BMJ  2004;328:1174 (15 May), doi:10.1136/bmj.328.7449.1174

Information in practice

Soft networks for bridging the gap between research and practice: illuminative evaluation of CHAIN

¹ Department of Primary Health Care, University College London, London N19 5LW

Abstract

Objectives To explore the process of knowledge exchange in an informal email network for evidence based health care, to illuminate the value of the service and its critical success factors, and to identify areas for improvement.

Design Illuminative evaluation.

Setting Targeted email and networking service for UK healthcare practitioners and researchers.

Participants 2800 members of a networking service.

Main outcome measures Tracking of email messages, interviews with core staff, and a qualitative analysis of messages, postings from focus groups, and invited and unsolicited feedback to the service.

Results The informal email network helped to bridge the gap between research and practice by serving as a rich source of information, providing access to members' experiences, suggestions, and ideas, facilitating cross boundary collaboration, and enabling participation in networking at a variety of levels. Ad hoc groupings and communities of practice emerged spontaneously as members discovered common areas of interest.

Conclusion This study illuminated how knowledge for evidence based health care can be targeted, personalised, and made meaningful through informal social processes. Critical success factors include a broad based membership from both the research and service communities; a loose and fluid network structure; tight targeting of messages based on members' interests; the presence of a strong network identity and culture of reciprocity; and the opportunity for new members to learn through passive participation.

Introduction

Although there is widespread support for the concept of evidence based health care, a large gap remains between research and practice.^1-3 Getting evidence into practice requires both explicit and tacit knowledge (box 1).⁴

In 1997 the NHS research and development programme established CHAIN (Contact, Help, Advice and Information Network for Effective Health Care www.nhsu.nhs.uk/chain/), an informal email network for people working in health care with an interest in evidence based health care. Membership is free and voluntary. CHAIN aims to remove barriers between research and practice, by facilitating and enabling the informal processes through which members identify new contacts, exchange expertise, and provide mutual support. We aimed to determine the important features and critical processes of CHAIN.

Box 1: Explicit and tacit knowledge Explicit or codified—knowledge that is transmittable in formal, systematic language Tacit—knowledge that has a personal quality, making it hard to formalise and codify, rooted in action and involvement in a specific context but not easily transmitted between people or organisations. It is generally acquired by experience, apprenticeship, and informal discussion with experienced practitioners

Methods

Illuminative evaluation is a form of naturalistic inquiry.^5-7 It uses a range of qualitative methods to explore an initiative as a whole. We adopted an open ended and collaborative approach, exploring perceptions and experiences and working with stakeholders to progressively clarify and agree CHAIN's critical processes. In particular we sought to document the types of knowledge exchanged, the social processes by which knowledge is exchanged, and how the knowledge began to help health professionals address the research-practice gap in their own work. We were careful not to adopt an over-simplistic, linear model of the evidence into practice sequence, but instead attempted to engage with the complexity of the process, and recognised that CHAIN's role was likely to be diffuse, long term, and subtle rather than specific, immediate, and readily auditable.

Data collection and analysis
We sought the cooperation of all members of CHAIN by email. We collected and classified the 102 messages posted over three months; tracked the 22 "request to network" messages sent out by CHAIN over two months, and replies; interviewed the two core staff (face to face and by telephone) and the members whose messages we had tracked; observed the network in operation; ran three virtual, asynchronous focus group discussions using private email groups (see bmj.com); and collated all feedback (invited and unsolicited) to CHAIN's central office during 2002.

We independently read the email messages, interview transcripts, and focus group discussions, and agreed emerging themes. We shared our preliminary analysis with intended users of the evaluation, progressively focusing on key themes and triangulating our sources of data.⁷ We drew on the literature on use of knowledge to help set the findings within a broader explanatory context.⁸ The role of the illuminative evaluator at this stage is to "sharpen discussion, disentangle complexities, isolate the significant from the trivial, and to raise the level of sophistication of debate."⁹

Results

CHAIN is open to anyone working in the NHS "family of organisations" who is willing to share information and experience with other members of the network. At the time of our study, between April 2002 and January 2003, CHAIN had 2800 members. Members contact each other either through the database (which includes searchable fields of members' interests and expertise) or by asking CHAIN's staff to send out on their behalf an email message targeted to a relevant subgroup of members; brokering contact between members by targeting emails is now the most important part of CHAIN. This became the focus of our evaluation.

CHAIN is run by a head of development, a manager, and an administrative officer. Information for dissemination comes from two sources: that circulated by staff about jobs, studentships, courses, conferences, funding opportunities, and key publications (a horizon scanning service); and that from CHAIN members which is checked, edited, and targeted by staff. Messages may be offers of information or requests to network (see bmj.com).

Targeting by staff ensures that email is only received by a subset of members (typically 50 to 100) with matching interests. This process is labour intensive and requires skill in database searching. Targeting also depends on an up to date database. CHAIN aims to keep records that are no more than six months out of date, and has a rolling programme to contact members for updates. Staff and members, however, identified this area as one for improvement.

A potential drawback of targeting is that members may fail to receive potentially useful messages, although, overall, members commented positively on targeting. A notable feature of CHAIN was the willingness of members to respond to requests to network—we defined this as "reciprocity." Members were typically "overwhelmed by the generosity of responses." CHAIN helps people in practice in four key ways, as shown below.

A rich source of relevant, useful information
CHAIN members perceived the targeted email service as a valuable source of information about conferences, training events, research calls, funding opportunities, and new publications. A view expressed by several respondents was that "CHAIN is my lifeline to what is going on out there!" Members also acted as a rich source of research evidence, commonly that members had not been aware of from literature searches. An area identified for future improvement, both by members and staff, was for this horizon scanning service to be extended, possibly by linking up with other scanning services.

Access to people with know-how
Overwhelmingly, members found the opportunity CHAIN provided to tap into other members' experiences most valuable. Many messages related to the uncodifiable know-how required to obtain or action evidence. Such information was often in the form of contextualised stories (local lessons) embellished with operational details, warnings, troubleshooting advice and humour:

[A colleague] and I are doing a health needs assessment of sex workers in one area, and we asked CHAIN for help. We had 6 replies from people working on similar studies or those who had done similar studies already, and some of them sent us references we could check out straight away. That must have saved us at least a week's work of trawling the net and libraries, and it was very useful because some of the people who responded were happy to talk through some of the issues with us. I can't think of a more direct way to reach people than via CHAIN (unsolicited feedback from a specialist in public health)

Other characteristics of this support identified as important by CHAIN members were its availability when required and its boost to both motivation and confidence. Responses to a networking message often included an invitation to liaise further (box 2).

Diversity of members' backgrounds, expertise, and experience
Many respondents explicitly commented on how the network enabled them to access others from different organisations and professional groups:

My personal network tends to be limited to people in similar fields to me [public health]. I don't tend to know nurses, academics, or social researchers, whereas CHAIN has all of them as members (unsolicited feedback from a specialist in public health)

A particular advantage identified by respondents was that researchers were able to communicate directly with practitioners in the service sector and vice versa. The value of this cross boundary networking for our focus group respondents was that it encouraged them to look outside their usual profession or organisation; it prompted them to reconceptualise their problems and produce new potential solutions; it enabled the sharing of innovation and good practice; and it opened up possibilities for research agendas to be informed by service needs. Some respondents suggested that an additional benefit of the virtual medium was that it bridged the gap between novice and expert: "In CHAIN, I have found that you can be anybody and anyone will reply. It is sort of more equal in status" (PhD student in focus group 1 discussion).

Flexibility to participate at different levels
The most intangible benefit of CHAIN identified by respondents was the value that many attached to just knowing it was there and that it could be used if need be:

I have not used CHAIN much but it is a security blanket! I am a novice researcher and not a natural one! Knowing there are a bunch of people out there who would if I asked and if they could share their expertise with me is comforting (general practitioner in focus group 2 discussion)

The virtual medium of CHAIN was seen as allowing members to choose to be passive rather than active but to still feel connected to the network and benefiting from it. A minority of respondents were less keen on the virtual medium.

Discussion

Our study has produced additional findings on knowledge sharing from a dimension of informal space (email networking) that has been largely unexplored by those researching the research-practice gap in health care, and it has raised some important methodological issues. CHAIN provides an example of how knowledge can be targeted, personalised, and made meaningful through informal social processes. It offers a mechanism for people to span the divisions between organisations and professional groups, to capture obscure items of codified knowledge, to share and shape the know-how and know-what of implementing evidence, and to link novices with experienced practitioners who are motivated to help them solve problems. Our findings thus add significantly to research from the evidence based medicine tradition on how to bridge the gap between research and practice, which has focused on the production, presentation, and distribution of codified knowledge and to an emerging tradition of in-depth exploratory studies of the social processes and networks that support the development and application of tacit knowledge.^{1 2 5 10}

Box 2: Soft networking in practice A member of CHAIN sought help from other members: "I have been asked to document the primary care clinical audit criteria (including milestones) for each of the National Service Frameworks. This seems a big job to tackle on my own and I wondered if any CHAIN members had already done this work and would be willing to share it." We asked this member to keep us informed of responses. She sent the following summary: A useful web link sharing the department's strategy for prioritising audits A request for further clarification Sent a copy of a data collection tool and report they had produced when conducting a CHD [coronary heart disease] baseline audit; it wasn't what I was looking for, but it was nice they had taken the trouble Had gathered all the relevant information together into a couple of documents with references, etc. This was close to what I was interested in and a useful resource. They also offered further support should I need it and were open and supportive Asked that if I received what I was looking for would I share it with them as they too thought such a piece of work was useful and had made several unsuccessful attempts to produce it themselves. I intend to seek permission from the originators before forwarding the documents and references above In her feedback to us, she wrote: "I was overwhelmed by people's support and kindness. The query was quite straightforward, but I'm fairly new to audit, and a complete stranger to primary care audit, and this was a pretty big piece of work with a tight deadline. I would certainly use CHAIN again and have in fact spoken about the progress of my query to a colleague who has since registered with CHAIN"

Nonaka and Takeuchi suggest that the creation of complex knowledge within an organisation occurs as a result of a dynamic interchange between explicit and tacit forms of knowledge.^{11 12} They identified four modes of knowledge creation: socialisation, externalisation, combination, and internalisation. CHAIN has examples of each of these modes (see bmj.com). Our application of this theoretical model to the processes within CHAIN illuminates the importance of the interplay between tacit and explicit knowledge and the role of social interaction and informal dialogue in getting evidence into practice. The transfer of complex knowledge between organisations critically depends on the individual boundary spanner—that is, someone from one organisation who networks with people from other organisations. According to this model, soft networking occurs when such individuals identify the type of knowledge they need as missing and draw effectively on the network to fill the gap.

Critical success factors
Increasing interest has been shown in the use of networks within the NHS, and our study suggests certain critical success factors for such networks to flourish.^{13 14-16} Firstly, the skilled staff at the centre of CHAIN help establish, maintain, and develop the networking processes. Fenton and coworkers also found that successful networks have strong central cultures, which create values for members, galvanise interest, set rules for behaviour, and build capability by linking individuals and groups.¹⁷ Secondly, the nature of CHAIN's communication by simple email enables its members to draw on what one author has called "the strength of weak ties."¹⁷ This is the notion that people who have little in common have more potential to exchange information. Thirdly, CHAIN provides both the medium and the impetus for small groups of people to come together and set about making sense of a common problem—a phenomenon known as the emergence of "communities of practice."¹⁸

A final critical success factor for CHAIN is silent or passive participation, known as "lurking"—reading the email postings to a group without posting a reply.¹⁹ Our respondents, especially those who were newcomers to evidence based health care, seemed to place great value on the network even when they made little active contribution to it. This illustrates why, when evaluating electronic soft networks, researchers must not simply quantify the number of messages or the proportion of members who post them but should also explore the more intangible benefits perceived by members.

With additional resources, CHAIN might further develop the central support service for a soft network—for example, by providing a more systematic horizon scanning service, making available an archive of collated responses to email inquires, and providing more proactive facilitation of research collaborations. A fine balance, however, exists between a strong centre that enables, facilitates, and supports and one that stifles the energy of networking by too much control.¹³

CHAIN Canada is about to be launched (www.epoc.uottawa.ca/CHAINCanada/index.htm), and the NHS University, as well as providing future funding for CHAIN, is extending the model to bring together other interest groups in health and social care. For such networks to flourish and for their potential benefits to be realised, healthcare organisations will need to provide an enabling environment for participation. Because of the informality of networking, particularly virtual networking by email, there can be a danger that it is perceived as, at best, a marginal activity to be squeezed in if time permits rather than an integral component of the evidence into practice cycle.

What is already known on this topic The volume and complexity of evidence from research makes it inaccessible to busy practitioners, who often lack sophisticated search and appraisal skills Evidence is usually only available for part of the sequence of decisions and actions in real life clinical problems Evidence might indicate what works but not how to do, it and it cannot take account of local context, resources, and politics What this study adds Bringing researchers and practitioners under the same "virtual roof" in an accessible, low technology email forum can help bridge the gap between research and practice Soft networking enables knowledge for evidence based health care to be personalised and made meaningful through informal social interaction Skilled staff can encourage a strong culture of support and reciprocity within the network and can target messages to individuals with matching interests

---

Examples of request to network messages are on bmj.com

This is an abridged version; the full version is on bmj.com

We thank David Evans, Wendy Zhou, Natasha Karpava, and the CHAIN members who contributed to the evaluation, and Olympia Kyriakidou, Janet McDonnell, Jeanette Buckingham, and two reviewers for helpful advice on earlier drafts of this paper.

Contributors: See bmj.com

Funding: NHS research and development programme.

Competing interests: None declared.

Ethical approval: Not required.

References

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(Accepted 2 April 2004)

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