translation capacity and capability growth, which led to the development of a plan to implement a rural RTC program.

The planned RTC program comprised three fixed term part-time roles (18 months, 3-days per week) each implemented in a geographic sub-region of Victoria. The primary employers and therefore place of work for the RTCs were three rural health services (MM4), each of which has four campuses. In addition to their employing rural health services, the incumbents were to provide support to a larger regional health service, a private hospital, and the local primary health network. Due to the advent of the COVID-19 pandemic, recruitment of the three RTCs was staggered, with the first employed in December 2019, the second in February 2020, and the third employed in July 2020.

Study design

An exploratory qualitative case study approach was used to investigate the implementation, development, and types of outcomes of the rural RTC program. The RTC program implemented by the AHSC in the three geographic sub-regions constituted the ‘case’ at the centre of this study.

Case study research provides a useful mechanism to explore and evaluate programs and interventions that are influenced by complex environmental and contextual factors [25–27]. Data collected from multiple sources as they relate to the health services, resources, or individuals involved in the program, were combined, and synthesised to produce a single case study to develop an understanding of the implementation, development and types of outcomes of the RTC program in rural health settings.

Participant sampling and recruitment

With ethics approval (Barwon Health Human Research Ethics Committee, reference 22/65), three stakeholder groups were invited to participate in the case study: the rural RTCs (n = 4); the chief executive officers (CEOs) of the employing health services (n = 3), and the AHSC executives (n = 2).

The rural RTCs, health service CEOs, and AHSC executives were invited via email to voluntarily participate in the research. Potential participants were asked to read and sign a participant information and consent form prior to their interview or submission of their data.

Data collection

Data from the rural RTCs (interviews and documentary data) and the AHSC executives (interviews) were collected between August and September 2022, when the three RTCs had been in post for between 26 and 32 months. On analysing these initial data, the research team identified the need to consider the views of CEOs who oversee the programs in their respective health services. Interviews with the health service CEOs were conducted between October and November 2023. Interviews were conducted by an independent research consultant via telephone or videoconference. Interviews with the RTCs explored their perspectives of their roles, the skills and qualities they bring to it, the challenges and enablers of their roles, the outcomes they had achieved and any learnings from working in the role. Interviews with the AHSC executives explored their experiences during the initial development of the program, the early implementation, learnings from the early stages, and perspectives on the future of the roles. Interviews with the CEOs explored their perspectives of the research culture within their health services, how the RTCs have contributed to the research culture and activity, their experiences and perspectives on the initial implementation of the roles, and any learnings they could share. Interviews lasted between 26 and 72 min (mean 46 min). All interview data were audio-recorded and transcribed. See Supplementary file 1 for the interview guides for the three participant groups.

The documentary data (i.e., activity reports and impact case examples; see Supplementary files 2 and 3) were sent via email from the consenting RTCs to a researcher with whom they had no direct collegial relationship. The template for the activity reports was developed by the RTCs in consultation with their health service CEO or manager during the early stages of their tenure, as a way for the RTCs to document and report the details of their activities to their health services and the AHSC. The consenting RTCs supplied these completed templates as data for the current research.

Data analysis

All data were anonymised in preparation for thematic analysis. Data were analysed using a five-step framework approach [28]. Three authors (OAK, HB, and AB) familiarised themselves with the data and conducted initial analyses of two data sources each. These inductive analyses were used to develop an initial thematic framework. The coding framework was refined with reference to the research questions and aims and in consultation with the research team. The framework was then used by one author (OAK) to code all the interview, impact case example, and activity report data via NVivo12. In consultation with the research team, patterns were identified within and across the data.

Researcher reflexivity

Our research team participated in a structured reflexivity exercise prior to commencing the data analysis. Through this exercise we identified varying levels of clinical, qualitative and health services research experience, and different levels of knowledge and experiences of embedded researcher roles. All research team members contributed to the data analysis processes and reflected regularly on their past and current experiences and perspectives in relation to the current study. These deliberate reflections and team discussions supported a balanced approach to the analysis [29].

Results

Participants included four rural RTCs (three were in post at the time of data collection, one had moved on to a new role), three health service CEOs, and two AHSC executives. This represents a 100% participation rate. Eight participants took part in a semi-structured interview (three RTCs, three health service CEOs, and two AHSC executives), and a total of 15 activity reports and six impact case examples were collected from the four rural RTC participants.

These data contributed to the development of themes which are presented with illustrative data from the interviews, under the following three major headings: Enabling and challenging implementation factors; Development of the rural embedded research translation coordinator role, and Types of outcomes of the rural embedded research translation coordinator program. The key findings are summarised in Table 1 with example data from the three collection methods.

Table 1.

Themes and example data from the three collection methods

Theme	Interview data	Impact case study data	Activity report data
Enabling and challenging implementation factors
Rural health service ownership	.. you actually need to have the intellectual capacity in those facilities in rural communities because that’s how you build capacity. We have numerous people coming out, talking about building capacity.. but they fly in and fly out, they’re not actually embedded Health Service (CEO 1)	The first project was initiated by a health service Executive in response to the COVID-19 pandemic. It was an opportunity to study the effects of ceasing planned exercise groups during lockdown. The study was initially undertaken in collaboration with another small health service (Impact Case Example C 3)	Support and supervision of Research Assistant at [Health Service]. [RTC] is line manager (Activity Report B 3)
Region-wide implementation	I don’t know if you had one individual going into an organisation doing this that it would work. I think it works because of the wrap around support that those individuals get, and how they’re managed from a collective, and that they have peer support (Health Service CEO 2)	A very supportive and united regional network of people working across health services in related roles (Impact Case Study A 2)	Seeking input across all [AHSC] members and key contacts to identify most appropriate study design supports for our emerging researchers (Activity Report A 3)
Development of the rural embedded research translation coordinator role
Emerging and responsive	It’s an evolutionary role that when we’re considering the evaluation - and I think you’ve kind of touched on this in the questions - that we took the approach of putting these in place, knowing that we didn’t know exactly what the needs were going to be yet but that the right people to understand that were people who were embedded, and had the time and ability to gather those needs, and work through a plan to support that (AHSC Executive 2)	My role has been to work closely with health services to determine (in collaboration with their existing research teams) what their organisational research priorities are (Impact Case Example A 2)	Supporting the development of an organisational Research Strategy for [Rural Health Service] (Activity Report A 1)
Driving the translation of research	Often we’ve used their research to drive change so we’ve put those papers that have been published or what we’re doing about it and they’ve made their way towards sub-committees as well (Health Service CEO 3)	I maintain a mentoring relationship with the emerging researcher from project inception to completion and write up. In these cases, inexperienced researchers were able to further the development of a research idea that comes from a real problem within the health service or primary care context. Several emerging researchers have translation-focused projects under development or in mind for the near future (Impact Case Example A 1)	Established Food Safety Research and Audit Working Group. Chair of this working group. Post-implementation food safety audit and follow-up research currently in development (Activity Report B 2)
Engaging strategic partners	Developing networks or facilitating networks across the region so that someone from a small rural service now has the ability contact someone at one of the larger university departments or being able to deliver some of the education and capability building content has been important (RTC 2)	Ongoing support to the Research Committee – facilitating member engagement, preparing agendas and minutes, liaising with external stakeholders about research proposals and research opportunities (Impact Case Example C 1)	Fostering relationships with two newly filled research translation positions across the region at [Health Service] and [Region]. Ensuring we stay connected with these roles and working collaboratively with the [Regional] role (Activity Report A 2)
Types of outcomes of the rural embedded research translation coordinator program
Rural clinician-researcher level	One example of an impact has been working with a clinician who was at a rural health service and had had no research experience but was passionate about the particular area of the clinical discipline they worked in. They contacted me and we went through the process of appraising the literature, designing the research question and then all the way through an ethics application, collecting data, analysing it and now having them publish the first author paper (RTC 2)	The skills acquired by the clinician working alongside [RTC] were then applicable to the second project, with the clinician taking more of a leading role. The clinician’s awareness of the research process has developed over time, as well as their ability to anticipate research activities and understand the implications that decisions have on the project. The clinician now asks insightful questions like ‘do we need an amendment to do [research activity] after beginning this journey in 2020 (Impact Case Example C 3)	Supported 11 potential applicants for the STaRR emerging researcher program develop and submit their [expression of interest] (Activity Report A 2)
RTC level	As the RTC, you think that you need to have all the answers and you should know things, but honestly, I felt like I probably got a lot out of it, as much as the people that I supported did.. I don’t think it’s just that we [RTC] support other people, but you also learn through the process as well (RTC 3)	I was not an expert in the content of the [emerging researcher’s] planned research project, I drew on my existing research network and was able to establish a collaboration between the study team and a researcher who had experience in this area. This proved valuable to both the [emerging researcher] and [RTC] in terms of better understanding some of the research context in this particular topic and gaining access to some more specific recommendations regarding study methods (Impact Case Example B 1)	[RTC] was lead author of a paper published in Australian Journal of Rural Health (Activity Report B 1)
Organisational level	I think that sort of strengthens what we’re doing within an organisation that likes to be evidence based.. I think it’s valuable where you do have these ideas that are a bit outside the norm.. so that people [who] need the evidence can see that there is something holding it up other than just someone saying it’s a great idea (Health Service CEO 2)	Enhanced communication of research activities and awareness of research opportunities within the health service; for example, to CEO, Board, executive, staff (Impact Case Example C 1)	Strengthening of administrative/operational ‘research teams’ within the health services, bringing together key personnel to oversee research processes, manage risk, and ensure consistency of process (Activity Report A 2)
Regional level	We now run a flagship research program, which means it [research] involves all of our partners. I don’t think something like that would’ve been possible without that on-the-ground support. I don’t think something like our very large MRFF-funded program would’ve been possible without them being in their positions (AHSC Executive 2)	Facilitating introductions and connections between university partners and health services (Impact Case Example A 2)	Through activities including [RTC] assisting with multi-site grant applications and study development, mutually beneficial collaborations between [University], [Health Organisation] and health service partners have been formed. Networks reaching outside of the [AHSC] have also been formed (Activity Report B 1)

Enabling and challenging implementation factors

The key enabling and challenging factors related to the initial implementation of the region-wide rural RTC program were coded to two overarching themes: Rural health service ownership of roles and Region-wide implementation and support. These overarching themes and the factors therein were described as both enabling and challenging.

Rural health service ownership

The AHSC’s overarching directives to the RTCs were to identify the priorities and research capacity building and support needs of the rural health services with a view to addressing these. Consequently, the most commonly described defining feature of the rural RTC program at the centre of this case study is that the roles were “fully owned by the health services”:

“We’re going to move away from the academic side, and these are going to be fully owned by the health services. That’s why [Government Department Funder], saw this as an opportunity because they’re beholden to the health services, and so there was a good alignment with what we were proposing and what they were trying to do from a research perspective. So, we really made sure the roles were health service-based and health service-owned.” AHSC Executive 2.

This sense of ownership facilitated the active engagement of senior managers and executives as “champions” for research activity and supported evidence-based decision making at that level:

“I read every article, every publication that they produce so I feel that I’m across the research and I make sure it goes to the appropriate committees and things like that. I say to them.. ‘this is the [research] work, how can we leverage off it?’” Health Service CEO 3.

This senior level operational support and endorsement was critical in the context of health services with little or no research culture and activity and legitimised both research and the RTC roles. With senior management overseeing and championing the roles, systems were developed to enable effective communication of research activity and send a clear message that research is encouraged:

“[RTC] reports to the board through a quarterly report.. research activities, grant applications and all that.. I’ve got [research] from the highest profile through the organisation and for me, it’s strategic. [The Board] understand the reasons and they’ve learned through that process why research is so important.” Health Service CEO 3.

Health service buy-in also meant a shift from academic or research key performance indicators, in recognition of the challenges of producing research outputs in a health service context, which are further compounded in rural areas:

“One thing that I found refreshing was not having KPIs [key performance indicators]. So not having quotas on publications or number of projects that go from A to B. Because particularly in a rural or regional setting, people come in and out of projects and they can’t always meet their own deadlines. It [KPIs] was also something that I was worried about coming into the role.. knowing that research takes a long time.” RTC 3.

Nonetheless, the health service ownership of the RTC roles and the absence of research key performance indicators, led the RTCs to lack clarity and focus particularly in the early phases of implementation:

“.. it was probably just finding that space, where was my time best invested, and what could I best achieve?.. I’m not saying I’m not doing lots of things, but in terms of an outcome or an aim.. I always felt like I wasn’t doing enough.” RTC 3.

To address the lack of clarity and focus, the RTCs negotiated with their employing health services, the types of activities and targets they would work toward, and in doing so, produced an activity reporting template. The lack of clarity was also addressed, to some extent, by the AHSC executive using their knowledge and understanding of the rural health services context to supplement the guidance from the health services for the RTCs. This guidance and support ensured that the broader strategic imperative remained central to the RTC program:

“I would go to [AHSC Executive] if I was like, ‘how should I approach this?’ Our strategies come really from [AHSC Executive]’s strategic work. So, we are only as effective as we are connected to that strategic side of things.” RTC 1.

The RTC program and role ownership by the health services meant the research agenda was shaped by rural health service executives and in response to the broader, dynamic health and socio-political context and priorities. With the support of the RTC, local rural health services were able to address their own emerging research and practice priorities:

“I don’t think that anyone in my health services is crying out for more research. I think they want the right research to be happening, and they want it to further their strategic aims, and, obviously, that’s for the best care for their population.” RTC 1.

The rural health service ownership of the RTC roles influenced the nature and outcomes of the roles in both positive and negative ways. Health service ownership introduced challenges related to the lack of clarity of the roles, how they function, and the expected outcomes, yet facilitated high level research engagement and leadership within the health services.

Region-wide implementation

Although employed primarily by one rural health service, the RTCs worked in a part-time capacity across a defined geographic sub-region. Each of the roles provided support to their primary rural health service, as well as a larger regional health service, and a private hospital within the geographic sub-region. Collectively the roles supported the primary health network, with its objectives of supporting translational activities across the entire region. Despite the staggered recruitment of the RTCs over seven months, they promptly established a team-based approach to their roles once they were all in-situ, and began to work collectively toward improving research capacity and culture across the whole region, as planned for the program:

“Then the biggest part from a support mechanism point of view, was that we weaved them into each other so that they were able to support each other and feel like they were working as a team.. there were two reasons for that: one, they were supported, and two, so that the work wasn’t isolated and duplicated. Knowing there are similar issues across the different regions, they eventually work on kind of strategies that were across the whole broader region rather than at their own little ones” AHSC Executive 2.

The health service CEOs also identified the need for the RTCs to be supported externally, and that the AHSC was well placed to provide this: “I think it works because of the wrap around support that those individuals get, and how they’re managed from a collective, and that they have peer support” Health Service CEO 2.

The RTCs shared experiences, information, expertise, and resources where possible, to solve problems common to the health services and region:

“[the RTC role] might have been more challenging if there was only one of the positions and no one else to compare notes with. But we’ve certainly had several occasions where there might be a challenge and then a person from another region can say, ‘oh, we’ve recently had a similar challenge, and this is how we navigated that.’” RTC 2.

Working across and being accountable to multiple geographically dispersed health organisations meant that the RTCs were often concerned with trying to meet the priorities of each organisation with limited time capacity related to their part-time employment:

“I think one of the challenges is really ensuring that each of the organisations receives appropriate value or benefit from the research translation coordinator position in the time fraction that’s available.” RTC 2.

Nonetheless, as a team, the RTCs collectively utilised their understanding of rural health service and clinicians’ capability building needs to contribute to the development and delivery of a region-wide research training program and resources (e.g. biostatistics support pathways), accessible by beneficial to all AHSC members:

“So that’s invaluable in terms of the insights of the RTCs’ health services to be involved in research in the first place, and their needs. I don’t think the research training program that we’ve put together would’ve worked in the same way or really been possible or effective, had [the RTCs] not been in their positions.” AHSC Executive 2.

The region-wide implementation and operationalisation of the RTC program meant that the RTCs worked together toward the shared goal of improving research capacity and culture in their primary health services and their geographic sub-regions. The program achieved more than the sum of its parts, enabled the development of infrastructure available to all AHSC members, and provided critical support to the RTCs.

Development of the rural embedded research translation coordinator role

Three key elements were identified as integral to the development of the rural RTC role which was designed to support region-wide research capacity development: Emerging and responsive to health service needs; Supporting the translation of research, and Engaging strategic partners.

Emerging and responsive to health service needs

The rural RTC program concept was initially born out of discussions between the AHSC executives and the CEOs (and Board Directors) of the member organisations. It was identified that the member health services, particularly the smaller rural ones, needed ‘on-the-ground’ support and infrastructure for clinicians who identified a problem or issue that could be addressed by using existing evidence or conducting research. These identified resource and support needs informed the implementation of the rural RTC program, which required a responsive and rural health service-focused approach:

“We’re really not here to be the researchers ourselves, for the most part.. One of the goals has been to build capability for the different member organisations for them to achieve their own research and translation goals and us facilitating that process.” RTC 2.

The initial implementation of the rural RTC program enabled significant flexibility of the roles and the program more broadly. The position descriptions for the rural RTCs were deliberately broad to allow for the roles to be shaped organically in response to the health service needs identified, and how best to direct/focus their initial and ongoing efforts:

“.. these roles build the relationships, which is important locally.. understanding the realities of what is happening within a health service as well and what is meaningful for it...” Health Service CEO 2.

The rural RTCs were linked with one of the two AHSC member universities, either informally, or through an adjunct role. These affiliations were advantageous, providing access to research infrastructure and support, and enabling the RTCs to keep abreast of research opportunities for their respective health services. With time and space to explore and understand the health service needs, the RTCs understood the capacity and priorities of the health service and in turn, adopted a gatekeeping role for the health service. They presented opportunities to their rural health services where they aligned with the evolving priorities and needs of their primary employing health service:

“We filter the opportunities that come to the health services.. that’s what they [the health services] wanted.. someone who knows what research is about to look at the opportunities and filter them through some kind of lens that says, ‘Are we interested in this? Would it be a good use of our time? Are there the signs of a good partnership?’ So, sometimes, the skill is knowing when to hold back a bit.” RTC 1.

To facilitate a more systematic filtering approach, the RTCs developed formal processes to analyse the alignment of research opportunities with health service priorities. These processes supported their function as gatekeepers and advocates for the health services, yet also facilitated important collaborations with potential partners:

“I set up a research proposal [template] so if someone wanted our health service to participate in their research, or even if one of our own staff wanted to do a research project, they would complete it. Some questions on there were about, how will this improve our research capacity for our staff? Being explicit about what they needed from us - did they need staff time? Were we just a name on a grant? What was it specifically that they were asking? Those research proposals then went to the research committee for consideration. Really, just trying to think, ‘does this make sense for our organisation? Does this make sense for our community? Would this be something that would be expected that we would participate in?’ If we’re not going to benefit directly, do we think that by participating it’s going to add to rural health, and therefore we’d be willing to spend our time?” RTC 3.

Even with systems in place, the gatekeeping role caused tension at times, particularly when the commitment and resources sought from the health services by potential academic partners were for research activities that did not represent priorities of the health services:

“.. one of the hardest parts of this role has been when they [RTCs] have a university pushing a particular project and they feel like they’re in a position where they should try and get the health services on board, but the health service isn’t ready. So there’s some tension around that.” AHSC Executive 2.

The rural RTC program was implemented in a way that enabled the roles to be responsive to the rural health service needs. This flexibility afforded the RTCs the opportunity to deeply understand the dynamic context and needs of their rural health services; there was some tension reconciling the differing priorities between various AHSC member organisations.

Supporting the translation of research

Promoting research activity to inform rural health practice and care delivery was a central agreed aim of the rural RTC program. The RTCs supported emerging clinician-researchers and teams conducting and translating research, and inspired clinicians new to research to get involved to varying depths and degrees. A health service CEO described such a case:

“[RTC] was there every step of the way, connecting the physiotherapists who’d never done research previously to other people that could help in terms of supports, mentoring, providing technical assistance.. without that support they wouldn’t have continued through very difficult circumstances. That [project] made a profound difference to that physiotherapist in terms of enhancing their job satisfaction, and also giving them an opportunity to explore other things.. Then we look at the results from that research.. it shows that the residents and the community members that participated saw a reduction in the swelling in their limbs as a result of the intervention.” Health Service CEO 2.

Other examples of translation-specific support and guidance were also provided by the RTCs, including membership of working groups to implement practice change on the back of locally led research:

“.. following completion of some research done locally, [rural health service] was the lead site for this research.. I was able to join a committee in that clinical domain which then I sat on as a research representative. I assisted them to implement some of the recommendations based on the results of this research. So they’ve been able to take one of the key recommendations, implement organisation wide practice change.. something that’s involved lots of different departments within the organisation but has ultimately been rolled out in a really effective way and we’re now sort of taking the next step in that translation process to actually conduct a follow-up audit so that we can evaluate the impact of this practice change.” RTC 2.

The RTCs generally inspired emerging researchers and “made research more accessible in terms of the language that is used and created a face for research.” (Health Service CEO 2). This was important for the employing health service CEOs, particularly for promoting a positive research culture and leveraging and enhancing existing quality improvement processes:

“[RTC]’s just part of that [Quality Improvement] group and hearing the ideas but also understanding where the opportunities are guides the conversation. It’s an informal group and I want it to be like that. I want staff to feel they can free think and it’s also putting it out there that [RTC] is accessible..” Health Service CEO 3.

The translation of research into rural health practice was supported and at times, driven by the RTCs in multiple ways including promoting place-based clinician-led research, participating on practice change committees, and leveraging existing quality improvement processes.

Engaging strategic partners

The rural RTCs were physically located in rural health services however, they were described as a conduit for research support and resources through their networks and connections with academic researchers. These networks were formed through the RTCs themselves and their existing relationships, through the mechanisms implemented by the AHSC, and through connections with other health service embedded researchers. Networks were largely across rural and regional settings, however the RTCs also fostered connections with metropolitan-based researchers. The RTCs worked individually and collaboratively as a team to strategically engage with partners and potential collaborators, and foster research-practice relationships that could be leveraged on behalf of their health services.

“So, if they [emerging clinician-researchers] need expertise, support to understand where funding buckets might be, and all those sorts of things. [RTC] is the one-stop shop who has created that local connection and has that expanded network of researchers and academics that [they] are working with, and [they are] obviously respected by [their networks] across Victoria and Australia. We wouldn’t have access that otherwise.” Health Service CEO 2.

The RTCs were aptly connected and alert to relevant funding opportunities. They utilised their expanding collective networks to connect clinicians and other staff at their health services with academic and other researchers, opportunities, and capability building initiatives to optimise the impact of their roles:

“.. the success of many of the projects or the goals relies on a successful network and relationships between organisations as well as within organisations. I think that is something that can really super-charge the value that you provide. Knowing how to best link different partners with key people and where and how to find them is definitely important.” RTC 2.

These strategic connections facilitated the establishment of collaborative research projects driven by health service or academic researchers and directly benefitted the rural health services:

“Part of the reason for the initiative was to have a smoother way for our universities and health services being able to work together.. rather than one cold-calling the other, there’s this link in between. Having the three positions there.. you’ve got an academic or a health service who have this great idea, and they’re pushing for a grant, they can quickly contact one of the RTCs, and they can have a discussion as to whether this would be useful for the health services.. the RTCs really advocate on behalf of the health services,”. AHSC Executive 2.

Further, these strong relationships led to grant submissions, including a large national research translation grant for a project to support home-based care in rural health settings and also bolstered the activities and reach of the rural RTC and other AHSC programs and research capability building initiatives:

“The success of the Research Translation Coordinator program was a major factor in us securing a $9 million grant for a program that actually enables us to expand the Research Translation Coordinator program. So, we’re now bringing on another RTC through the [large grant-funded] program.. we were one of three major grants allocated nationally this year...” AHSC Executive 1.

The collaborations between and beyond the rural RTC team led to the development of infrastructure, strategic relationships, successful grant submissions, and processes to optimise and utilise available supports. These outcomes benefited multiple partner organisations and members.

Types of outcomes of the rural embedded research translation coordinator program

The types of outcomes of the rural RTC program reported after the first three years can be categorised at four levels: Rural clinician-researcher-level; Rural RTC-level; Organisation-level, and Region-wide or AHSC-level. The types of outcomes reported by the three participant groups (RTCs, health service CEOs, and AHSC executives) via the three data collection methods (interviews, activity reports, and impact case studies) are summarised below (Table 2).

Table 2.

Types of outcomes of the rural research translation coordinator role

Short-term (within 12 months)	Medium-term (within 2 years)	Long-term (beyond 2 years)
Rural emerging clinician-researcher outcomes:	Rural emerging clinician-researcher outcomes:	Rural emerging clinician-researcher outcomes:
- Accessed research resources or opportunities - Accessed research capability building opportunities or support - Submitted conference abstracts - Submitted ethics applications - Narrowed and refined research idea - Led successful small/seed grant funding applications	- Led manuscript preparation and publication - Career progression (e.g., new role or enrolment in higher degree) - Led successful larger grant funding application	- Led manuscript preparation/publication - Career progression (e.g., new role or enrolment in higher degree) - Led successful grant funding applications
Rural RTC outcomes:	Rural RTC outcomes:	Rural RTC outcomes:
- Led or contributed to research outputs (manuscripts, conference presentations) - Achieved personal satisfaction or professional growth - Established new or expanded professional networks - Led successful grant funding application	- Achieved career progression (e.g., new role) - Co-investigator on successful grant funding application	- Achieved career progression (e.g., new role)
Organisation (health service) outcomes:	Organisation (health service) outcomes:	Organisation (health service) outcomes:
- Health service involved in research (leading or collaborating) - Rural health service-led research disseminated formally or informally - Established local research processes or systems - Submitted grant funding application (unsuccessful) - Research made “visible” within health service	- Supported health service decision-making (e.g., about resource allocation or research engagement) - Increased engagement of CEO/senior managers in research - Submitted grant funding application (successful)	- Perceived enhanced recruitment and retention of staff due to RTCs-supported activity - Perceived improvement in delivery of evidence-informed care due to RTCs-supported activity - Increased evidence-informed health service senior manager decision-making - Sustained research-practice partnerships and collaborations
Regional (academic health science centre) outcomes:	Regional (academic health science centre) outcomes:	Regional (academic health science centre) outcomes:
- Supported region-level research collaboration - Contributed to the development of a coordinated region-wide research training program - Developed region-wide research support and infrastructure (i.e., biostatistics support, research governance pathways)	- Supported successful region-wide large grant led by academic health science centre - Engaged in the ongoing development of AHSC research capability building and support programs and activities	- Supported successful AHSC accreditation bid

The relationship between the three themes is illustrated below in Figure 1.

Fig. 1.

Implementation, development and types of outcomes of the rural research translation coordinator role

Discussion

The nature of the rural health service RTC role was explored and identified as an emerging and evolving role, driven by and responsive to the needs of the employing rural health service. This deviates from other examples of embedded researcher roles, where the incumbents are either employed conjointly with a university [3], are held to more traditional academic key performance indicators [19], or are aligned with a particular project, program of research [1], or healthcare profession [21]. In these existing examples of embedded researcher programs, the key performance indicators are clearer from the outset. This program was developed in response to the identified need for support to conduct and translate research into practice, particularly in rural health settings [6, 30] where low levels of research infrastructure and resourcing were evident. The implementation of the program prioritised equity and collective capacity and capability building across multiple, otherwise operationally independent organisations. This strategic implementation approach meant the roles, although primarily focused on building the research capacity and capability in rural health settings, were simultaneously serving the broader region. In this sense, the rural RTC program was operationalised within a collectivist framework [31], and the RTCs navigated shared challenges and formulated solutions collectively [32]. This approach led to the development of both local (health service) and region-wide infrastructure including a coordinated research translation training program, specialist research support pathways, and other shared research resources.

Health service priority setting is essential to ensuring the efficient and effective use of resources, however formal and comprehensive priority setting is recognised as resource-intensive and time-consuming [33–35]. Moreover, priorities can shift rapidly in the health service context in response to socio-political and other factors beyond the realms of the immediate environment [36, 37]. Being embedded in, and therefore part of the health service, the researchers became trusted advocates for the health services. This enabled the research agenda and questions to be set by the health services rather than academic partners. Establishing the roles as health service owned facilitated a deeper level of engagement from senior or executive health service managers, who “championed” the program and the RTCs and facilitated ongoing health service priority identification. Where there was a sense of what Melville-Richards and colleagues describe as “convergence” [38 p. 530] of the current health service and potential partner priorities, these processes led to the progression of several collaborative initiatives, including research activity and grant submissions.

Nonetheless, the lack of structure around the program particularly in the early implementation was a source of discomfort for the RTCs, an experience common to embedded researchers studied previously [1, 12]. Research into the introduction of new nurse practitioner roles in a primary care setting revealed issues of complexity related to the clarity of the intention of the roles, involvement of team members in the implementation of the role and eventual acceptance by team members [39]. In the current study, the RTCs were aware of their accountability to the interests of their primary employing rural health service and were also positioned to support the endeavours of their strategic partners to ensure all member organisations benefitted from the program. At times, these accountabilities caused some tension for the RTCs particularly when they were called on to take on roles and tasks that they did not perceive as being directly aligned with the priorities of their health service or the intent of the program. Bowen et al. [13] study exploring senior health managers’ experience and perspectives of health organization-university research partnerships, also described some instances where there were “frustrating interactions” (p. 691) between senior health service staff and researchers. To some extent, the rural RTCs in the current case study shielded their health services from these types of interactions. The establishment of some structure and initial guidance for incoming RTCs should be considered a priority to optimise the roles, ensure appropriate boundaries are applied to their scope, and reduce the likelihood of frustrating or taxing encounters [17].

Building research capacity and culture in low resource settings, such as rural health services, is recognised as a challenge [5, 30, 40]. This case study demonstrates the embedding of a small team of researchers within rural health services who have pre-established linkages with larger regional health services and academic partners can be an effective way to promote equity across a large geographic region through a collectivist lens [31]. Despite the lack of explicit academic key performance indicators as drivers of measures of the role, the rural RTCs still achieved and supported traditional academic outputs including peer-reviewed written publications, conference presentations, and small and large grant funding. The link between research activity and engagement and improved delivery of care has been established in previous research [41, 42]. Importantly, in the current study, these research activities and outputs supported or led by the RTCs have enabled the dissemination of rural health research evidence which has influenced practice within and beyond the region. Moreover, these outputs, when attributed to the RTCs contribute to their ongoing researcher track record which may be important to these individuals for future career opportunities [43]. These and the other types of outcomes identified may be used to guide the development of impact measures for similar rural research capacity building initiatives.

Recommendations for rural embedded researcher programs and future research

Through this case study, we have developed several recommendations for organisations seeking to implement embedded researcher or similar research capability building initiatives in rural health contexts.

1. The autonomy and flexibility afforded to rural embedded researchers to explore and take action to meet health service research support and capacity building needs is key, while balancing a base level of program structure and role guidance from a program manager.

2. Commitment and tangible program support from a rural health service senior or executive level manager is central to the successful implementation and development of rural embedded researchers to ensure they meet health service needs.

3. Rural RTCs achieved different types of outcomes at four levels of influence; these outcome categories may guide the implementation and evaluation of other similar rural research capacity building programs and roles.

Future research is needed to better understand the interplay between the contextual factors, mechanisms, and outcomes, which could be achieved using realist methods. Deeper exploration into the networks established and drawn upon by the RTCs through a network analysis would also generate evidence needed to guide the development of rural research networks. Further, more attention to and funding for career pathways for rural embedded researchers is needed. Finally, investigation into the impacts of rural embedded researchers on rural population health outcomes is needed.

Strengths and limitations

This research is strengthened by the variety of data sources used to inform the case study, including different media (i.e., interviews, activity reports, and detailed impact case examples) and perspectives (i.e., health service CEOs, AHSC executives, and the RTCs). The case study is limited, however, by the absence of data from clinicians who have participated in RTC-supported activity. Although the RTCs described the outcomes achieved by the clinicians they supported, these data were not attained directly from the clinicians. The outcomes reported in this research are from the perspectives of the RTCs themselves, the AHSC executives, and the employing CEOs, and are not quantified or compared with baseline data. These outcomes, however, may serve to guide the development of quantifiable measures of impact for similar future programs. An alternative method of data collection such as focus groups may have yielded different data to the individual interviews, activity reports, and impact case studies; however, the risk of exposing participants to the power imbalances inherent in the three stakeholder groups was not justified.

Conclusions

This case study exemplifies an evolving, yet ostensibly successful rural RTC program implemented by an AHSC across a large regional area. The RTCs were primarily employed by and operationally accountable to a rural health service, while simultaneously supporting, serving, and collaborating with partner larger regional health services and universities. Representing a uniquely rural health-service driven embedded researcher program, it has operated within a collectivist framework and has led to different types of outcomes as these relate to the needs and priorities of the health services. The outcomes categories identified may serve as a framework for other similar programs to guide the implementation and evaluation of impact.

Abbreviations

AHSC

Academic Health Science Centre

CEO

Chief Executive Officer

FTE

Full Time Equivalent

KPI

Key Performance Indicators

MM

Modified Monash

RTC

Research Translation Coordinator

Biographies

Olivia A. King

(PhD) is Manager of Research Capability Building for Western Alliance, an Adjunct Research Associate with the Monash Centre for Scholarship in Health Education, and Affiliate Senior Lecturer with Deakin Rural Health.

Hannah Beks

(PhD) is a Research Fellow with Deakin Rural Health and funded by the Rural Health Multidisciplinary Training program (Australian Government).

Alison Beauchamp

(PhD) is Associate Professor in the School of Rural Health at Monash University.

Kevin Mc Namara

(PhD) is Deputy Director, Research at Deakin Rural Health (School of Medicine) and Stream Leader, Economics of Pharmacy at Deakin Health Economics (Centre for Population Health Research) and is funded by the Rural Health Multidisciplinary Training program (Australian Government).

Alesha M. Sayner

is Allied Health Research and Knowledge Translation Lead at Grampians Health and affiliate researcher with Deakin University (Deakin Rural Heath).

Emma West

is Program Officer of Capability Building for Western Alliance, and a scholarship holder with Deakin University.

Anna Wong Shee

(PhD) holds a conjoint appointment at Grampians Health and Deakin University (Deakin Rural Health) as Associate Professor of Allied health.

Authors’ contributions

OAK, HB, AB, KM, AS, EW, and AWS contributed to developing the research protocol and methodology. OAK, HB, and AB contributed to the data analysis. OAK drafted the manuscript, and all authors critically reviewed, contributed to, and approved the final version.

Funding

This study was funded by Western Alliance Academic Health Science Centre.

Data availability

Additional qualitative data collected and analysed as part of the current study are not publicly available due to ethical considerations and participant privacy. Data may be made available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethics approval was conferred by the Barwon Health Human Research Ethics Committee (Ref. 22/65). All methods were carried out in accordance with relevant guidelines and regulations. Informed consent was obtained from all participants.

Consent for publication

Not applicable.

Competing interests

OAK and AWS received funding from Western Alliance Academic Health Science Centre to undertake the research.