Are relationships as important as strategies for evidence-informed policy and practice?

Over the past decade, the field of implementation research has identified many strategies to support the use of research evidence in practice. Talking to practitioners, it is clear that trusting relationships are at the heart of what they do to promote evidence use. However, they don’t often feature strongly in the literature. In this blog, we look at what we are learning about the role of relationships and how this knowledge might be better mobilised as a core and explicit element of implementation support. In doing so, we aim to bring implementation research and practice closer together.

As part of a William T. Grant funded study on implementation strategies in child welfare, we recently conducted interviews with professionals who had extensive experience supporting the implementation of evidence in child and family services (referred to as implementation support practitioners). We asked about the implementation strategies used to support evidence use, the approaches to and results yielded from engaging stakeholders, and the role of relationships in supporting effective implementation.

Although interviewees identified many discrete strategies to support evidence use, they emphasized with a striking amount of uniformity that high-quality relationships between implementation support practitioners and partners in child and family services was a — if not the — critical factor for achieving implementation results. Emerging themes speak to a potential deepening divide between implementation research and practice.

What are we learning about relationships, implementation, and the value of empathy?

Interviewees described building trusting relationships as at the heart of what they do to promote evidence use.

Interviewees described building trusting relationships as at the heart of what they do to promote evidence use. They explained in great detail the strategies they use to build trust: entering the implementation space with humility as a learner, rather than an expert; engaging in honest and active listening; providing credible information; demonstrating value; demonstrating commitment in the face of complex challenges; staying in difficult situations; showing kindness and vulnerability; and demonstrating empathy.

Let’s take a closer look at empathy, a principle that overwhelmingly resonated with interviewees. While empathy has historically been described as part of the helping process in psychology, more recent definitions of empathy move beyond a unidirectional definition and conceptualize empathy as mutual, interactive, and humanist. Interviewees described empathy as foundational for the growth-promoting relationships needed to support change. This aligns with how implementation support practitioners describe their work building affiliation, making personal connections, and recognizing themselves as outsiders.

Interviewees described entering the implementation space with empathy as requiring:

1. affective attunement to stakeholders at the implementing site,
2. the ability to maintain flexible boundaries and a well-differentiated sense of self,
3. comfort in a relational context of mutual understanding and reciprocity, and
4. the ability and willingness to feel the presence of each other, and the impact each has made on the other in the context of implementation activities and decision-making.

Why has relationship building been overlooked in implementation research?

As we reviewed interview responses, we couldn’t help but wonder why the role of relationships is not overtly addressed in taxonomies of implementation strategies. One clue may be the growing divide between implementation research and implementation practice. Interviewees noted they were not incentivized to publish on their “real world” implementation work and could not easily identify a receptive venue for the type of articles they could contribute. Additionally, interviewees described interpersonal strategies not often represented in research studies that tend to emphasize more transactional implementation support strategies.

What questions might we ask to bring implementation research and practice closer together?

Taking the role of relationships seriously within implementation research poses new and challenging questions for future exploration.

Can the relationship between implementation support practitioners and implementing site partners be conceptualised as an implementation strategy in its own right? That is, can a high-quality relationship directly yield desirable implementation outcomes?

Is the relationship better conceptualized as a moderator of associations between commonly applied implementation strategies and implementation outcomes? That is, can a high-quality relationship magnify the impact of implementation strategies on implementation outcomes?

A common challenge identified by implementation researchers is the mismatch between selected implementation strategies and the implementation barriers they are intended to address. Beyond attending to these possible mismatches, our interviewees foreground a critical question: are high-quality relationships between implementation support practitioners and implementing site partners necessary for overcoming challenges and successfully implementing evidence-informed programs and practices? The answer appears to be “yes.”

Allison Metz is Director at the National Implementation Research Network and Research Professor, School of School Work, UNC-Chapel Hill

Annette Boaz is Professor of Health Care Research at Kingston University and co-lead of Transforming Evidence.

Todd Jensen is a Research Assistant Professor in the School of Social Work and Family Research and Engagement Specialist in the Jordan Institute for Families at UNC-CH.

Amanda Farley is an Implementation Associate at the National Implementation Research Network.

Leah Bartley is a Senior Implementation Specialist at the National Implementation Research Network