“Between Two Worlds”: Healthcare Decision-maker Engagement with Regional Training Centres

Abstract

The engagement between Regional Training Centres (RTCs) and healthcare decision-makers within the context of Applied Health and Nursing Services Research (AHNSR) takes many forms, and is critical to the development of the next generation of researchers. Such engagement supports the concept of linkage and exchange by inculcating in students and healthcare decision-makers alike an understanding of and respect for each other's worlds. This process builds bridges of immense importance to contemporary healthcare. The authors of this paper discuss the rationale for such engagement and describe the varied types of interaction between students and faculty with healthcare decision-makers and organizations. Bridging these two worlds for mutual advantage represents an innovative and highly successful strategy for graduate education in AHNSR. While this effort is not without challenges, the work of each world is relevant and valuable to the other and to the Canadian public.

Key messages

• The two worlds of graduate education in applied health services and nursing research and healthcare decision-making can be successfully bridged for mutual benefit by the active engagement of healthcare decision-makers in training activities.

• The engagement between these two worlds requires clear vision, mutual understanding of context and mutual respect.

• Successful engagement depends upon sustained nurturing and financial support.

A key requirement of the Canadian Health Services Research Foundation's (CHSRF) call for Regional Training Centre (RTC) proposals (Conrad 2008) was an explicit discussion of how healthcare decision-makers (DMs) could be engaged in applied health services and nursing research capacity building. The need for engagement was based on CHSRF's conception of, and emphasis on, linkage and exchange (Lomas 1993) as a response to the divide between the worlds of healthcare researchers and decision-makers. The “two worlds” view, not unlike that of C.P. Snow's “two cultures” of art and science some 60 years ago (Snow 1959), saw both academic researchers and healthcare decision-makers as wary of, if not hostile to, each other's motives, activities and influence over management and policy decisions. RTCs were mandated to engage with DMs to develop experiences that would allow both worlds the opportunity to escape perceived dysfunctional views of “the other” through linkage and exchange in various contexts. To the greatest extent possible, RTCs were organized so that students and DMs would “walk in each other's shoes.”

As this rapprochement was to occur within university-based training centres, one challenge was not only to shift student thinking (relatively easy), but also to shift university thinking (less easy). While there is much rhetoric in contemporary university mission statements regarding the importance of linkages with the wider world, most of this activity remains predominantly on the university's terms. Thus, the RTCs' challenge in bridging these two worlds was to create opportunities for substantive engagement between students and DMs through as many different activities and contexts as possible. This paper tells the story of how DM engagement has been achieved.

Types of Engagement

The engagement of students with DMs can take many forms, including participating in seminars, courses, workshops, institutes, conferences; facilitating the enrolment of DMs in educational training (e.g., the EXTRA Program; see Conrad 2008) or degree programs; participating on admission, advisory or planning committees; and supervising students from academe DM settings (field placements, practica, residencies). Each of these types of engagement is used, in varying degrees, by the RTCs to achieve not only linkage and exchange of ideas but also to gain a basic sense of healthcare decision-making dynamics and to utilize the DMs' wisdom and experience. Of critical importance is the fact that insight and sense making (Weick et al. 1999) involve active participation of students and DMs.

DM involvement in seminars, courses and conferences is, conceptually, not a big stretch in contemporary graduate education. However, active student participation within DM settings has until recently been a greater challenge, given an isolationist view that sought to protect students from the distractions of the “real world.” Although exceptions to this general rule have existed for many years (e.g., professional training in such fields as medicine, nursing and engineering), engagement of students outside the university, particularly at the graduate level, has been a recent phenomenon. In 1936, Antioch College in Ohio was one of the first (if not the first) undergraduate institutions to make cooperative experience credit a requirement for graduation. Such a formal requirement for most graduate students is still uncommon, although “working in the lab” in the basic sciences is a comparable experience. However, because the “lab” was typically located on campus, this experience did not fully engage students with the world beyond the academy. Thus, experiential, non–university-based learning as a requirement for graduation from academic doctoral programs (and to a lesser extent, master's programs) is new and, indeed, innovative.

RTCs have spearheaded this innovation, and have actualized as well as expanded the notion of linkage and exchange beyond the realm of ideas and debate to a fully integrated practical experience in DM contexts. Such experiences, of course, are highly relevant to applied health and nursing services, as well as to policy research. In this multidisciplinary endeavour, context is everything, and understanding context (competing pressures, values and options for action in the realm of healthcare operations and other socially important activities) is critical. Not to require structured engagement with DMs in the training of students in healthcare services and policy research training would, in our view, be a severe dereliction of duty both to students and to society.

RTC Engagement

Each of four RTCs has put the ideas enunciated above into action. Each was asked to describe some types of engagement with DMs. Together, these descriptions provide examples of the breadth of DM engagement, a number of which are common across sites (see Brachman et al. 2008) as a core objective in the training of graduate students.

Western Regional Training Centre

The WRTC has involved DMs in seminars, courses and institutes as experts providing field perspectives and experience on a wide variety of topics. Moreover, the institutes – held in conjunction with either the Manitoba Centre for Health Policy's (MCHP) Rural and Northern Research Day or the Centre for Health Services and Policy Research's (CHSPR) annual conference – bring together students, researchers and DMs to discuss policy issues or review and explore the meaning and implications of specific data sets. In Manitoba, DMs include Regional Health Authority board members as well as managers, an added dimension of DM interaction given that RHA board members are often not clinical or managerial professionals. Thus, watching them grapple with healthcare data can provide insights into how the general public might perceive the issues discussed. In addition, the WRTC has co-sponsored both a CIHR Summer Institute (for 60 students from across the country) held in June 2004, at which more than half the presenters were DMs, as well as a CHSRF Research Use Week, held in Prince George in 2006.

While these activities, as well as Centre governance, are critical for understanding DMs' perspectives on a variety of special topics, and demonstrate how researchers and decision-makers might collaborate, they do not have as powerful an effect on students as the field placement does. The field placement is the WRTC's key process for student–DM engagement. The core task is the student project, which must be one of high priority to the organization. Project objectives and deliverables, issues of confidentiality and intellectual property, use of the project data, support (e.g., space, computers, etc.), remuneration (virtually all field placement organizations have provided funding) and field placement time frames are described in a field placement agreement signed by the student, the field placement supervisor and WRTC.

After initial contact with the field placement site, meetings occur prior to the start date (within two weeks of starting) to confirm that all is well, then again at mid-term and at the end for evaluation. Evaluation comprises questions regarding the student's performance (“exceeded,” “met” or “did not meet” expectations) as well as narrative comments from and signed by the field placement supervisor, the student and the WRTC. Two important aspects of this experience are (a) an initial period of job shadowing to understand the roles of key decision-makers within the organization and (b) students' participation in meetings and other decision-making activities (relevant to their project). Both aspects provide insights into the personal and organizational dynamics of decision-making within the DM context. Of importance is the fact that the field placement is often a source of ongoing work on a contract or permanent basis (post-degree); in some instances, new positions have been created specifically to take advantage of students' skills and their field placement experience within the organization.

Ontario Training Centre

In addition to completing a 200 hour field placement in policy settings, OTC students are required to attend 2 Summer Institutes.

The Summer Institutes, which are an important educational activity of the OTC, are used to highlight DM engagement and encourage students to learn to collaborate with DMs on matters ranging from issue identification to policy analysis to research dissemination. Consistent with this objective, the OTC engages DMs – from governments, health services planning bodies and healthcare agencies – as much as possible in various Summer Institute activities. The annual Summer Institutes are intensive, weeklong events that give OTC students an opportunity to examine selected healthcare topics in depth and to learn from and exchange ideas with academic and DM experts.

Each of the six participating OTC universities takes turns hosting a Summer Institute. To date, four have been held: Research and Policy Implications of Delivering Mental Health Services in Rural and Northern Parts of Ontario (Lakehead University, 2004); Health Human Resources Research and Policy: A Focus on Rural and Northern Issues (Laurentian University, 2005); Women's Health in Research, Policy and Services: Challenges for the Future (York University, 2006) and Regionalization of Health Services in Terms of Planning, Funding and Delivery (McMaster University, 2007).

Critical to the success of the Summer Institutes has been active DM involvement. For example, all four Summer Institutes involved DMs on planning committees or as advisers, who contributed to the formulation of institute learning objectives; identification of topics, speakers and reading material; and, in many instances, financial co-sponsorship. In addition, DMs were invited as keynote speakers or presenters who shared with students their organization's stance on a given issue. For instance, the 2005 Summer Institute had speakers from key DM organizations, such as the Ontario Ministry of Health and Long-Term Care and Health Canada, thus adding a policy perspective to decision-maker engagement. Some DMs also played a mentoring role in guiding student discussions and providing information and insights that might not be available from conventional research literature.

Student assignments (in the form of letters of intent for a research granting agency) were assessed on the basis of a set of criteria that included the significance of the proposed research for DMs and the involvement of DMs as partners in the research. Lastly, some DMs offered to host site visits to their institutions. In the 2004 Summer Institute, students visited various mental health agencies (e.g., a mental health client advocacy group) and Aboriginal health centres as part of their learning process. Interestingly, in addition to their own participation, some DMs sent some of their staff to the Summer Institutes as students. For example, several senior policy analysts of the Ontario Ministry of Health and Long-Term Care and Health Canada enrolled in the 2005 Summer Institute. Their participation helped enrich the learning experience of their fellow students by bringing the perspectives of DMs to bear on a variety of issues.

Decision-makers have played an important role and contributed significantly to the success of the OTC Summer Institutes. Without their participation in various capacities, the students' learning experience would not have been as rich, comprehensive and policy-relevant.

Centre FERASI

The Centre FERASI engages DMs to provide appropriate training to nursing administration researchers and, in the long term, foster a renewal of nursing administration practices. DMs from healthcare organizations are key partners involved in the governance of FERASI (e.g., board, executive committee), critically influencing the orientation of this RTC. They are involved with master's and doctoral students in different ways.

DMs contribute 50% of the scholarship funding for doctoral students and are paired with them as mentors over a four-year period. Significantly, DMs collaborate with the student and academic supervisors at the earliest stage in developing a research protocol that is based on common interests and is of high priority to the organization. The DMs also provide support by accepting doctoral students as residents within their organizations throughout the doctoral candidates' studies. These residencies are designed to foster integration of doctoral students into healthcare organizations from the outset, in order to develop research competencies and knowledge transfer capacity with the goal of enriching the organization's research culture. This fully integrated practical experience is a significant innovation in nursing education that has been highly successful (Centre FERASI 2005). DMs are enthusiastic about student participation in and contribution to their organization because students play critical roles in supporting knowledge transfer and promoting the use of research-informed evidence in decision-making.

For master's students, DMs spend two years providing a milieu for students' research project and helping them develop a better understanding of the organizational culture and context. This becomes an opportunity for knowledge transfer to students and establishes a tangible link between research and field work. In addition to their engagement with individual students, DMs are involved in various learning activities such as key speakers at FERASI seminars. For example, in 2007, FERASI organized a colloquium, Informed Nursing Services Administration Saves Lives, at which DMs, EXTRA Fellows (see Conrad 2008) and students collaborated in presenting research projects. Finally, DMs take part in knowledge transfer activities with master's and doctoral students, as well as academic supervisors, by working together on specific committees within their organizations or as co-authors on papers and conference presentations based on students' research projects.

Centre FERASI is committed to meeting the difficult challenge of establishing a critical link between the academic community and practice settings. The student–DM partner–academic supervisor triad provides many formal and informal opportunities for knowledge exchange. Thus, real solutions to real problems are developed in the very context from which they emerged.

Atlantic Regional Training Centre

While the involvement of DMs is integral to the ARTC's master's and doctoral programs, a unique feature is the involvement in ARTC governance of deputy ministers of health from all four Atlantic Region provinces. Such involvement provides a very high level of engagement, facilitating not only provincial awareness of ARTC activities to ensure their relevance but also helping to ensure the Centre's future sustainability. decision-makers also act as mentors and advisers to students in the program. The planned curriculum for the ARTC program includes a mandatory residency placement with a Decision-maker organization, for which students receive academic credit. The residency enables ARTC students to spend four months working on research projects to inform health policy and/or healthcare decision-making. These projects are determined based on the mutual interests of the student and the decision-maker agency, and are designed to meet a high-priority need in that agency.

The primary goals of the residency are (1) to facilitate interaction among DMs, researchers and graduate students, (2) to consolidate students' learning about knowledge transfer and dissemination of research and (3) to illustrate to students how evidence is used in decision-making. The development of residency opportunities is the responsibility of the ARTC principal at each of the four participating universities. Student supervision involves host organization preceptors and an ARTC principal. The principal is also responsible for orienting the preceptor at the residency site. Once on-site, the preceptor is then responsible for providing regular feedback to the student and a formal evaluation at the end of the residency. While on placement, students have the opportunity to attend decision-making meetings at their host agency.

DMs also play a key role in the theme-based workshops that are held twice a year as part of the ARTC program. Many of the workshop participants have been EXTRA Fellows who are able to share their expertise as DMs. These workshops are an opportunity to bridge theory and practice, allowing students to hear panel presentations by DMs and to interact with them on a one-on-one basis. Such meetings generally occur informally, during coffee breaks and at dinnertime. In recent years, panel discussion themes have included “Addressing Wait List Times in the Healthcare System” and “How Your Research Has Influenced Policy and Decision-making.” The Fall Workshop is held in Halifax at the end of the first term with both first- and second-year students. The Winter Workshop, on policy and decision-making, is held in St. John's for first-year students only. It is during this workshop that students have their first exposure to decision-makers from various settings, including deputy ministers involved in ARTC governance, and an opportunity to hear these people speak about the role that research plays across the spectrum of health decision-making.

Lessons Learned

• Decision-makers, despite being extremely busy individuals, enjoy working with students committed to understanding the challenges of the DM context.

• RTC students gain enormous insight from interaction with DMs regarding the application of evidence and the dynamics of using evidence to inform healthcare services and policy decisions.

• The RTCs have found it easy to engage DMs in training activities when these are based on mutual respect, a clear rationale and a focus on active learning and exchange.

Conclusion

Engagement with DMs is clearly a high priority for RTCs; thus, they have successfully carried out their mandate from CHSRF. The engagement is continuous, takes a number of key forms that vary across RTC sites, and reflects an emphasis not only on learning from DM experience but, perhaps more importantly, working closely with them – in effect, closing the loop essential for effective linkage and exchange (Denis and Lomas 2003; Huberman 1987; Lavis et al. 2003). As noted by Graham et al. (2006), knowledge transfer and translation is an active, indeed interactive process, bridging quite different cultures and perspectives. The challenge for the student and DM is the ability to acknowledge and understand these cultural differences. The challenge for the RTCs is to provide a meeting ground based on mutual respect and to facilitate shared learning.

Applied nursing and health services research applies research methods to critical questions regarding health services provision and policy choices. Thus, DM engagement requires understanding the DM world and the choice-making process, and is critical for effective communication and learning. The RTCs have championed a knowledge-to-action process by “making it real” to both DMs and students – to their mutual benefit, and to the ultimate benefit of public health and of individual users of the healthcare system.