What is known about this topic?

Research suggests there is value in researchers and knowledge-users working together through a collaborative approach to research. Involving knowledge-users as equal partners alongside researchers has the potential to produce research that is more relevant, useable, and used. There is limited evidence for its effectiveness, uncertainty about the factors that influence integrated knowledge translation (IKT) processes, and how to conduct and support IKT in different contexts.

What does this paper add?

Research co-production using an IKT approach takes time, and resources, to engage knowledge-users, build trusting relationships, and ensure meaningful engagement throughout the research process. Barriers and facilitators influence research co-production activities, which, in turn, influences outcomes. Feedback is critical to success, and through stakeholder engagement, partnerships, group and communication processes, key information is available to address barriers and optimize IKT activities and outcomes. The diverse outcomes achieved using co-production influence not only the context of care, but also research partnerships, IKT processes, health system delivery, co-produced resources, and the quality and relevance of research itself.

Introduction

Integrated knowledge translation (IKT) involves the co-production of research knowledge with people who use it.1 IKT is a process where researchers and knowledge-users (e.g., patients, care providers, clinicians, policy-makers, health system leaders, community members and/or leaders) work in partnership to identify relevant problems, engage in the conduct of research, and have the authority or ability to implement the research recommendations.2,3 This process has the potential to increase the relevance, applicability and use of results of research to improve health service delivery and patient outcomes.3,4 IKT shares many similarities with other participatory research approaches such as participatory action research, research co-production, mode 2 research, engaged scholarship, community-based participatory research, and patient engagement.5 Research funders in Canada have encouraged the use of IKT approaches to accelerate the uptake of research findings.5

Knowledge-users are a category of stakeholders who have the ability to make decisions or take actions based on study findings (clinicians, managers, policy-makers, patients/families and others).3 Other stakeholders (governments, funders, researchers, health system managers and policy-makers, patients, and clinicians) may have an interest in the research, but would not directly act on the findings.1,3

Although research suggests there is value in researchers and knowledge-users working collaboratively,6,7 and there is emerging evidence of the benefits of a co-production approach, IKT is not widely understood.7 Nevertheless, more and more researchers are embracing partnered research as a more inclusive scientific approach that includes diverse input, but there is uncertainty about how best to conduct and support IKT, the factors determining effective IKT, and how researchers and knowledge-users should go about collaborating.2 More research is needed to understand how IKT processes function in different contexts and the factors that influence the achievement of best results.3,8

The Integrated Knowledge Translation Research Network (IKTRN), funded by a Canadian Institutes of Health Research 7-year foundation grant (https://iktrn.ohri.ca/), is focused on building the science base and capacity for IKT. Specifically, it aims to increase understanding of the barriers and drivers of IKT, determine its effectiveness at increasing research use, identify the best practices and appropriate conditions for conducting IKT, and how to support research co-production.9 To capture some of the experiential knowledge acquired through the process of research co-production, the IKTRN has issued calls inviting researchers and/or research teams to submit case studies describing their experiences using an IKT approach (https://iktrn.ohri.ca/projects/casebook/).

With research co-production, informal or tacit knowledge accumulates with experience and often relates to the mechanisms that make partnerships work (know-how), relational aspects influencing decision-making and change, and other experiential learnings (tips and tricks) that make partnering strategies work.10 Sharing informal experiential knowledge can contribute to the current theoretical and empirical published literature and be used to improve collaborative efforts, which could translate into greater impact upon application of the research findings.10

Casebooks are one way to do this.10 Casebooks are essentially collections of stories on a theme. They are intended to provide insights into real-world experiences (capture informal knowledge including challenges and benefits of working collaboratively) to create better understanding of phenomena, make knowledge more accessible to more audiences, and promote know-how about activities and impacts. This knowledge can then be used to build a theoretical understanding of how IKT is supposed to operate using real-world examples of IKT teams working in different contexts.9,10 Four IKT casebooks were published between 2019 and 2021 and were available for the metasynthesis. These included 35 cases describing how researchers partnered with knowledge-users, the challenges and benefits of these collaborations, and the perceived impact of working in this way.9,11–13 Many of the cases are co-authored by researchers and knowledge-users, and while some share the perspective of the researcher, others describe student or trainee experiences using a co-production approach.

Overall aim of the project

The aim of this project was to complete a metasynthesis of the IKTRN Casebook Series to date to identify the informal knowledge about how research co-production works in real-life settings.

Methods Theoretical framework

We used a modified realist review approach to guide the development of the coding template and the research questions for this metasynthesis. Realist review is a theory-driven synthesis methodology designed to explore complex programs,14 and increase understanding about “what works for whom, how, and in what circumstances.”15,16 Realist review methodology has been used to guide case study evaluations17–19 and fits with the purpose of this metasynthesis because it can help to identify effective co-production processes, the contextual factors, and the barriers and facilitators that influence co-production, and the resulting outcomes.

Study design – metasynthesis

This study used metasynthesis, a qualitative research design, to examine IKT case studies. Case study research enables the study of different phenomena in real-life settings.20,21 A metasynthesis of case studies does not reuse primary data from each case, but instead uses the insights that the original researchers of the primary studies constructed based on their own interpretation of the case.20Metasynthesis can be used to extend an existing theoretical perspective to a broader range of contextual conditions, refine existing theory or generate theory through the identification of new constructs or relationships.20 For the purposes of this project, metasynthesis was used to extend existing theoretical perspectives about how research co-production works. The metasynthesis involved seven iterative steps adapted from Noblit and Hare's framework for conducting qualitative synthesis (Table 1).22

Table 1 - Steps in the metasynthesis (based on Noblit and Hare's seven steps21,22) 1. Clarify the purpose of the metasynthesis and frame the research questions 2. Delineate the case studies included in the metasynthesis 3. Examine the case studies and extract and code data 4. Derive themes from the coded data 5. Determine the relationship of the themes to IKT 6. Synthesize the concepts as overarching lessons learned/key messages 7. Build theory from the metasynthesis

To support this project, we established an advisory group (A.K., I.D.G., C.M., J.R., S.I.D., D.K.B.) with expertise in IKT and metasynthesis methodology. The advisory group was engaged throughout the metasynthesis to review the coding template, the themes generated, the interpretation of the results and the theoretical framework generated.

Step 1: Clarify the purpose of the metasynthesis and frame the research questions

The purpose of this metasynthesis was to increase understanding about how IKT works, for whom, how, and in what circumstances. The specific research questions were:

1. What contextual factors and processes facilitated use of an IKT approach for research co-production? 2. What were the barriers and challenges to using an IKT approach for research co-production? 3. What IKT activities were used to increase the likelihood of successful research co-production? 4. What outputs and outcomes resulted from using an IKT approach to research co-production? Step 2: Delineate the case studies included in the metasynthesis

The focus of this synthesis involved case studies published from 2019–2021 in the IKTRN IKT Casebook series. We included all case studies published in Casebooks 1–4 and only reviewed the information described in each case study for the metasynthesis. We did not appraise the quality of the written case studies or the quality of the research project described. A total of 35 cases was reviewed. This census sampling approach enabled the analysis of diverse health-related case studies describing the IKT approaches used for each project. The case studies provided insights from international, national, and regional research projects for the metasynthesis.

Findings Step 3: Examine the case studies and extracted and coded data

We developed and piloted a customized data extraction form to obtain basic characteristics of the included case studies. Two researchers (S.I.D., D.K.B.) extracted the descriptive data for each case study. Of the 35 cases reviewed, seven involved international collaboration, 10 focused on national or provincial initiatives, and 18 focused on institution-based or regional projects. Twelve of the 35 cases involved student/trainee projects. The cases covered a variety of topics and focused on diverse areas of research (e.g., acute care, primary healthcare, community care/public health, education/research, family integrated care, industry collaboration, global health) (Tables 2 and 3).

Casebook Lead editor/year Number of cases 1 McCutcheon et al./2019 (9) 12 2 Kothari et al./2020 (12) 7 3 Boland et al./2020 (11) 6 4 McCutcheon et al./2021 (13) 10 Total 35 Type of cases International collaboration 7 National/provincial 10 Institution-based/regional 18 Student/trainee 12
Table 3 - Case study descriptions Authors Title Casebook Context Theme Focus 1. Nadia Y. Bashir, Julia E. Moore, Marcello Tonelli, Rachel Rodin, Sharon E. Straus Integrating evidence-based methods and knowledge user perspectives into guideline development and implementation 1 Primary care Guideline development and implementation International Collaboration 2. Wasifa Zarin, Inthuja Selvaratnam, Alison M. Hoens, Annette McKinnon, Linda Wilhelm, Cheryl L. Koehn, Priscille-Nice Sanon, Kim Critchley, Sharon E. Straus, Andrea C. Tricco Integrated alliance of knowledge users and researchers to develop a grant proposal 1 Education/research Rapid learning health system International Collaboration 3. Katrina M Plamondon, Lydia Kapiriri, on behalf of the Canadian Coalition for Global Health Research's Gathering Perspectives studies research teams Dialogue as a catalyst for equity-centered research: The Canadian Coalition for Global Health Research's Gathering Perspectives studies 2 Global health Equity-centered research International Collaboration 4. Ilja Ormel, Susan Law Piloting co-design in a humanitarian setting: new insights and lessons learned – the importance of cultural and contextual adaptation 3 Community care Humanitarian assistance after crises such as earthquakes and disease outbreaks International Collaboration
Student/Trainee . A partnership to foster knowledge translation in Norwegian nursing homes 4 Community care Norwegian nursing homes International Collaboration 6. Vyshnave Jeyabalan, Elysée Nouvet, Patrick Meier, Lorie Donelle Working with WeRobotics, a not-for-profit organization, to guide and co-develop a master's level research project 4 Industry collaboration Drones International Collaboration
Student/Trainee 7. Femke Hoekstra, Rhyann C. McKay, Heather L. Gainforth A trainee perspective on an integrated knowledge translation approach to developing the first Integrated Knowledge Translation Guiding Principles for the spinal cord injury research system 4 Acute care IKT guiding principles for a spinal cord injury research system International Collaboration
Student/Trainee 8. Ashleigh Townley, Cristine Provvidencza, Shauna Kingsnorth Pain, Pain, Go Away: Co-creation of a toolbox to standardize pain assessment 1 Acute care Pain assessment Provincial 9. Laura Boland, Allyson Shephard, Margaret Lawson Implementing Shared Decision-Making in Pediatrics: Spotlight on Integrated Knowledge Translation 1 Acute care Shared decision making Provincial 10. Heather L. Gainforth, Peter Athanasopoulos, Sheila Casemore, Amy E. Latimer-Cheung, Kathleen A. Martin Ginis Using IKT to Translate the Spinal Cord Injury Physical Activity Guidelines in A Community-Based Organization 1 Community care Spinal cord injury guidelines Provincial 11. Nicole Letourneau, Carlene Donnelly, Michelle Gagnon, Martha Hart, Lubna Anis University of Calgary; Calgary Urban Project Society; Palix Foundation The Attachment and Child Health (ATTACH) integrated knowledge translation project 2 Community care Attachment and child health (ATTACH) Provincial 12. Sandra Dunn, Jessica Reszel, Deborah Weiss, Ian D Graham, Ann E Sprague, Mark Walker, on behalf of the Maternal Newborn Dashboard team The experience of using an integrated knowledge translation approach to develop, implement and evaluate an audit and feedback system in Ontario maternal-newborn hospitals 2 Acute care Audit and feedback Provincial 13. Nedra Peter, Anita Kothari, Nancy Murray, Ruta Valaitis, on behalf of the “Does Early Engagement of Knowledge Users Support Uptake of Strategies for Local Health Integration Networks and Public Health Agencies Collaboration?” research team Does early engagement of knowledge users support uptake of research findings in a dynamic health environment? An integrated knowledge translation case 3 Public health/primary care Early engagement of knowledge users in a dynamic health environment Provincial
Student/Trainee 14. Melisssa Brouwers on behalf of the Ottawa Collaborative Team Ottawa Public Health (OPH) and School of Epidemiology and Public Health (SEPH) Collaborative: The Ottawa Collaborative 4 Public health/education Public health and epidemiology collaborative Provincial 15. Jessica Reszel, Ann E Sprague, Elizabeth K Darling, on behalf of the Ontario Birth Centre Demonstration project evaluation team An integrated knowledge translation approach to evaluate the first year of operations of two new freestanding, midwifery-led birth centers in Ontario 4 Community care – birth centers Birth Centre evaluation Provincial 16. Karmon E Helmle, Glenda E Moore, Leta C Philp, Rhonda L Roedler, Julie McKeen Be the change: The journey to improve inpatient diabetes care across Alberta 4 Acute care Diabetes care Provincial 17. Deborah A McNeil, Karen M Benzies, Pilar Zanoni, Jana Kurilova Alberta Family Integrated Care (FICare): From engaged clinicians in a cluster randomized controlled trial to health system partnership in scale and spread across a province 4 Family Integrated care Alberta Family Integrated Care Provincial 18. Janet Jull, Audrey Giles, Yvonne Boyer, Dawn Stacey, Minawashin Lodge Development of a collaborative research framework to foster IKT: the example of a study conducted by and with a First Nations, Inuit and Métis community and their academic research partners 1 Community care First Nations, Inuit, and Metis research collaboration Institution-based / Regional 19. Tram Nguyen, Julia Hanes, Debra Stewart, Sue Baptiste, Jan Willem Gorter Using an IKT approach in working with university students with and without disabilities to build capacity for supports through engagement and co-creation in disability research 1 Education Disability research Institution-based / Regional
Student/Trainee 20. Shannon L. Sibbald, Jennifer Y. Verma, Graeme Rocker An INSPIRED Story: How Integrated Knowledge Translation is helping patients with complex chronic needs 1 Community care Patients with complex chronic needs – INSPIRED COPD Outreach Program Institution-based / Regional 21. Monika Kastner, Leigh Hayden, Julie Makarski, Yonda Lai, Nate Gerber, Anu Jhajj, Joyce Chan, Victoria Treister, Sharon Straus Development of a multichronic disease tool (KeepWell) to support the self-management of older adults and the clinical decision-making of providers: an IKT example 1 Community care Multichronic disease tool (KeepWell) Institution-based / Regional 22. Sara Kreindler Scaling Up IKT? Adapting Integrated KT Strategies to a Large Multijurisdictional Network 1 Acute care Scaling up IKT for health system redesign to address ER congestion Institution-based / Regional 23. Christine Cassidy, Laura Foley, Mary-Beth Rowe, Shauna Best, Janet Curran Fostering an Academic-Clinical Partnership to Redesign Care on a Pediatric Inpatient Unit 1 Acute care Redesign care on a pediatric inpatient unit Institution-based / Regional
Student/Trainee 24. Erin Coates, Paul Hasselback From Coalition to Action Plan: Addressing Malnutrition in Older Adults through IKT 1 Community care Malnutrition in older adults Institution-based / Regional
Student/Trainee 25. Wendy Gifford, Della Adams, Eddie Gray, Amber Montour, Vivianne Grandpierre, Roanne Thomas Developing and implementing culturally safe cancer survivorship strategies with First Nations peoples 2 Community care Culturally safe cancer survivorship with First Nations Institution-based / Regional 26. Davina J Banner, Ian D Graham, Marc Bains, Sandra Carroll, Shawn Aaron, Jeffery Healey, Duncan Stewart, Anthony Tang, Mary Runte, Colleen McGavin, Damanpreet K Kandola Ready to go: Using an integrated knowledge translation approach to support the development of a funding application to explore patient engagement in Canadian circulatory and respiratory diseases research 2 Acute care Patient engagement in Canadian circulatory and respiratory diseases research Institution-based / Regional 27. Julia C Poole, Dennis Pusch, Keith S Dobson, Nicole Sherren, Michelle Gagnon, June Bergman Using an integrated knowledge translation approach to better understand the impacts of adverse childhood experiences among adult primary care patients: The EmbrACE Study 2 Community health/primary care Impacts of adverse childhood experiences among adult primary care patients (EmbrACE) Institution-based / Regional 28. Krystina B Lewis, Dawn Stacey, Sandra L Carroll, David Birnie, for the ICD replacement patient decision aid study team Development of a patient decision aid to accept or decline implantable cardioverter-defibrillator replacement: An example of integrated knowledge translation in PhD research 2 Acute care Patient decision aid for cardioverter defibrillator replacement Institution-based / Regional
Student/Trainee 29. Emily R Ramage, Meredith Burke, Margaret Galloway, Heidi Janssen, Elizabeth A Lynch, Dianne L Marsden, Amanda J Patterson, Catherine M Said, Coralie English An integrated knowledge translation approach to co-design a complex exercise intervention for stroke survivors: A case report 3 Community care Co-design of a complex exercise intervention for stroke survivors Institution-based / Regional
Student/Trainee 30. Laura Boland A doctoral student perspective about using integrated knowledge translation to evaluate a pediatric shared decision-making program 3 Acute care Pediatric shared decision making Institution-based / Regional
Student/Trainee 31. Aislinn Conway, Maura Dowling, Aine Binchy, Jane Grosvenor, Margart Coohill, Deirdre Naughton, Jean James, Declan Devane Working together towards impact: An integrated knowledge translation initiative aimed at health-care providers 3 Acute care/education Evidence rounds – an IKT initiative aimed at health care providers Institution-based / Regional
Student/Trainee 32. Celia Laur, Donna Butterworth, Roseann Nasser, Marilee Stickles-White, Mei Tom, Heather Keller Working with hospital teams to treat food as medicine 3 Acute care IKT support to the sustainable intervention to treat malnutrition in hospitals Institution-based / Regional
Student/Trainee 33. Brianne Wood, Erin Cameron, Christopher Mushquash, Kelly Meservia-Collins, Jessica Logozzo Mobilizing an integrated knowledge translation collaboration during COVID-19 in Northwestern Ontario 4 Community health IKT collaboration in Northwestern Ontario Institution-based / Regional 34. Jasmin K. Ma, Smruthi O. Ramachandran, Alison M. Hoens, Shanon McQuitty, Louella Sequeira, Jon A. Collins, Karen Tsui, Eileen Davidson, Sadiq Jiwa, Cheryl Koehn, Linda C. Li Co-developing strength-training behaviour change interventions for people with rheumatoid arthritis 4 Community care Strength-training behaviour change interventions for rheumatoid arthritis Institution-based / Regional 35. Dawn Stacey, Claire Ludwig Evaluating implementation of COSTaRS symptom practice guides using an integrated knowledge translation approach across studies 4 Primary care/Cancer care Implementation of COSTaRS symptom practice guidelines Institution-based / Regional

Table 4 summarizes the roles and expertise represented in the IKT research teams across the cases (roles/expertise related to the setting, research expertise, and special expertise). Membership inclusion varied depending on the focus of the project.

Table 4 - Who was involved? What expertise did they bring? Knowledge user expertise or role related to setting Researcher expertise Special expertise • Administrative expertise and support
• Leadership support
• Decision-maker
• Employed or embedded in setting
• Family advisory
• Bring lived experience of patients, children and families
• Site champion
• Implementation team lead
• Implementation team member • Academic – research expertise
• Clinical scientist
• Research-Project Coordinator
• Scale and spread committee
• Student-IKT Trainee • Clinical expertise
• Community advocacy
• Design and e-health technology expertise
• Funders
• Government
• Health services expertise
• Human factors engineering
• KT or IKT expertise
• Patient engagement expertise
• Public policy expertise
• Thought leaders

Appendix I, https://links.lww.com/IJEBH/A124 provides examples of activities that researchers and knowledge-users worked on together throughout the research process. Involvement in the research process varied from case to case and ranged from full shared involvement throughout all stages of the project to limited or intermittent involvement in specific aspects of the research (e.g., consultation about context, facilitating recruitment, co-producing the implementation strategy/intervention, assisting with dissemination of results).

Conceptual framework and coding template

In consultation with the IKTRN Advisory Group, we created a conceptual framework for the study based on the realist review domains of context, processes, and outcomes. We then created a coding template listing items within these domains identified as relevant to IKT from existing literature18,19,23,24 (Table 5).

Table 5 - Coding template Context Processes Outcomes Inner + outer context (macro, meso, micro) How did the case evolve over time? What impact did they have? Communication infrastructure Engagement/communication processes What outputs produced? Barriers identified – how neutralized Contribution of each member to research process How were outputs used? Facilitators that enabled success How did they build relationships (group – forming, storming, norming, performing)? What changed as a result of use of outputs? Leadership style (command and control versus facilitative) Implementation strategies and approaches What would they do differently next time? Type of networks (tighter less penetrable versus looser/more open) What issues/challenges did they face and how was it solved? Limitations in their study/project Who was involved - What did they bring to the relationship? Evaluations (internal/external) Roles (e.g., leadership, boundary spanning/implementation, academic, clinical academic, patient & public involvement (PPI)) Lessons learned about IKT processes Presence of boundary spanners (e.g. organizational, epistemic, semantic, professional, geographic) What IKT activities did they use to co-create? Boundary spanner role (knowledge broker, facilitator) Tailoring and/or adaptation

The 35 cases published in the four IKTRN casebooks were uploaded to NVIVO (QRS International-Release-1.5.1 for Mac). Two researchers (S.I.D., D.K.B.) independently reviewed the cases from two different casebooks each (S.I.D. – Casebooks 1 and 2; D.K.B. – Casebooks 3 and 4), and reviewed and confirmed the coding of the cases from the other two casebooks (S.I.D. – Casebooks 3 and 4; D.K.B. – Casebooks 1 and 2). Questions and discrepancies related to the initial coding were resolved through discussion at biweekly meetings and via e-mail. We then classified items within each domain to identify codes where abundant data were available, codes where limited data were found, and codes where there were no data available in the published case studies (Table 6).

Table 6 - What works, for whom, how, why and in what circumstances + relevant codes What works For whom How Why In what circumstances What IKT activities did they use to co-create?a Who was involved – What did they bring to the relationship?a How did the case evolved over time?b Barriers + issues/challenges faced + lessons learned (challenges of the IKT processes)a Inner + outer context (macro, meso, micro)a Facilitators + lessons learned (strategies that increased likelihood of success)a Contribution of each member to research processa Engagement/communication processesb Lessons learned (benefits of the IKT processa Communication infrastructureb What outputs produced?a Roles (e.g., leadership, boundary spanning / implementation, academic, clinical academic, patient & public involvement (PPI))b How did they build relationships?b Evaluations (internal/external)b Leadership style (command and control versus facilitative)b What impact did they have?a Presence of boundary spanners (e.g. organizational, epistemic, semantic, professional, geographic)c How were outputs used?b Limitations in their study/projectb Type of networks (tighter/ less penetrable versus looser/more open)b Implementation strategies and approachesb Boundary spanner role (knowledge broker, facilitator)c