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Bridging the Gap Between Service Delivery and Research

Presentation by Evelyn Shapiro

spent most of my working life on the “front line” or in program I administration. About a decade ago I switched careers to do re- search. One reason for making the change was my feeling of frustra- tion at the number of questions I had which few researchers were addressing. Now, with the shoe on the other foot, I sometimes feel frustrated about the limited interest of program people in research and about the inattention or slowness with which planners or practitioners respond to the information I have unearthed. What are the barriers to cooperation? How important is it to reduce or remove them? And finally, what can we do about it?

Home Care’s Point of View Program administrators and staff often perceive researchers as per-

sons preoccupied with their own interests rather than with what is im- portant or potentially helpful. Those who have co- operated with researchers when approached have found it time-consuming to familiarize the researchers with their organization and services. When a study is completed. the complaints range from the research results’ being inconclusive to the results’ being misinterpreted because the re- searcher(s) did not understand or have adequate knowledge about the program. Of course, the complaints are even louder when the results refute cherished beliefs. In the worst cases, agencies may end up feel- ing that they have been “used“ rather than helped.

These complaints are at least partly, and at least sometimes, jus- tified. However, program planners, administrators and staffs also have some responsibility to:

i) keep up with the literature without confining your reading to jour-

ii) learn how to read articles critically even if it means registering in

iii) make sure they understand clearly what the researcher proposes to

iv) try to get the researcher to include at least some questions they

v) make sure the researcher agrees in advance that they are entitled

nals of your specific discipline;

continuing education classes;

do, and why and how he or she proposes to do it;

want to address in the research design; and

to read early drafts of the report so they can bring errors or misinterpretations to the researcher’s attention.

The Researchers’ Perspective Researchers perceive administrators and practitioners as persons

who are often too attached to what they are doing to question the results of their activities. They also claim that they are all too rarely in- vited to help design and cany out studies. Furthermore, researchers feel that their attempts to do research in an applied setting are either rebuffed or made difficult by limitations imposed on investigations be- cause the organization’s priority is service delivery. However, the most frequent complaint I hear from researchers is that they try very hard to incorporate in their reports the implications of their research results for policy makers, planners and practitioners, but no one lis- tens.

These complaints are all at least partly true or at least sometimes justified. Research careers are largely university-based, so tenure and promotion prospects depend heavily on research productivity. Conse- quently, there is a much greater premium on doing “publishable” re- search rather than on responding to a program’s need.

Most researchers also come directly from specific fields of graduate

study, with little or no training in public policy and with little or no ex- perience in policy, planning or service delivery. Their policy or program assessments or recommendations are therefore not always well-founded, and they show little understanding of the barriers to change even when everyone agrees that change is desirable.

The point I am making is that both practitioners and researchers have valid complaints about each other that can only be resolved if each group acknowledges its own limitations and is prepared to change its own attitudes and behaviours. Research in applied settings is so important that active attempts must be made to improve this un- easy relationship.

Why Research in Home Care is Important All of us in home care, as in other fields, probably use techniques

and interventions which have no proven efficacy. Moreover, this state of affairs is not confined to traditional ways of doing things which predate the emergence of adequate testing tools. It is also true of rela- tively recent innovations whose use becomes widespread before ef- ficacy is fully established. It is therefore critical to test whether what you are doing with individuals or groups works.

Second, we often do not know if what we are doing, even if it helps, is being done for the “right” people. Assuming that funding constraints limit our ability to do everything for everybody and assum- ing that we do know who should get priority, we need to find out if, under pressure of decision making and service delivery, we are indeed serving our target population.

Third, even if we know that what we are doing works and is both reaching and meeting the requirements of the most needy, a key ques- tion, especially these days, is whether the same goals can be ac- complished more efficiently or cost-effectively. I acknowledge that perhaps we are hearing far too much these days about “getting a big- ger bang out of the buck” with its implication that somehow we have been sluggards up to now, but this does not absolve us of the respon- sibility to have a good look at ourselves from that perspective.

Fourth, organizations tend to develop structures and processes that become increasingly en6enched over time. The problem is that these structures or processes may hinder innovation, may not suit day-to- day operations or may limit the capacity of the organization to change in line with emerging needs or changing conditions. We need to be in- terested in and committed to assessing and reassessing the strengths and weaknesses of the organization in which we work and the proces- ses it uses to achieve its objectives.

Fifth, we have a unique opportunity from time to time to compare the efficacy of a new approach with an old one. Such controlled ex- periments could improve our capacity to help people and assist others in our field to do a better job.

Sixth, we need data with which to convince funders that home care makes a quantitative and qualitative difference in health care delivery and in people’s lives.

Research is too essential to let current barriers defeat or dilute ef- forts to undertake such studies. I now propose to briefly examine what we need to do to increase the quantity and improve the quality of re- search done in home care.

Suggestions For Change If we agree that research on home care is important, we have the fol-

lowing three options:

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i) To do the research ourselves, either completely or by seeking limited amounts of help in the design or analysis phase but main- taining total “ownership”;

ii) To invite a researcher we respect and trust to undertake a specific study; and

iii) To wait until approached by a researcher and decide at that point if the research proposed is worthwhile, if the researcher is credible and prepared not only to work co-operatively with us but also to accommodate our own research agenda, at least partially.

I think we should take advantage of all three options. Option one has the advantage of putting you in the driver’s seat. However, the demands the research will make are substantial. If you decide to go it alone, the first step is to write down what you want to know; the next is to do a systematic review of the literature to make sure that the in- formation you want is not already available. The importance of such a review cannot be overemphasized. It will provide you with examples of how others have studied the subject or an aspect of the subject. I stress this because my reviews of research proposals by program people indicate that too many are bent on rediscovering the wheel.

If you discover from your literature review that the information you want is inadequate or unavailable, do not be afraid to tackle the job of writing down your objectives and how you propose to assess the ex- tent to which the objectives have been met. In a first effort, your best bet is to see if there is someone in the research community who can help with the design and methodology, even if it is a small venture. If you can develop a good working relationship with such a person, you will learn a lot in the process which you can use yourself in future en- deavors’and you increase the legitimacy and usefulness of your results. However, do not let the researcher talk you into undertaking a more ambitious project than you want.

If you choose option two, remember that., for researchers, working in an applied setting is not an easy task. You may think that it takes a lot of your time to orient them to what you do and how you do it, but it also takes a great deal of their time and effort to understand your or- ganization and its service delivery, to clarify what you want to know and why. These are, however, not their only problems in doing re- search in an applied setting. Inadequacies in record keeping, people who do not have time for them when they have questions, and accom- modating research requirements within service delivery priorities are only a few of the difficulties they will encounter.

Doing research in an applied setting also takes a bit of a thick skin.

The way the researchers work, and the results and conclusions may be subjected to criticism despite the time and effort expended and the limitations under which the study was carried out. However, you must make sure when the invitation is first extended that the researcher agrees to share preliminary results and conclusions with you. Just as the researcher may have got something wrong, you may well find that you also omitted to provide key pieces of important information.

The advantage of option two is that you usually get better expertise in designing and doing a study than you may have yourself. However, you have to recognize that, even though researchers may listen to your criticisms and suggestions, they usually retain the right to pub- lish and interpret the results without your approval.

Frankly, I think we cannot afford to wait to take advantage of op- tion three but we can respond positively to those requests which we think will contribute to the information required by our agency.

One other suggestion is to take advantage of university-based re- search in progress. A number of university faculties and departments hold regular colloquia during which faculty and visiting scholars present research findings. Some of these may be relevant to your ac- tivities. In addition, they offer an opportunity to learn more about re- search in which you may want to engage. Find out about these colloquia in faculties of medicine, nursing, social work and in depart- ments such as sociology, psychology, and others, and discuss getting on the list of regular invitees so you can choose to go if the topic is in- teresting. Our own department sends invitations to our colloquia to in- terested parties and we find that they add significantly to the quality of our discussions.

Summary Home care research is important. In fact, it is too important to be

left exclusively to researchers even if the currently existing barriers to such investigations were to disappear. Finally, governments can have a major impact by recognizing the importance of encouraging prac- titioners to be investigators and by helping them improve the quality of their proposals. Paradoxically, improving the skill of practitioners to do research may also increase trust and co-operation between them and researchers.

Evelyn Shapiro is an associate professor in the Department of Community Health Sciences at the University of Manitoba.

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Free Services versus Fee for Services

Presentation by Tim Young

ee service versus fee for services is a topic that many of us are not F comfortable with and find difficult to discuss without getting all wrapped up in our own value systems and problems associated with how we think about the world. I am going to try to present to you a framework of ideas and issues that we are using in the Ontario govem- ment to attempt to grapple with some of these difficult issues as they pertain to community services. I am going to touch on the key popula- tions that we are considering concerning user charges, co-payments or fees depending on how you look at it; some of the program implica- tions; the charging framework or the framework within which we are considering charging policies; revenue generation potential; the impact

on clients; and some of the risks and benefits of approaching user char- ges in a social and health services system.

I hope this will stimulate discussion even though it does not present any answers at this point, because the Ontario government has an- nounced that it is considering options in looking at user charges for community services and reviewing them, but has as yet made no decision in that regard. The particular focus, of course, has been on homemaking and on whether or not to start to charge for provincial homemaking programs. This is of particular concern, of course, to Ontario’s home care programs. They are looking forward to what the government is going to have to say on this. So today I am going to out- line some of the considerations that we are looking at while trying to