A Foot in Both Camps: Graduate Voices at the Interface of Applied Health Services Research, Policy and Decision-making
The Regional Training Centres (RTCs) have established a new, non-traditional model of applied health services research training. Graduates report that the programs provide an academic "home" where they can pursue their health and nursing services research interests while engaging with decision-makers. This discussion paper shares perspectives from eight RTC graduates about their lives and careers at the interface of applied health and nursing services research, policy and decision-making, in particular, training in a novel graduate program, building lasting connections among researchers, policy makers and managers and acting as liaisons among these communities. Graduates cite their exclusive access to a health services and policy network as an enticing feature of their training experience. They have forged careers that require work in both the research and decision-making realms, and clearly prefer having "a foot in both camps."
- The Regional Training Centres (RTCs) offer a novel approach to applied health services research training, using tangible tools and imparting practical experiences.
- This training fosters the development of lasting connections between students and those in the research and decision-making realms.
- Graduates see themselves as liaisons, moving back and forth across the divides of research, policy and decision-making.
Bringing together the applied health and nursing services research community with that of policy and decision-making has its share of challenges (CHSRF 1999). Martens and Roos (2005) have likened the relationship between these communities to "tectonic plates": although the plates tend to move slowly past one another, they sometimes collide, dramatically altering the health services landscape. Indeed, leaders of both communities have made concerted efforts over the last decade to increase and improve their interactions, collaboration and exchange of ideas (Lomas 1997; Lavis et al. 2003; Huberman 1994; Roos and Shapiro 1999). For the most part, these efforts have involved researchers reaching outside their comfort zone to embrace a decision-relevant way of doing research and actively learning from decision-makers about the challenges they face. Policy makers and managers have also been challenged to practise a more evidence-informed way of making decisions.
The Canadian Health Service Research Foundation (CHSRF) and the Canadian Institutes of Health Research (CIHR) formed a partnership in the late 1990s and set up a 10-year funding arrangement for the development of Regional Training Centres (RTCs). The RTCs were established to increase capacity at the graduate level in applied health and nursing services research (HSR) (CHSRF 2008b; Conrad 2008). The RTCs - each representing a consortium of universities - include the Atlantic Regional Training Centre (ARTC), the Centre FERASI (Centre de formation et d'expertise en recherche en administration des services inﬁrmiers), the Ontario Training Centre (OTC) and the Western Regional Training Centre (WRTC). To date, the RTCs have admitted 345 students (Table 1). Of these, 144 have graduated, with 102 at the master's level and 42 at the doctoral level.
For RTC graduates, the silos within research disciplines and decision-making are less of an obstacle than for their predecessors, owing to the opportunity to learn about research methods and policy application simultaneously. In fact, every component of their training - from coursework to conferences, institutes and workshops to a residency or placement in a decision-making environment to an HSR thesis - is aimed at interdisciplinary training to unite these worlds. At the end of it all, graduates ﬁnd they have morphed into "unique creatures," occupying a unique niche - the interface of health services research, policy and decision-making.
In this paper, we share perspectives from eight RTC graduates about their life and careers at this interface. In particular, we explore the three major themes that emerged from interviews with these graduates: the RTCs' novel approach to HSR training, using tangible tools and imparting practical experiences; training that fosters the development of lasting connections between students and those in the research and decision-making realms; and the graduates' view of themselves as liaisons, moving back and forth across the divides of research, policy and decision-making.
We conducted informal telephone interviews with eight graduates from the RTCs. We asked Program Managers from each RTC to nominate master's and doctoral graduates for these interviews. Purposive sampling was used for nomination and ﬁnal selection of graduates interviewed, since the aim was to provide a diverse interviewee pool of graduates, considering such factors as geography, area of interest, professional background and post-graduation career path. Each interviewee gave written, informed consent before being interviewed. Interviews took place between December 2007 and January 2008 and explored such issues as what initially attracted graduates to the program, their general experiences and how the training affected their career path and prepared them for their current roles. The interviews were professionally transcribed. Analysis was conducted informally, with three major themes emerging. Graduates were given an opportunity to verify these themes as well as the facts in this paper.
The paper aims to give a snapshot of graduate perspectives in conversational style. We considered this approach the most effective way of representing the graduates' "voices." We begin with an introduction to the graduates.
RTC students are drawn by design from a variety of disciplines and professional backgrounds. Their career paths post-graduation are similarly diverse.
From the WRTC
Dug Andrusiek (MSc, Health Care and Epidemiology, 2005) came to the WRTC program as a paramedic and a master's student in 2003. Dug is presently a doctoral candidate with WRTC support, and also works as Manager of Research, Medical Programs with British Columbia Ambulance Service in Vancouver, a position created for him after completing his master's degree.
Vicki Crites (MA, Political Science, 2005) graduated from WRTC's afﬁliate stream. With her background in political science and her ﬁeld placement with Health Canada - BC Division, Vicki now works as a policy analyst with the BC Division in Vancouver. (To learn more about the WRTC's afﬁliate program, see Brachman et al. 2008.)
From the OTC
Faith Donald (PhD, Nursing, with a Diploma in Health Services and Policy Research, 2007) is a nurse practitioner and graduate from the OTC. Since graduating, Faith has continued in her role as Associate Professor in the School of Nursing at Ryerson University in Toronto. In addition, she recently became one of the CHSRF/CIHR post-doctoral award holders.
Kristin Shields (MPH, with a Diploma in Health Services and Policy Research, 2005) has a background in life sciences and now works as Senior Consultant, Planning and Community Engagement with the North West Local Health Integration Network (LHIN) in Thunder Bay, Ontario.
From the Centre FERASI
Lily Lessard (MSc, Community Health, 2005) has a background in nursing and is Associate Professor at the Université du Québec à Rimouski in the Department of Nursing, and is pursuing her doctorate in Community Health at Université Laval.
Marie-Claire Richer (PhD, Nursing, 2007) recently accepted a position as Director of Transition with McGill University Health Centre (MUHC) and is Assistant Professor and Joint Coordinator for the Centre FERASI program at McGill University in Montreal, Quebec.
From the ARTC
Roger Chafe (PhD, Community Health, 2008) came into the ARTC with a master's degree in philosophy. Now pursuing his CHSRF/CIHR post-doctoral award at the University of Toronto, Roger works closely with his decision-maker partner, Cancer Care Ontario.
Brad Osmond (MSc, Applied Health Services Research, 2006) had a background in business and marketing when he entered the program. Since graduation, Brad has carved out a new position as Community Health Planner for Annapolis Valley Health District Health Authority in Nova Scotia.
Training within a Novel, Applied Training Model
A new model for training applied health services researchers
The RTCs operate under what some graduates refer to as a new model for educating health services researchers. "I've always seen this program as a research program that is similar to a health MBA," says Roger, who is the ﬁrst doctoral graduate of the ARTC. "The program is in tune with the decision-maker environment and has a practical focus on health system analysis."
This practical focus makes sense given the momentum "to push health services research outside the academic environment and to make research resemble what is actually occurring in healthcare provider organizations," says Roger. It also reflects the underlying philosophy of the RTC model: "to build a consortium of post-secondary institutions, departments, faculty and decision-makers to augment current training and offer applied research training that is interdisciplinary and sensitive to health system decision-maker concerns" (CHSRF 2000).
Fellow ARTC graduate Brad agrees. He says his training went "far beyond the scope of an average graduate program," providing him with the necessary skills for his current role as a community health planner in a district health authority. In particular, he refers to his coursework, which encompassed such broad topics as qualitative and quantitative research methods, population health and the determinants of health, healthcare policy and knowledge translation.
Kristin notes one drawback to participating in a new program. As one of the ﬁrst graduates of the OTC, she considered herself a "guinea pig" of the newly established program. Yet, all graduates stated that they felt the beneﬁts of participating in the RTC programs far outweighed any disadvantages.
Tangible tools and practical skills
Students reported that their training gave them tangible skills and tools for working closely with policy makers and managers while conducting health services research. On the one hand, they learned how to write brieﬁng notes and summaries that appeal to the policy and decision-making community; on the other hand, they were trained to be proﬁcient in conducting research, writing research papers and putting together research proposals. Faith remembers the lesson on how to write a research proposal letter of intent during the OTC's summer institute. Taught by a "renowned researcher and healthcare provider duo," the session was practical, relevant and unlike anything Faith had previously been taught in her coursework.
Marie-Claire says that elements of her graduate coursework at the Centre FERASI were similarly unique. For example, faculty challenged students "to see how the papers or work we were doing was relevant, and how it could be applied to a real situation with the decision-makers we were working with."
"As you go through the program you gain a completely different perspective on engagement in research," says Dug of his experience at the WRTC. "You understand the unit of analysis, [but also] where the intervention is being applied, and how the intervention affects the health services setting."
The tailored approach: feels like home
Clearly, the RTC programs have succeeded in providing HSR training, but graduates say the course of study is also customized to meet the unique learning needs of students from a host of disciplines. At the OTC, for example, students are required to create a personal learning plan, which is intended to deﬁne what each student expects from RTC experience. "The plan was helpful for keeping me on track and offered an opportunity for reflection on the training experience," says Faith.
With the RTC programs' flexible nature - whether the coursework, thesis or other components - students have an opportunity to conduct research in unique areas of interest. Dug says this flexibility is precisely why he was eager to join the WRTC at the University of British Columbia. He felt the program was a good ﬁt to pursue his interests in paramedic medicine - interests that Dug says "didn't really have an academic home" otherwise.
Arguably, the WRTC has gone out of its way to become a home for students like Dug. In 2002, after receiving enquiries from students and faculty in various departments and universities across the region, the WRTC opened its training to afﬁliate students. The afﬁliate program provides a health services research home for students from various disciplines who have an interest in health services.
Overall, the RTCs' training allows students greater freedom of thought than traditional departments. For example, Brad says the ARTC program helped him make the connection between his business savvy and desire to work in the healthcare system. "Is there any other [sector] so based on supply and demand?" he says. "I can understand decision-makers' perspectives and now I can talk to them about it without all the jargon."
For Kristin, ﬁnding the OTC program was like ﬁnding a diamond in the rough. During her undergraduate studies, she met with a faculty adviser to discuss her career options. At the time, she was taking pre-med courses, but wanted to pursue "system-level planning." Her adviser told her that this role didn't exist and she should instead apply to medicine, pursue a specialty and ultimately aim to become a medical director in a public health unit. "I decided that wasn't for me," says Kristen. "That's when I started my master's [degree and] I remember the OTC seemed to perfectly match what I had pictured myself doing."
By necessity, HSR training requires students to develop academic rigour, but with full consideration of the real health system issues and constraints related to undertaking formal research in decision-making settings. A fundamental characteristic of the RTCs is that curricula must be applied and relevant to context, hence the considerable interaction between students and decision-makers.
Networking to Develop Lasting Connections
A national network
In the strictest sense, a network "is a system of interconnected individuals who interact with each other for mutual assistance or support" (CHSRF 2008a). Such networks usually require a signiﬁcant level of infrastructure and ﬁnancial support to promote knowledge sharing, facilitate communication and foster a culture of innovation and change (CHSRF 2008a). While there is no ofﬁcial pan-Canadian network of students, researchers and decision-makers, RTC graduates acknowledge that one exists, and they say the network itself is one of the fundamental beneﬁts of joining an RTC program. Arguably, this network is nurtured by the RTCs. For example, the RTCs have all - to a greater or lesser extent - allotted funding for students to attend conferences, such as the annual national CAHSPR (Canadian Association for Health Services and Policy Research) conference.
Faith says the OTC program has given her access to a signiﬁcant network of health system managers, policy makers and researchers. "[This network] is one of the major advantages of joining the program," says Faith. "I knew the training centre would afford opportunities to expand my research network to other universities both within Ontario and, indeed, across the country." Now an Associate Professor in the School of Nursing at Ryerson University, Faith says having these network connections and mentorship is "critical to becoming an established researcher," particularly in this ﬁeld.
For the most part, graduates cited annual, RTC-hosted conferences, seminars, institutes and workshops as settings for invaluable networking. Lily says she was initially attracted to the Centre FERASI by the opportunity to engage with students with similar research interests. She says the connections she built during her training were relevant for her career, and only now has she begun tapping into this broad network.
Institutes are fundamental to the curricula of the RTCs. Kristin, an OTC student, recalls attending a national Spring Institute in 2004 that focused on "knowledge transfer in context." She says it was an opportunity for face-to-face connections with "students and faculty members who have common interests in the area [in which] you're doing your thesis or your research or policy work." (Brachman et al., 2008) These conferences afford students a chance to get a handle on healthcare issues nationally, too. "We [had the opportunity] to network nationally and learn about the experiences of students from different RTCs and the health service policy research that was being done outside our own province," says Kristin.
Vicki, a Policy Analyst with Health Canada, says these were the same connections that "laid the foundation" for her career in health services research. Of course, making these connections extended far beyond the classroom setting. "I was able to meet people from other universities, other disciplines," she says. "That helped to give another perspective on each topic that we looked at through the seminars, [which was] undoubtedly one of the most valuable experiences for me."
"The part that attracted me most was the fact that there was going to be a partnership between a decision-maker and somebody from academia," says Marie-Claire. These are the kinds of partnerships, she says, that help create an organizational environment that is receptive to the development of a research culture.
Attendance at conferences that bring together health-system research, policy and management experts from across Canada to share experiences and perspectives allows students access to a range of health system players, so they develop "a whole new mindset on [health services research]," says Dug.
Connections that last
While connections with health system players from beyond the walls of the RTCs have proven invaluable, it is the connections developed inside that graduates spoke of most fondly. Graduates frequently remarked about the support that RTC faculty and staff provide to students and how these early relationships form the basis of lasting connections. Lily says she felt "very welcomed" and "encouraged" by Centre FERASI faculty and staff. In fact, she says it's why she continues to be actively involved with the centre. Kristin shares a similar experience. "The faculty were embracing from the beginning and they were really there for the students, with the whole program being very student-centred," she says.
These early linkages have grown into long-lasting connections for graduates. In particular, graduates have developed a sense of who's who in academia, policy and management, which makes future pursuits in health services more tangible. For those like Kristin and Vicki, who have thoughts of pursuing doctoral work, the RTC experience has provided a sneak peek at the research world, opening their eyes to who's working on what and where. For the majority, the real value and impact of having a network at their ﬁngertips has been more evident post-graduation, as students have continued to exchange information and ideas with those on the researcher and decision-maker side of things.
"I think the notion that research is not an independent venture, that we can't do it alone and that good research requires a team with a variety of perspectives, has been an important lesson," says Faith. It's a lesson that resonates with decision-makers, too.
Employers seek out graduates
Marie-Claire says that for her employer, having a Centre FERASI doctoral graduate on staff has created the agenda and opportunity to conduct research. She was involved in multiple projects at the McGill University Health Centre throughout her graduate training. "During my thesis proposal development, it was beneﬁcial that I was actually in the decision-making environment," she says. "I think relationships are built from being there, developing trust, exchanging, learning from each other. I was there to learn from them, but they also realized that they could learn from me."
With these kinds of positive experiences, it's no wonder that decision-maker organizations see RTC graduates as employees of choice (see also Sheps et al. 2008). As such, graduates are often recruited by host residency or placement organizations even before graduation.
"Employers are starting to seek out the RTC programs, which are gaining a reputation across the country for developing the type of graduates that decision-maker organizations are looking for," says Roger. Roger is familiar with this scenario. Before moving to Toronto for his position with Cancer Care Ontario, he was working at the same regional health authority - Eastern Health in St. John's, Newfoundland and Labrador - that hosted his ARTC research residency. "My career is a direct result of the program, which gave me the skills, training and the experience that my employer was looking for and which are increasingly recognized as a unique collection of skills," says Roger.
Brad concurs. "If it wasn't for the ARTC, I wouldn't be doing what I'm doing."
Whether graduates are pursuing careers in academia or policy and management, they report being adequately prepared. In particular, they say the RTCs have given them an appropriate balance of theoretical research concepts as well as real-world application. In the end, the balance is serving them well in their careers (see also Rathwell et al. 2008).
Filling a New Niche in Health Services
"A foot in both camps"
Upon entry into the RTC programs, many graduates envisioned that they would be pursuing discipline-speciﬁc research. For most, this conjured images of one day inhabiting the hallowed halls of an academic institution. However, by the time students reach graduation, many report having developed a new vision.
"You are now starting to feel more active involvement between decision-makers and researchers, and you are seeing researchers who actually hold decision-making roles within organizations," says Dug, who has experienced the interface of health services research and management in his evolving career at the BC Ambulance Service.
"Health services research positions are moving outside the traditional university setting and creating 'researchers in the world,' so to speak," says Roger, who also knows what it means to have "a foot in both camps," having worked as a researcher in a regional health authority. Marie-Claire has the same intimate knowledge: despite working full-time at the MUHC, she says she still has "one foot in the university" with her cross-appointment in the School of Nursing at McGill University.
For the most part, graduates argue that their current roles challenge existing boundaries among research, policy and decision-making. For some, this means they have only "one foot" ﬁrmly planted in either arena. Others are less able to fully articulate their footing, seeing themselves more as "brokers" between the communities. In fact, all report playing a liaison role that requires them to move back and forth across the divides of research, policy and decision-making.
Brad also describes himself as one of these "unique creatures," using his abilities to access and assess research ﬁndings in his career in the decision-making environment. Of his career in a district health authority, Brad says, "I can take the data to the decision-makers and sit down with the right people 'around the kitchen table,' and help them to understand it and what it actually means to them and their programs." Over time, Brad says he has earned a reputation as the "evidence guy," and he's ﬁnding that decision-makers in his region are gaining an "appetite for data and evidence," even "asking the questions they didn't ask before."
"What I am is an information gatherer, an interpreter [of research ﬁndings]," says Vicki, who says her policy analyst role has a strong knowledge-brokering component. "I contribute to the decision-making process, but I'm somewhat removed from it." Vicki says her training made her the perfect candidate for this role - one she didn't even realize existed before her training experience with the WRTC.
HSR training has clearly "opened doors" for graduates. For Faith, "going through the process of my PhD [in the OTC] provided me with the conﬁdence, knowledge and skills to feel that I could move forward with [a career in] health services and policy research. It also gave me a network of experts in research and in policy and health services that could give me the support and the guidance to become an independent researcher in the true sense of the word."
For some, the pursuit of Health Services Research has been a journey. "When I was completing my master's thesis, before I entered the WRTC and even initially at the WRTC, I never had the desire to work in the healthcare policy ﬁeld," says Vicki. "I knew I wanted to work in policy or in government, somewhere, [but] I [wasn't sure] where. This [career] just sort of dovetailed for me perfectly."
"As I've moved along, doors have opened as a result of the training I was involved in," agrees fellow WRTC graduate Dug, who is now pursuing doctoral studies. "I started out thinking I would become a clinical researcher. Then I had this shift as I moved through my training. … I began to see a role within the decision-making environment for the skills I was gaining." Today, Dug uses his research skills to influence policy and decision-making in paramedic medicine.
The RTCs offer a non-traditional approach to interdisciplinary training in HSR. Graduates who come into the programs say they have found a ﬁt - one between what they wanted to pursue and what the programs offer. The programs are a "home" of sorts; a place where students can pursue their unique research interests in health services. At the same time, students are given exclusive access to a network that extends from researchers to policy- and decision-makers. The training and networking opens students' eyes to possibilities they had not yet contemplated. In terms of where graduates are now, the experience can be challenging to put into words. Their roles involve moving back and forth across the boundaries of research, policy and decision-making. And they like it that way. They desire to take a research perspective and make it work for the decision-making world. At the same time, they see how the decision-making perspective must help to shape research, so that it is relevant to the major health services questions of the day.
Avoir des intérêts dans les deux camps : la voix des diplômés à l'interface de la recherche appliquée en services de santé, des politiques et de la prise de décisions
Les Centres régionaux de formation (CRF) ont établi un nouveau modèle non traditionnel de formation dans le domaine de la recherche appliquée en services de santé. Les diplômés indiquent que le programme est un point d'attache leur permettant d'approfondir leurs intérêts pour la recherche en services de santé tout en établissant des liens avec les décideurs. Ce document de discussion présente les perspectives de huit diplômés des CRF quant à leur vie et à leur carrière à l'interface de la recherche appliquée en services de santé et de soins inﬁrmiers, des politiques et de la prise de décisions, surtout en ce qui concerne (1) la formation dans un nouveau programme d'études, (2) l'établissement de liens durables parmi les chercheurs, les décideurs et les gestionnaires, et (3) l'établissement de rapports dans ces communautés. Les diplômés citent l'accès exclusif à un réseau de services et de politiques en santé comme une caractéristique attrayante de leur expérience de formation. Leur carrière exige d'eux qu'ils déploient des efforts autant dans le domaine de la recherche que de la prise de décisions. Les diplômés préfèrent clairement avoir des « intérêts dans les deux camps ».
About the Author(s)
Erin Morrison, BScN, RN, MHSA
Program Ofﬁcer, Knowledge Summaries
Capacity for Applied and Developmental Research and Evaluation
Canadian Health Services Research Foundation
Jennifer Thornhill, MSc, BJH
Senior Advisor, Knowledge Summaries
Canadian Health Services Research Foundation
Sam Sheps, MD, MSc, FRCP
Professor and Director, Western Regional Training Centre for Health Services Research
The School of Population and Public Health
Faculty of Medicine, University of British Columbia
Correspondence may be directed to: Erin Morrison, Program Ofﬁcer, Capacity for Applied and Developmental Research and Evaluation, Canadian Health Services Research Foundation, 1565 Carling Avenue, Suite 700, Ottawa, ON K1Z 8R1; tel.: 613-728-2238, ext. 219; fax.: 613-728-3527; e-mail: firstname.lastname@example.org.
AcknowledgmentThe authors would like to acknowledge the participation of the eight Regional Training Centre graduates who generously contributed their experiences, time and, most importantly, their voices.
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