Conducting applied health research in alcohol-related liver disease: a rapid qualitative inquiry with healthcare providers

doi:10.21203/rs.3.rs-4471569/v1

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Research Article

Conducting applied health research in alcohol-related liver disease: a rapid qualitative inquiry with healthcare providers

https://doi.org/10.21203/rs.3.rs-4471569/v1

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Background: Current treatment options for alcohol-related liver disease are limited by evidence, clinical and practice gaps. Applied health research can promote the generation of high-quality evidence by embedding experimental research designs in clinical settings. The present qualitative inquiry aims to explore healthcare providers’ experiences of conducting applied health research in alcohol-related liver disease.

Methods: A rapid qualitative approach was adopted to fulfil the exploratory nature of the present qualitative inquiry. Sixteen healthcare providers with varying roles (administrative, clinical, nursing) and formal duties (clinical, research) were interviewed. Inductive thematic analysis was employed to identify relevant themes and subthemes from the data.

Results: Three major themes emerged from the interview data. These include the motives to support alcohol-related liver disease research within clinical settings, descriptions of the research-clinical interface, and the challenges encountered while facilitating and conducting research. Identified barriers to applied health research included intraprofessional and extraprofessional role conflicts, time constraints and insufficient resource availability.

Conclusion: Although healthcare providers expressed a strong commitment towards advancing research in ARLD, structural and organisational challenges affected their involvement. These challenges underly the existing research gap in alcohol-related liver disease care. The findings favour the adoption of a community-based participatory research approach to advance evidence-making interventions in alcohol-related liver disease treatment, improve patient outcomes and foster an egalitarian research culture.

applied health research

healthcare providers

alcohol-related liver disease (ARLD)

rapid qualitative research

Alcohol-related liver disease (ARLD) is an overarching term encompassing a range of clinical presentations (fatty liver, hepatitis, and cirrhosis) characterised by liver injury resulting from alcohol use. In England, deaths due to ARLD increased 74.2% over the past two decades, consisting of a leading cause of morbidity and premature mortality [1]. Despite a continuing rise in disability and mortality, effective pharmacological and psychosocial interventions for the management of ARLD remain limited [2–4]. A discrepancy between research attention devoted to ARLD compared to other liver aetiologies, unequal access to research opportunities and subsequent lack of representation of this patient group in clinical trials may underly the scarce development of evidence-based interventions [5, 6]. Aspects including the complex nature of ARLD, suboptimal identification of therapeutic targets and early diagnosis prevent the establishment of evidence-based interventions to improve long-term outcomes in this patient population [7].

Applied health research can bridge the translational gap and facilitate the uptake of evidence-based interventions from controlled research settings to real-world contexts, establishing their validity [8]. The implementation of experimental study designs in clinical settings can also foster collaborative approaches, data sharing and knowledge transfer across organisations. Despite the potential of applied health research to improve patient outcomes and reduce health inequalities, a key challenge that research-active clinical settings face is the capacity to implement research protocols while meeting a rising demand for clinical care [9]. While providers’ experience of engaging in research is regarded as meaningful and important for job satisfaction, participation can be constricted by barriers such as time pressures and resource shortages (Royal College of Physicians, 2020; J. Williams et al., 2020).

Applied health research and rapid qualitative approaches

Stemming from interpretivism, the exploratory nature of qualitative research allows a deeper understanding of the complexities and singularities of the social, cultural, and institutional dynamics that shape phenomena in healthcare [12, 13]. Within fast-paced, demanding clinical settings, rapid qualitative approaches allow a non-burdensome, expeditious identification of context-specific issues. Through the adaptation of conventional data collection and analysis methods, rapid approaches can capture the intricacies of complex environments within a short time frame [14]. In healthcare delivery, these have been highly convenient to provide a quick turnaround of data during time-sensitive contexts such as COVID-19. Rapid qualitative research allows the timely identification of key priorities that require strategic action and real-time optimisation of resource allocation (Vindrola-Padros & Vindrola-Padros, 2018). Thus, the flexibility and adaptability of rapid qualitative approaches to specific environments allow for expediting research findings, while ensuring an accurate and transparent account of the setting under study [16].

An extensive body of work has supported the ability of such approaches to capture a comprehensive insight into phenomena of interest [17]. Most recent studies have been conducted within the context of COVID-19 [18–20]. For example, rapid qualitative research has been applied to understand the experiences of people experiencing rough sleeping during a nationwide public health response to COVID-19 [21].

Current study

This qualitative inquiry derives from a pilot trial of a psychosocial intervention to reduce alcohol-related harm in patients presenting ARLD (NCT06183710) [22]. The research team has faced a range of challenges during the implementation of the trial, namely at the stages of recruitment and intervention delivery. The present study therefore aims to further delve into healthcare providers’ experiences of conducting applied health research in ARLD, understand the challenges and identify future directions to advance current applied health research practices.

A rapid approach to data generation allowed a comprehensive insight while considering the pressures that healthcare providers are subject to in fast-paced, demanding settings. To date, limited research has applied rapid research models beyond health emergency research [23, 24]. The nature of this qualitative inquiry therefore fills a methodological gap by establishing the applicability of these approaches beyond emergency health research.

Qualitative research is suitable to explore core questions on implementation processes from applied health research and evidence-based medicine in ARLD [25]. As such, the study adds to the current knowledge by providing an account of the inherent challenges of conducting clinical research in this area. ARLD research crosses disciplinary boundaries by involving healthcare providers from addiction and hepatology backgrounds. This investigation also convened participatory research. Participatory health research is a paradigm that can guide research processes through the involvement of and collaboration with key stakeholders to foster the quality and relevance of the findings [26].

Rapid qualitative approaches

As described, a rapid qualitative approach was adopted to fulfil the exploratory nature of the present qualitative inquiry. This methodology allows understanding and informing ARLD research on a larger scale while acknowledging experiences, needs and priorities at a local level. Rapid qualitative approaches are iterative in design, with various research stages being carried out in parallel (data generation simultaneously to analysis) (Vindrola-Padros & Vindrola-Padros, 2018). In the present article, rapid qualitative research techniques were applied at the data generation stage, through short, focused interviews. Data generation and analysis were also carried out simultaneously.

2.2 Design and setting

The present rapid qualitative inquiry was conducted in a university-affiliated hospital located in South London, United Kingdom. The pilot trial from which this investigation emerged aimed to assess the feasibility of contingency management, a psychosocial intervention, to promote engagement with treatment. Contingency management relies on a system of rewards provided upon the completion of a specific, positive behaviour such as treatment attendance [28].

The article adheres to the Standards for Reporting Qualitative Research (SRQR) guidelines [29] (Appendix A). Ethical approval was granted by Camden and Kings Cross NHS Research Ethics Committee (reference 22/LO/0744).

Study population and sampling

Stratified purposive sampling allowed the identification of members (clinical, non-clinical and administrative staff) involved in ARLD research and care. There were no restrictions based on role to ensure a representative account of healthcare providers’ experiences. Due to the exploratory nature of this investigation, a sample size was not specified. A member of the research team (SH) approached and provided a study information sheet to potential participants. Some healthcare providers were also contacted via e-mail as their roles required them to be frequently relocated across hospital premises. Upon approach, the researcher clarified that participation was voluntary and that data would be anonymised to preserve confidentiality. If willing to participate, written or audio-recorded consent was obtained.

Data generation

Rapid semi-structured interviews were conducted in March 2024 by a trained female researcher (SH). Interviews were conducted in person or via MS Teams, according to participants’ preferences. The topic guide was developed within the research team and included exploratory, broad questions. These were focused on obtaining insight into healthcare providers’ experiences and exploring challenges encountered while engaging in research. The interviewer relied on probing, contextual querying, and response clarification to validate the information provided. A £15 gift card was offered to participants for their contribution. Interviews were recorded using an encrypted device and transcribed verbatim by a professional transcription service. Transcripts were anonymised and cross-checked against the original recordings for accuracy.

Researcher familiarity and reflexive identity

At the time of writing (April 2024), the researcher had been engaging with staff members in the clinical setting for 16 months. Through an observant participation role, an ongoing, collaborative partnership established familiarity with the healthcare professionals and with the clinical environment. This also fostered the reflexivity of the researcher while conducting the present investigation. Such readiness and familiarity have been noted as facilitators for the implementation of rapid qualitative studies within clinical settings [30].

Data management and analysis

Transcripts were uploaded to NVivo 12 for data management and analysis. Data were analysed through inductive thematic analysis, a 6-step approach proposed by Braun and Clarke (familiarisation with the data, generation of codes, generation of themes, review of themes, definition of themes, write-up) [31]. The method was chosen based on its suitability to provide a constructivist understanding of the phenomena being studied, while not being bounded to a priori epistemological and theoretical constructs. This aligns with the exploratory nature of the present qualitative inquiry [32]. Coding and analysis were conducted by the first author (SH) and discussed within the team to ensure triangulation and trustworthiness of the findings. Illustrative quotes were included as empirical data to support the identified subthemes.

Findings

Participants

Eighteen healthcare staff were approached, of which sixteen agreed to participate (Table 1). The mean age was 42.3 years old and 81.3% (n = 13) of participants identified as female. Half of the participants belonged to ethnic minorities (n = 8). Roles varied across the administrative (n = 1), clinical (n = 4) and nursing (n = 11) sectors. 62.5% (n = 10) had a clinical-facing role and 18.7% (n = 3) had a research-oriented role. 18.7% (n = 3) carried both clinical and research duties.

Table 1

Sample characteristics
Characteristic	Overall sample (n = 16)
Mean age (SD, range)	42.3 (10.0, 25–60)
Gender identity, % (n)
Female	81.3 (13)
Male	18.7 (3)
Ethnic group, % (n)
Asian, Asian British or Asian Welsh	31.3 (5)
Black, Black British, Black Welsh, Caribbean or African	18.7 (3)
White, White British, White Welsh	50.0 (8)
Role, % (n)
Administrative	6.3 (1)
Clinician	25.0 (4)
Clinician-researcher	18.7 (3)
Nurse	68.7 (11)
Clinical Research Nurse	18.7 (3)
Formal duties, % (n)
Clinical	62.5 (10)
Research	18.7 (3)
Dual	18.7 (3)

Three major themes emerged from the interview data. Participants outlined motives to support ARLD research. Then, the interface between research and clinical duties was described. Finally, participants highlighted challenges and made recommendations to improve future research capacity.

Theme 1: External drives and internal motives for involvement in ARLD applied health research

The existing evidence gap on ARLD treatment consisted of an external drive for supporting the trialling new interventions. The multidisciplinary nature of ARLD meant that widespread research priorities were reported across the hepatology and addiction fields. As noted by P16:

“I think a lot of the research on ARLD has been done by hepatologists, and there’s a major philosophical difference between the way hepatology and addictions research is done. I don’t think the literature captures that at all.” (P16, clinician-researcher, dual role)

From an addictions’ perspective, and as illustrated by P13, the incorporation of a harm reduction approach and adaptation of services should be further researched:

“How can services adapt or encourage people? That is going to be slightly different about how we can promote abstinence or harm reduction from alcohol use. That’s just an unanswered question at present.” (P13, nurse, clinical-facing role)

From a hepatology point of view, P11 indicated that ARLD patients are an understudied population whose health outcomes could benefit from earlier identification and intervention:

“Patients with ARLD present quite late. By the time they come to the hospital, they are severely decompensated, so there is not much of an interest or a research interest in identifying patients and treating them early on.” (P11, clinician, clinical-facing role)

Contributing towards the improvement of patient outcomes through research consisted of an internal motivation. Despite the above differences, a recurrent view amongst participants was a sense of duty towards improving patient outcomes, aligned with their professional ethos. Thus, the generation and translation of high-quality evidence motivated research involvement. This was described by P16:

“In my role there’s a great deal of death. And that takes an emotional toll, and research has an emotional function for me. It enables me to still feel like I’m doing something to help, while not spending all my time in that emotional space, so it’s very protective in that way.” (P16, clinician-researcher, dual role)

Participant 16 proceeded to emphasise the role of research in guiding practice and policy as an external drive for conducting research. Particularly, embedding research designs into real-world, clinical settings allowed for a better translation of evidence:

“I think it also gives you a really good idea of what’s important to patients to focus on, because you’re talking to them all the time (..) you are very aware of what a clinically meaningful outcome is, which I would distinguish from a statistically meaningful outcome (…) that shift probably comes from being immersed in clinical practice.” (P16, clinician-researcher, dual role)

Personal interest was an additional internal motive for supporting applied health research. For participants with a clinical-facing role only, such as P11, the ability to develop a researcher identity prompted an active involvement:

“I’m not in a formal post of research, but it’s a personal interest and there are future aspirations to have an academic career alongside my clinical work.” (P11, clinician, clinical-facing role)

Participants valued and found it rewarding for their professional identity to develop research skills relevant to their area of expertise. This was explained by P5, who had recently formally started a research post in addition to their clinical role:

“The novelty of it (...) I know that there isn’t very much about this area in this field, and that’s quite interesting. And the whole process of research is new to me since starting here doing this role, so I guess it’s like another skill, it’s everything that comes along with it (…) the whole process is new and interesting.” (P5, clinician-researcher, dual role)

Theme 2: Research-clinical interface: collaborations, knowledge and skill-sharing

A common theme surfacing across all participants was the researcher-clinician collaborations. For participants with clinical duties, interaction with research frequently involved the identification and referral of potential participants to ongoing clinical trials. As described by P4:

“If I get new referrals from patients in the clinic or the wards and if there’s a potential candidate, I just give them the number and then they decide whether the patient is suitable or not.” (P4, nurse, clinical-facing role)

Participants with a research-facing role often accompanied clinicians on ward rounds to get familiar with patients and obtain a more detailed insight into their clinical profiles. This allowed research teams to better ascertain patients’ suitability for the trials while strengthening researcher-clinician links. In addition, as observed by P9, the integration of research teams was also noted to shape patients’ perceptions of research:

“That means the research team can understand a bit more about the patient what is being said to them on that day. If you show the patients that we all work together, they see it in a completely different way - some patients can be reluctant to engage because they see it as separate.” (P9, clinical research nurse, research-facing role)

The co-location of teams and shared use of clinical resources enabled an exchange of knowledge and skills. By accommodating each other’s needs, this exchange strengthened interpersonal links and optimised research procedures taking place. This was noted to ease the research burden upon clinicians while improving patient experience. P1 explained these points:

“We try as much as we can to work along with them, because at the end of the day we’re looking after the same patients (…) we accommodate their patients, do their FibroScans and record it for them. I have initiated for some of their nurses to be trained on how to use the FibroScan. That will save time for the patient and for the staff as well.” (P1, nurse, clinical-facing role)

Theme 3: Implementation of ARLD applied health research: challenges and recommendations for future research

Despite being eager to be involved in applied health research, participants reported challenges in supporting research processes. Namely, these included competing demands, role conflict, and insufficient resource availability, which shaped research capacity.

As noted in the interview data, research involvement was often described as burdensome. This was mostly due to competing demands and time constraints and echoed across participants involved in hepatology and addictions care. For example, P10, a participant with a clinical-facing role in addictions, identified that workload as limiting research capacity:

“We’re interested in doing and seeing the data and the results of a study, but also is it going to put pressure on the team and our clinical caseload? That’s my worry when a study is mentioned to me, that is this going to be heavy to the team.” (P10, nurse, clinical-facing role)

The same observation was mirrored by hepatology staff. Despite the importance of applied health research, P4, with a role in hepatology, recognised that time constraints prevented further participation:

“I know research is important, and it’s part of our roles, but I cannot get involved with more than I do at the moment because I’m on my own in the unit, so it will be stretching my role a lot.” (P4, nurse, clinical-facing role)

As suggested above by P4, participants described a pressuring expectation to be involved in research. This expectation, often described as an imposition as opposed to a complement to their formal duties, represented a source of role conflict. Role conflict refers to incompatible, conflicting expectations and demands experienced in the workplace [33]. This can be within (intraprofessional) and between (extraprofessional) roles. The excerpts below, by P17 and P7, illustrate how research processes originated conflicts within and between roles, respectively:

“You cannot say no. I will just do what am I told to do. I remember one of my colleagues saying ‘we should just do what our boss tells us’ because it’s research and there are expectations.” (P7, clinical research nurse, research-facing role)

“It’s just put on the team, we really don’t have a choice if the study is there. It should be clarified that ‘this is not going to be additional to your caseload’. The NHS is very short-staffed, and we all have pressure on timeframe and performance” (P10, nurse, clinical-facing role)

Intraprofessional role conflict was reported by clinician-researchers. At the stage of recruitment, experiential knowledge of the setting and clinical population were heuristic devices facilitating patient approach and recruitment (P14). However, research processes often conflict with clinical demands (P5). This is described in the statements below:

“I think as a medic I know my way around with the time limitations that I have. So I found it quite easy to find the right people to ask which patients are suitable for my studies.” (P14, clinician-researcher, dual role)

“I find it a bit difficult to just combine it at the same time, in the sense that if I see them in the clinic, it’s the ideal setting for recruiting as well. But if the clinic’s busy it’s difficult to recruit them at the same time” (P5, clinician-researcher, dual-role)

Intraprofessional role conflict at the stages of recruitment and intervention delivery was also experienced by participants who were exclusively dedicated to research. This often consisted of barriers to fulfilling recruitment and study targets due to resource strains, described by P9 below:

“I guess the more people you have in the team, the more resources you put in, the more likely you are to be able to offer research to patients. That’s the problem we have sometimes: we haven’t got the resources to deliver all the trials safely, so if you haven’t got enough resources to look after all the patients then you need to make a pause.” (P9, clinical research nurse, research-facing role)

During the above stages, participants also reported extraprofessional role conflict when supporting research. From an administrative perspective, delivering interventions as part of standard care posed operational challenges. This was described by P8 and P11, involved in ARLD care and research, and had implications for patient experience:

“The only thing with clinics is that they are very full. And we can’t keep overbooking because if you keep overbooking, the time is shorter with patients.” (P8, administrative, clinical-facing role)

“Although it is not that arduous in terms of my reviewing them in the clinic, it definitely takes up my clinic slot, which I’m not able to offer to someone who needs it. Or I have to overbook my clinic, which creates a strain on my clinic list.” (P11, clinician, clinical-facing role)

At the operational level, an additional source of extraprofessional role conflict was due to the availability of facilities to embed research in clinical settings. As noted, the co-location of research and clinical structures can enhance patient experience and reduce research attrition, through familiarity and minimisation of research. It may also foster a sustained alliance between healthcare providers, researchers, and patients. P4 attributed this to ease of access and convenience:

“It’s good because they’re easy to contact and patients can see either the clinicians or the nurses at the same time they see the research team. It’s more comfortable for them and for the staff.” (P4, nurse, clinical-facing role)

However, as reported by P7, due to the broad spectrum of liver aetiologies and respective numerous research teams, resource coverage and facilities to conduct research in clinical environments were insufficient:

“We need more rooms to prepare the medications for the patients and conduct assessments. We only have one room at the moment, and we are fighting over that, or we have to wait for clinical rooms to be vacant for us to be able to use them.” (P7, clinical research nurse, research-facing role)

Within this intersection of research care, the shortage of physical spaces resulted in an additional source of extraprofessional role conflict:

“Most of the time all the rooms are occupied, and this affects the research team. If we are on board, and they [research team] understand that they need to come out of the room before the clinic, that gives my team time to tidy up the room and get it ready for consultations. Where I have a problem is when they go over time, and whoever needs that room to start their clinic is waiting outside. That means I’m not coordinating well; I’m not organising well.” (P1, nurse, clinical-facing role)

Resource shortage and lack of funding were therefore reported as barriers to applied health research. Participants showed concerns about the insufficient financial resources available to trial novel interventions for ARLD. As explained by P12:

“Addiction is not a very funded area, even though it’s important that we have the information to be able to put forward solutions. I just think it’s seen as a lower priority, with an already quite a low budget.” (P12, nurse, clinical-facing role)

While seeking an understanding of the above, two explanations were obtained. The first, indicated by P14, related to stigma historically associated with substance use and respective funding allocation:

“I think in the past there was a big stigma surrounding these patients and there wasn’t the research interest. I think we’re behind cause of that. Lack of research interest in the past, lack of resources.” (P14, clinician-researcher, dual role)

Another justification offered for the underfunding of ARLD research was linked to the role of industry in funding research. P11 suggested that this was due to a lower financial interest in non-commercial research:

“When there’s a potential pharmaceutical involved the money is injected in there and that propels the research. Whereas that’s not the case for ARLD. And if it’s hard to get funding, then clinicians are naturally not inclined to explore research in this field. If you’ve got money then you can have resources, nurses, space, but without funding it is difficult.” (P11, clinician, clinical-facing role)

Finally, pressures upon clinical care also influenced research procedures. P16 explained how the rapid throughput of patients during hospitalisation affected patient enrolment into research:

“Because of modern-day bed pressures and the use of hot clinics, people are discharged quite early on in their recovery, meaning that they are gone very quickly! Which gives you quite a limited space to see them, consent them, recruit them, all of that.” (P16, clinician-researcher, dual role)

Staff’s perspectives on future directions for applied health research

Participants were unanimous in the view that equal participation across all phases of research, as well as further organisational support, could enhance future research. P9 stated a need for more agency to be given to stakeholders across the research life cycle:

“I think a problem is that before this was done mainly by PIs only. The research nurse and the poor fellow would have to just deal with that and try to meet targets. Whilst if everyone gets involved and the nurses get a voice, and then we can say ‘let’s commit to do less. If we then have the resources and the capacity to do more then we can’. So then we don’t have as much pressure from the sponsors to recruit.” (P9, clinical research nurse, research-facing role)

Protected time was an additional recommendation for future research. Participants with clinical-facing roles, such as P15, identified a need for dedicated time to develop research skills and support ongoing studies:

“It’s quite interesting doing it, gives you something else to do other than your daily job. It would be nice to have allocated time every week to do research, to look into research, to build our own project.” (P15, nurse, clinical-facing role)

Finally, an additional suggestion relates to a need for further support to foster collaboration across research teams by sharing resources and data. As noted by P14, this can optimise applied health research and improve patient experience:

“In my opinion we should find a way to share samples. There are so many competing studies that I think it would be better for patient experience if there was a way to collaborate so that only one sample is taken, and you share the sample.” (P14, clinician-researcher, dual role)

Healthcare bodies should prioritise research as an integral step for the improvement of care and patient outcomes [34]. The bridging of the evidence gaps in ARLD treatment, through the engagement and translation of evidence into practice, is synergic with research capacity [35]. The present study aimed to explore healthcare providers’ experiences of supporting applied health research in an under-researched clinical area. While there is an emergent need to trial novel evidence-based treatment of ARLD, the implementation of research protocols in clinical settings can be challenging. By adopting a rapid qualitative approach, three major themes emerged from the data: the motives for supporting ARLD research, the research-clinical interface, and the challenges from implementing research designs in clinical settings. Participants also suggested directions for future applied health research.

Across a range of roles, participants were unanimous about the potential of research to address the evidence, clinical and translational gaps in treatment. The co-location of research and clinical settings allows the trialling of novel interventions in real-life contexts. Consistent with previous research, participants pointed to the ability to improve patient care and advance evidence-based practice as drives for participation in research [36]. Accordingly, there is a direct correlation between clinical research activity, improved patient satisfaction and health outcomes [37, 38]. Therefore, applied health research can bridge the existing translational gap between health research and clinical practice, yielding clinically meaningful outcomes [39].

Research priorities and therapeutic goals differed across disciplines. This is consistent with previous research outlining different endpoints across hepatology and addictions [25]. The choice of abstinence is supported as an optimal research and clinical endpoint across hepatology clinical guidelines for the management of alcohol-related liver disease [40–43]. This is aimed at preventing further disability and mortality by reducing the risk of decompensation and cirrhosis. On the other hand, an increasing body of addictions’ research has supported a harm reduction approach as a more sustainable therapeutic endpoint [44]. These are in line with participants’ suggestion to consider modifications in drinking behaviour as viable outcomes for alcohol research. Shifting from an abstinence-focused treatment by encompassing reduction as an intermediate step may elicit behaviour change in patients who are ambivalent [45]. This approach may translate into a public health benefit [46, 47]. As observed in this study, the lack of consensus between hepatology and addictions regarding research may consist of a clinician-level barrier to applied health research. In real-world clinical practice, these tensions may reflect on inconsistencies in ARLD treatment across clinical settings. Thus, the integration of multimodal research priorities, through improved academic and clinical communication and integrated knowledge translation may privilege the interdisciplinary research and management of ARLD. Examples of such integration across disciplines are multistakeholder, research priority-setting partnerships, which enable the co-production of knowledge and meaningful engagement [48–51]. Emphasis should also be given to the involvement of individuals with ARLD lived experience during the research cycle. As suggested by the data, contact with patients can cultivate patient-centred research through the identification of patient needs. Accordingly, patient advocacy and centredness were major drives for research participation. Therefore, interdisciplinary, participatory research, in which the role of patients and research clusters goes beyond ‘objects of evidence production’, can favour a shift from a utilitarian research culture and improve patient experience and care outcomes [52–54].

As a major theme emerging from the data, the research-clinical interface entailed knowledge exchange. In line with previous studies, the present investigation identified interpersonal links between researchers and clinicians, and inherent expertise exchange as stimuli to support and conduct applied health research (J. Williams et al., 2020). The strengthening of researcher-clinician collaborations can improve patient experience and optimise research processes. As observed, the co-location teams mediated opportunistic training in research and clinical skills. Through workforce development, skill-sharing can increase capacity for applied health research while meeting escalating demands for clinical care [56]. Healthcare providers valued access to training opportunities enabling career development, as also noted in the literature [57, 58].

The professional identity of clinician-researchers occurred in a continuum, with a shift between research and clinical duties. Heuristic devices and a combined skillset can facilitate research processes [59, 60]. This insider-outsider identity of healthcare providers with dual roles can foster reflexivity towards the research being conducted [61, 62]. While a dual professional identity can be advantageous for conducting research, intraprofessional role conflict was experienced upon escalating demands for clinical care. In these circumstances, healthcare providers found it strenuous to straddle between clinical work while conducting research. Thus, despite being in a favoured position, a dual identity often exacerbated role conflict. This matches previous remarks from qualitative research, noting prioritisation of clinical work as a barrier to research [63]. In the present study, healthcare providers in nursing roles experienced both intra and extraprofessional role conflicts. Particularly, this resulted from organisational expectations, time constraints and insufficient resources. Historically, the role conflict experienced by nurses, both in research and clinical environments, has been widely reported in qualitative research [64–66]. This is a major work stressor for the healthcare workforce and may result from unsustainable power relationships across different levels within the health research ecosystem [67, 68]. From a structural level, these findings highlight a need for a dialectical relationship between research bodies and healthcare providers to strengthen available infrastructures to support research [69]. As suggested, this may entail protected research time and whole-system, collaborative approaches for research capacity development [70–73].

The relational materiality between evidence, interventions and contexts and their influence on research practices can be considered under the light of an ‘evidence-making intervention’ approach. Such an approach favours a paradigm shift from epistemology to ontology with regards to knowledge-making practices, through the integration of relational materiality and performativity [74]. The findings also favour the adoption of a community-based participatory research (CBPR) model in ARLD research. CBPR is a methodological and epistemological approach in which researchers, healthcare providers and community members collaborate as equals during all phases of research [75]. CBPR can foster an egalitarian research culture by reinforcing collaboration and flattening traditional organisational hierarchies within research environments [76]. Correspondingly, participants in the study prompted a need for active, equal input. In research, bottom-up approaches are more readily implemented and yield a more sustained clinical impact compared to top-down approaches [77]. In addition, the co-creation of research evidence through collective approaches may improve inequalities in health outcomes in underserved clinical populations [78]. Accordingly, the data supported that direct contact with patients equipped clinician-researchers with a better understanding of patient needs. Furthermore, the inherent nature of ARLD, entailing interprofessional research and care, conveniently aligns itself with the collaborative principles of CBPR. Thus, adopting a CBPR model to ARLD research can bridge the current evidence, clinical, and translational gaps in treatment. Such an approach could ensure the acknowledgement of unmet needs under constrained health systems while empowering the workforce involved in applied health research.

Strengths and limitations

The current study fills a knowledge and methodological gap across the fields of ARLD and applied health research. By identifying the challenges of implementing experimental research designs in real-world, clinical settings, the findings of the study explore the underlying reasons for the lack of advances in ARLD research. Thus, this qualitative inquiry adds to the current knowledge in the field by integrating healthcare providers’ perspectives on the current challenges and needs for generating evidence-based care for ARLD. To the best of the authors’ knowledge, this investigation is one of the few to establish the applicability of rapid qualitative approaches beyond the scope of emergency health research. It builds upon the current state of the art by providing evidence of the applicability of such approaches and methodological adaptations in applied health research. Hence, the present study demonstrates the scope of short-term, intensive fieldwork to yield in-depth qualitative data.

Despite the above strengths, the breadth of the findings may be circumscribed to publicly funded clinical settings. Future research should explore and compare experiences of conducting applied health research within private care. Nevertheless, while the findings focus on a local setting, the exploratory nature of this qualitative investigation reports on broader-level needs regarding ARLD research, identifying the gaps needed to advance evidence-based treatment in this area.

Healthcare providers expressed a strong commitment to support applied health research in ARLD. Across different roles, involvement was mostly driven by a perceived need to improve care and patient outcomes for this clinical population. Researcher-clinician collaborations were identified as a key benefit of involvement. These not only allowed skill development but also improved patient experience. However, the research capacity of healthcare providers involved in ARLD care was constricted by role conflict, time constraints and resource availability. The findings support that a CBPR approach, fostering collaboration across all levels of stakeholders, could improve capacity and current practices in ARLD research, bridging the current evidence, clinical and practice gaps.

ARLD: alcohol-related liver disease

CBPR: community-based participatory research

UK: United Kingdom

Ethics approval and consent to participate: The pilot study has been reviewed by King’s College London and King’s College Hospital following the research ethical standards in place. A favourable ethical opinion was granted by Camden and Kings Cross NHS Research Ethics Committee (reference 22/LO/0744). Written informed consent was obtained from all participants.

Consent for publication: Not applicable.

Availability of data and materials: The datasets used and analysed during the current study are available from the corresponding author upon reasonable request.

Competing interests: In the last four years, SP has been part-funded by income from research grants obtained from MundiPharma Research Ltd and Camurus AB. The remaining authors declare that they have no competing interests.

Funding: This work was supported by the National Institute for Health Research Applied Research Collaboration South London [grant number NIHR200152]. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. CD and PD were supported by the NIHR Specialist Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust, King’s College London. CD and PD were also supported by the NIHR Collaboration for Leadership in Applied Health Research and Care at King’s College Hospital NHS Foundation Trust and the National Institute for Health Research (NIHR) Applied Research Collaboration South London (NIHR ARC South London) at King’s College Hospital NHS Foundation Trust. CD was supported by an NIHR Senior Investigator Award.

Author’s contributions: SH: conceptualization, methodology, formal analysis, data curation, investigation, writing – original writing, review and editing; SP: conceptualization, methodology, formal analysis, data curation, supervision, writing – review and editing; PD: conceptualization, writing – review and editing; CD: conceptualization, writing – review and editing.

Acknowledgements: The authors wish to thank members of staff participating in this study for their time and expertise. The authors also thank James Gunn for transcribing the interviews.

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Competing interest reported. Competing interests: In the last four years, SP has been part-funded by income from research grants obtained from MundiPharma Research Ltd and Camurus AB. The remaining authors declare that they have no competing interests.

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Conducting applied health research in alcohol-related liver disease: a rapid qualitative inquiry with healthcare providers

Status:

Version 1

Abstract

Background

Applied health research and rapid qualitative approaches

Current study

Methods

Rapid qualitative approaches

2.2 Design and setting

Study population and sampling

Data generation

Researcher familiarity and reflexive identity

Data management and analysis

Findings

Participants

Theme 1: External drives and internal motives for involvement in ARLD applied health research

Theme 2: Research-clinical interface: collaborations, knowledge and skill-sharing

Theme 3: Implementation of ARLD applied health research: challenges and recommendations for future research

Staff’s perspectives on future directions for applied health research

Discussion

Strengths and limitations

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

Status:

Version 1