Culture, cognisance, capacity and capability: The interrelationship of individual and organisational factors in developing a research hospital

Aim: To share our experience of implementing a programme of interventions aimed at building research capacity and capability of nurses and allied health professionals in a specialist children's hospital. Background: Clinicians at the forefront of care are well positioned to lead on research to improve outcomes and experiences of patients but some professional groups con tinue


| INTRODUC TI ON
Excellence in care is characterised by the use of research, with patients cared for in research-active institutions reportedly having better outcomes (Jonker & Fisher, 2018). Moreover, engagement in clinical research is associated with improved wider health care performance at an organisational level (Boaz et al., 2015), including increased organisational efficiency, improved staff satisfaction, reduced staff turnover, improved patient satisfaction and decreased mortality rates (Harding et al., 2016). It is these developments that have spurred the Care Quality Commission (CQC), a national body that inspects National Health Service (NHS) hospitals in England, and the National Institute of Health Research (NIHR), the overarching organisation for management of clinical research in the United Kingdom (UK), to incorporate clinical research activity as an outcome measure in CQC inspections (Gee & Cooke, 2018). Thus, there is now greater recognition of the role of research in highquality patient care and a process to strengthen the assessment of research activity, potentially signalling a new era for research in the NHS (Maben & King, 2019). However, questions continue to be asked about why NHS hospitals are not doing more research (Van't Hoff, 2019). Of course, the answer to this question is multifactorial (Dimova et al., 2018;Fletcher et al., 2020). There are some factors that have been consistently highlighted, at both organisational and individual levels, and underpinning all of these are culture, attitude, values and behaviours (Dimova et al., 2018). Understanding the context and culture of an organisation, and the professionals that work within it, are key to driving forward a research agenda, ensuring that those who wish to engage in research are enabled to do so.

| BACKG ROU N D
A research-active workforce is important to the NHS: we need 'to build the capacity and capability of our current and future workforce to embrace and actively engage with research and innovation' (Health Education England, 2019). What is needed are innovative and varied programmes to build a critical mass of research-active staff across all professional groups, including strategies to sustain this cohort, referred to in the UK as clinical academics. We have a long tradition of pathways for medical doctors who choose to combine an academic role with clinical practice (Trusson et al., 2019), with an expectation of opportunities and well-established clinical and academic partnerships enabling these roles to flourish. Clinical academics comprise around 5% of the medical structural barriers at an organisational level, however at an individual level, interventions were reflected in >30 fellowship awards; major concerns were reported about sustaining these research ambitions.

Conclusions: Success in building a research-active clinical workforce is multifactorial
and all professional groups report increasing challenges to undertake research alongside clinical responsibilities. Individuals report concerns about the depth and pace of cultural change to sustain Clinical Academic Careers and build a truly organisationwide research hospital ethos to benefit patients.
Relevance to clinical practice: The achievements of individual nurses and allied health professionals indicate that with supportive infrastructure, capacity, cognisance and capability are not insurmountable barriers for determined clinicians. We use the standards for reporting organisational case studies to report our findings (Rodgers et al., 2016 Health Services and Delivery Research, 4 and 1).

K E Y W O R D S
allied health professionals, clinical academic careers, nurses, research hospital What does this paper contribute to the wider global clinical community?
• Our single hospital case study has illustrated how local and national need has shaped a programme of interventions to develop clinical academics.
• We have shown how a strategic approach to planning and delivery of interventions, underpinned by leadership, commitment and support, has resulted in significant success at the individual level.
• The achievements of individual nurses and allied health professionals indicate that with supportive infrastructure capacity, cognisance and capability are not insurmountable barriers for determined clinicians. consultant workforce (Medical Schools Council, 2016). In contrast, the proportion of nurses is much less, with the current ambition to have 1% of midwives and allied health professionals (AHPs) as clinical academics in the workforce by 2030 (Baltruks & Callaghan, 2018).
In its 10-year report, the NIHR expressed concerns regarding an imbalance in progression of non-medical professionals, revealing poor academic advancement for nurses and AHPs (Morgan Jones et al., 2017). The steps taken to address this through a national infrastructure and networks supporting clinical academic pathways are well documented (Health Education England, 2018). National infrastructure, at the supra-organisational level, is not, however, enough. Healthcare systems, at the organisational level, need to invest and plan strategies to develop research capacity (Gee & Cooke, 2018), through local infrastructure and leadership (McCance et al., 2007;Richardson et al., 2019), a point noted almost 20 years ago by Rafferty and colleagues (Rafferty et al., 2003). Without local support, the development of successful funding or fellowship applications, or the ability to backfill posts prior to or after a successful award, are recognised as impossible (Cooke, 2005). The development of such structures is known to be complex and can be limited by the contextual challenges faced by organisations: what is needed are complex solutions to address complex and varied challenges in the NHS (Cooper et al., 2019).

| Design
Building on a decade of a committed focus to foster clinical inquiry in our hospital, we share the infrastructure, processes and evaluation of our programme to date.

| Aim
To share our experience of implementing a programme of interventions aimed at building research capacity and capability of nurses and AHPs into the research culture of a specialist children's hospital.

| Our approach
Development, implementation and evaluation were iterative.
Approval for the relevant aspects of this work was secured as service evaluation. This programme of work is presented in three discrete sections, describing the range of methods used to collect data with the accompanying findings: 1. Understanding the existing research culture for healthcare workers (survey); 2. Implementing a programme of interventions; 3. Evaluating change at the organisation (repeat survey) and individual (focus groups) level.
We detail first the case and the context to our programme.

| Procedures and findings
To offer the best illustration of the content and nature of this evolving programme of work, we detail our actions, followed by findings and the learning, that then informed further actions. We use the standards for reporting organisational case studies to report our findings (Rodgers et al., 2016; (Appendix S1)). We began by examining the culture in our organisation.
2.6 | Understanding the existing culture 2.6.1 | What we did We modified an unpublished survey developed by a team from the School of Nursing, Midwifery and Social Work in the UK as part of their research strategy, to reflect our local context. The modified survey was reviewed by the wider research team for assessment of face validity and relevance to our setting. The survey comprised two parts: • Part 1: nine questions focused on staff perceptions of their ability to support families to be involved in research within the hospital.
• Part 2: 22 questions focused on staff views concerning their engagement and involvement in research.
A free text box was available for comments. Staff were invited to provide contact details if they wanted to receive support with particular aspects of the research process. The survey was anonymised and distributed widely via the hospital all-users email, newsletter, intranet and screensaver, as well as hard copies being distributed to staff with the assistance of volunteers. Return of completed questionnaires was taken as consent to participate. Descriptive statistics were used to characterise the sample, and chi-square, Mann-Whitney and Kruskal-Wallis tests were used to compare respondent groups. Where provided, comments were used to illustrate quantitative findings and reveal important factors not addressed in the survey questions. Data entry was undertaken by two researchers (KO and JW), with the addition of two further researchers for the analysis (FG and DS). A total of 629 (16% of the workforce) completed surveys were returned, with similar numbers of responses from nurses (n = 190, 30%), AHPs (n = 167, 27%) and 'others', this included staff working in administrative, support, non-clinical and research roles (n = 178, 29%). Fewer responses were returned by doctors (n = 85, 14%).

| What we found
Key themes around capacity included research interest and awareness; research training and opportunities; research support and infrastructure; research activity and outputs; and research culture.
The theme of 'research culture' was a consistent thread in the free text replies. Anonymised verbatim quotes are used for illustrative purposes, with the respondent's professional group provided where this information was available.

Culture
The overwhelming majority of survey respondents expressed an interest in research (89%) and wanted more opportunities to share research ideas and information across the hospital (82%).
However, many commented that the culture was not conducive to their own research, with some nurses and AHPs underscoring the need for greater recognition of the value of non-medically related research: Research is key to the future of nursing … it doesn't get the profile it deserves.
One doctor also highlighted the need for a cultural shift in the way that research was perceived within the hospital: It would be helpful if [hospital] could promote a more general understanding and awareness of research … to promote understanding that all research does not mean 'invasive testing' but can cover a wide range of involvement and can be a positive participation with benefits.
There was a clear feeling that valuable skills and expertise were being wasted, and there was a failure in reporting and sharing unique patient data due to a lack of time for research within the organisation and variable support that was dependent on where staff worked: As an AHP I have been involved in many posters and have spoken at international conferences. The tight constraints on our clinical time is now meaning we are not able to complete a lot of this work and this is a great shame as there is so much expertise in our department.
I understand that as a healthcare scientist I am here to provide a service but with the unique nature of our patient cohorts it would be almost negligent not to gain information from their samples in addition to routine analysis. This involves going the extra mile.
One AHP highlighted the different relationship they had with external collaborators and local colleagues: I have held grants from the MRC and Wellcome Trust whilst working for the hospital, but ALL my research has been conducted with external collaborators.
These collaborators contact me to join their grant proposals, as they would appear to appreciate my skill set. Sadly, one is never asked to assist a group here.
It was notable that all staff groups perceived the hospital research culture as currently problematic and challenging to them and their colleagues undertaking research: If there was more research awareness around the hospital and more resource available it would have such a positive impact on the rate of recruitment. It would also make the process so much easier for both staff and patients -resulting in an improved patient experience and aid retention of staff to research positions.

Cognisance
The majority of nurses, AHPs and doctors agreed that they understood research terminology (79%), knew how clinical practice is influenced by research (87%) and felt confident about using research in practice (70%): perhaps reflective of the nature of respondents who chose to complete the survey. Despite this, and the fact that the majority (73%) of respondents had had some involvement with research in the previous three years, awareness about research support available for staff in the hospital was generally limited, with approximately half of respondents not knowing who to contact to start a research project, only 29% of respondents feeling able to provide information to families about ongoing research, just over half (56%) knowing who to direct families to for this information or knowing where to access information, or what was meant by patient and public involvement (PPI). Nearly, all respondents (96%) agreed that research studies were part of a patient's care pathway, but only 22% said that families often asked them about research opportunities. As one respondent highlighted: Having been involved in recruitment for a research study I would like to see older patients, parents and public being generally more aware of research and to feel it to be a positive and integral part of care at this leading hospital.

Capacity and capability
It was difficult disentangling respondents' views about capacity and capability due to their strong overlap. The majority reported barriers to their involvement in research, including lack of time (56%), skills and abilities (18%) and a lack of support from the hospital (14%). Looking across professional groups, 32% of nurses, 27% of AHPs and 13% of doctors reported having received no formal or informal training about research internally; a finding that appeared unrelated to which clinical department they worked in. The majority of respondents (88%) reported that they would value the opportunity to receive further research training and 20% requested further support. Allied health professionals were more likely than nurses (Z = −2.686, p = .007) or doctors (Z = −3.165, p = .002) to report being interested in research but lacked access to training and development. Moreover, nurses and AHPs were more likely to report not having the time to get in- Views about research infrastructure varied, with many respondents indicating 'don't know' in response to statements about different sources of support available for staff who wish to engage in research ( Figure 1). Overall, library facilities were viewed positively. However, a lower percentage of respondents agreed that access to online journals was good ( Figure 1). Whilst some respondents had accessed research evidence to inform their clinical practice within the previous week (43%) or month (35%), nearly a quarter (22%) replied 'never' or 'within the last year', with some giving a clear message that accessing research evidence was problematic due to a lack of time or resources. There was a significant correlation between access to online journals/health information and respondents reports of confidence using research evidence to inform clinical practice (online journals: r = .113; p = .017; health information: r = .148; p = .002). There was general agreement that the support staff get for research depended on where they worked within the hospital.
There was a clear and statistically significant relationship between beliefs about the existence of infrastructure in the hospital and feelings of being able to access facilities, support and time to do research and the incentives available (r = .129 to. 546; p < .005).
Perceptions of there being regular research meetings to explore ideas positively correlated with respondents feeling able to understand research terminology, feeling confident about research in practice and knowledgeable of how practice is influenced by research, as well as having opportunities to reflect on practice and having access to training and development opportunities (r = .235 to .513; p < .01). However, for nurses and AHPs, perceptions of there being regular research meetings were also associated with feeling pressurised by colleagues to undertake research (r = .266; p < .001).
In terms of research activity, there was a significant difference between professional groups in terms of having fulfilled a lead investigator (χ 2 = 117.743; p < .001) or co-investigator (χ 2 = 124.211; p < .001) role, with more doctors having been a lead investigator (36%) or co-investigator (42%) compared with AHPs (LI:10%, CI:10%) or nurses (LI:1.6%, CI:3%). Just over half of all respondents answered questions about presentations and publications. Few had published from their PhD (3.5%) or Masters (2%) compared to other research (22%). Whilst 70% of doctors had published research, this compared to only 31% for AHPs and 12% for nurses. For the 330 respondents who reported on conference presentations, there was also a significant difference between professional groups (χ 2 = 85.289; p < .001), with 94% of doctors having presented at a conference compared with 69% of AHPs and 31% of nurses.
The survey results demonstrated high levels of interest and commitment to research at the individual level; however, this was not always harnessed at the organisational level to facilitate a culture of inquiry. The results indicated a level of inequity between professional groups regarding access to research training, time to undertake research and research opportunities and outputs. We found that awareness and cognisance of research was core to understanding perceptions of roles and contribution to research in our organisation. Moreover, as organisational culture has a role in promoting some behaviours and blocking others, it being shaped by established attitudes, values and practices, it was important for us to capture this. In our view, without these insights of how staff experience this interplay of relationships, progress on developing the multidisciplinary clinical research workforce to improve care and treatment for children and families will remain uneven across professional groups and clinical specialities.

| What we did
We implemented an evolving programme of interventions (Table 1)  Some of these interventions (indicated in italics in Table 1)

| What we achieved
Building capacity was one of our major accomplishments. Prior to the programme, we were aware of only one nurse within the hospital who had applied for an NIHR fellowship, with no award being made. However, during the five-year programme of interventions we achieved considerable success across the NIHR CAC pathways, as well as other doctoral fellowship programmes (Figure 2). Although the data we collected from the surveys and focus groups does not illuminate the extent to which specific interventions contributed to outcomes documented in Table 1 There is no infrastructure at this Trust There is limited support for staff who want to undertake a higher degree by research This has resulted in ten NIHR and four non-NIHR funded Doctoral Level Fellowship Awards (six nurses, eight AHPs) with a total income in excess of £3 million. Of the remaining two staff whose submissions were unsuccessful, one was awarded a NIHR pre-doctoral fellowship the following year. Only one of the 18 staff members who participated in the doctoral internship programme has subsequently left the organisation. successfully applied to these internship calls.
In addition to our formal internship programme, we have provided more responsive support to nurses and AHPs to enable them to apply for the HEE funded Pre-MRes Internships and the Pre- which led to funding and support for a further two residential weekends solely for nurses/AHPs; the first being for local staff and the second extended to those working in the NHS within the region.
As a result of extending the training out-with the organisation, a wider CAC support group for nurses and AHPs was established. In terms of writing mentorship, 12 nurses/AHPs across the trust with experience of writing for publication received mentorship training provided by an external organisation; mentors were then allocated 'mentees'. We initially targeted nurses/AHPs who had recently completed a Masters qualification and put a system of structured and informal support in place that included monthly meetings and agreed targets.There was a lot of enthusiasm for this initiative, assisted by improving accessibility to a wider range of staff, such as including the provision of evening and weekend research/writing sessions.
Time to commit to writing, however, was a challenge for the mentees, and to date, only one has successfully submitted a manuscript to a peer-reviewed journal.

| What we did
To evaluate progress and the need for possible revisions to our programme, we repeated the staff survey in 2018. We used the methods described previously. We revised six of the questions to enable direct feedback on the interventions implemented. A specific question was also asked about support for staff on a CAC pathway.  Table 2, we report changes since the original survey in the domains of culture, cognisance, capacity and capability; we use free-text quotes to illustrate the quantitative findings. Overall, although we found relatively few significant changes over time, the pattern of change differed between the domains of culture, cognisance, capacity and capability, described here in more detail.

Culture
As illustrated in Table 2, although the enthusiasm for undertaking research in practice had significantly increased amongst respondents (93% strongly agreed or agreed that they were very keen to use research in practice, compared with 89% at baseline), in their free text comments they continued to report structural barriers to achieve this ambition for the organisation. These barriers were reported by all professional groups, in particular the tension of prioritising clinical responsibilities for medical and AHP professional groups. Inequities in opportunity were further articulated for nurses, AHPs, healthcare scientists and non-clinical staff. Strong statements were made in relation to limitations for career development associated with pursuing research across many different professional groups.

Cognisance
There were improvements in awareness and understanding of how to support children and families participating in research (able to provide relevant information to families: χ 2 = 9.201; p = .027; able to direct families to correct person: χ 2 = 13.52; p = .004), but these improvements were not carried through to increasing knowledge of how to undertake research projects. However, knowledge about how research influenced practice had increased significantly (χ 2 = 8.072; p = .045). There was also a significant increase in the proportion of respondents reporting that they were regularly updated about research studies, from 49% to 58% (χ 2 = 11.158; p = .011), with the greatest increase being seen in nurses (49% at baseline compared with 66% at follow-up).

Capacity and capability
There were few changes in aspects related to capacity and capabil-

| What we did
We selected participants so that we could begin to explain some of our findings, by exploring in further detail the experiences of individual nurses/AHPs who had embarked on a CAC pathway. We invited all of those who had accessed one or more substantial elements of the interventions on offer (see Table 1), to take part in a focus group interview (n = 44): we undertook five focus groups.
Invitations were sent via email along with a study information leaflet. Four nurses and six AHPs agreed to take part and included: (a) four undertaking or having completed an NIHR/HEE funded MRes or PCAF; (b) four undertaking a doctoral fellowship; and c) two with experience of preparing applications for doctoral fellowship funding.
All had experience of undertaking a funded research internship in the organisation, which will have shaped their experiences, they did not all achieve success in funding applications to undertake further research.

Free text quotations
Capacity and capability Perceived barriers such as lack of time and skills and abilities No change No differences between professional groups in proportions reporting having insufficient time (unlike baseline findings) 'There is limited time and scope for research in clinical roles. It is not well supported and does not link towards promotion (especially in radiology)' 'I think the support for NHS consultants to develop research is very limited … Any research undertaken has to be carried out in addition to one's job plan and clinical work understandably has to be prioritised' 'Time. There is so much focus on increasing patient flow and capacity without putting extra staff in place that research is often seen as an "optional extra"; something you do "if you have time".
Would value opportunity to receive further training Associations between regular staff meetings to explore ideas and staff feeling, able to understand research terminology, feeling confident about research in practice, feeling knowledgeable of how practice is influenced by research, having opportunities to reflect on practice and having access to training and development opportunities Similar findings to baseline (r = .291 to .546; p < .01) Being a lead investigator or co-applicant on a research grant Higher proportion of doctors (34%, 47%) compared with nurses (both 4%), similar to baseline 'it always feels very medically dominated in terms of research at (names hospital).
Nurses and AHP's appear to have to work much harder to get the same opportunities for example honorary contracts at the (names partnership HEI) are common. Academic appointments for nurses and AHP's are rare'….given that nursing is the largest staff group this appears unbalanced'

Presenting at conferences
No change

TA B L E 2 (Continued)
beforehand. With permission, each focus group was audio-recorded and facilitated by at least one experienced qualitative researcher who was not directly involved in supporting/supervising the participants (PK/KK/CRM). Discussion focussed on the drivers for participants undertaking research, their experiences of the process, opportunities and realities of combining research and academia with clinical work, including the infrastructures available to support them. Discussions were further framed in relation to their own definitions of CAC for healthcare professionals. Recordings were transcribed verbatim, and data were stored in accordance with data protection legislation (Information Commissioner's Office, 2020). The focus group data were analysed by two experienced qualitative researchers (KK & PK) using the framework approach (Gale et al., 2013;Smith & Firth, 2011). All transcripts were read independently by each researcher and coded inductively.
The initial codes were reviewed jointly and further developed into a coding framework used to re-interrogate the whole data set.

| What we found
We further expanded our understandings of culture, cognisance, capacity and capability drawing on the focus group data. Anonymised verbatim quotes are used for illustrative purposes. We have omitted the professional group to preserve confidentiality within a small cohort of respondents.

Culture
It was recognised that there was enthusiasm for positive change across the organisation and for embedding research into clinical practice, contributing skills and experience at a team level to impact on care delivery for patients: By having nurses and AHPs with particular areas of research interest and expertise dotted around different areas of the trust might be a step to becoming a research hospital … it's a different type of research, which is equally important and it can address priorities of patients.
However, whilst the hospital aimed to be a research hospital, it was apparent that research was still not embedded into daily practice but rather seen as an additional aspect of some roles. Furthermore, where nurses/AHPs contributed to medical research they were often excluded from being named authors on publications. Perhaps, in contrast, engagement in research for nurses working in a clinical role was not perceived as a priority. As others have found (Fletcher et al., 2020), whilst the narrative across the organisation was that research is important, perceptions were that limited practical or substantively supported conditions were in place for this to take place, particularly for nurses.

Cognisance
Organisational constraints, evident in our work, are not unique, and like others, the need for an integrated 'whole system' approach to research capacity building has been highlighted (Golenko et al., 2012;Luckson et al., 2018;. To be successful, research infrastructure needs to be combined with a positive research culture where research is valued and supported, enabling the generation of new knowledge and opportunities to translate evidence into practice (Matus et al., 2018), thereby influencing research engagement . Across all professional groups in our study, conflicting messages were reflected upon; research was felt to be celebrated and highly valued, but also somehow out of reach or even out of bounds for many. There were perceived tensions between clinical work and research aspiration, rather than all care and treatment reflecting a seamless integration of research and clinical work. Constraints, whether perceived or real, impacted on research engagement, and similar to others, lack of time, resources and opportunities were cited as ongoing challenges, in addition to mentorship (Marjanovic et al., 2019). Funding and lack of support leadership have been described as essential elements of any research capacity and capability strategy (Hartviksen et al., 2019). In our energies to focus on championing clinical academic roles, we designed interventions that would be most helpful in ensuring nurses and AHPs contribute to a research-active institution, by providing opportunities targeted at some of these known challenges. We anticipated that this might have some influence across the organisation. However, whilst we were able to harness the passion, energy and personal drive of a small number of nurses and AHPs to undertake research, characteristics known to fuel the best research (Maben & King, 2019), in the absence of research being operationalised as an organisational core value, our influence and impact to date have remained limited. This finding is important, and highly relevant, and links to what Cooke (Cooke, 2005) refers to as the sustainability of skills. Organisational infrastructure and supporting individual career planning and skills development are enabled by organisational processes (Gee & Cooke, 2018). Without these in place, career progression will not be facilitated. This remains our biggest challenge, in particular the recognition that research has yet to be truly embedded in a clinical role, in particular for nurses, and some AHPs. Our priority is to establish a structure for CACs; with a cohort of 14 doctoral prepared nurses/ AHPs reintegrating back into clinical roles over the next five years, this will be essential. Our findings highlight the need for organisational structures, to reduce known barriers during transition to postfellowship roles; barriers such as the availability of positions/new roles in which research activity is maintained (Newall & Khair, 2020;Richardson et al., 2019): and we would argue encouraged to flourish.

| Limitations
Although the use of surveys and focus groups allowed us to reach wide and also provide some depth, there are a number of limitations to our work. First, this was a hospital-wide survey, from which we have, in the main, isolated data that relate to healthcare professionals. In terms of the culture, we recognise that all hospital staff have a contribution to make to 'being a research hospital'. Second, we acknowledge that the survey respondents were different across the two time points, we cannot comment on individual 'change'. Third, we might have only reached those who had an interest in research, our work presents the views of only a small percentage of the overall workforce. Fourth, this was an unvalidated survey, which we then adapted further, comparisons to other hospitals are therefore limited. Finally, although quantitative and qualitative interpretation was made throughout our work, there is scope for further study, using collective case studies and individual interviews, to examine findings across cases to draw out the nuances that relate to single disciplines, such as nurses, and to more explicitly illustrate a link between the programme of interventions and outcome.

| CON CLUS ION
Our single hospital case study has illustrated how local and national need has shaped a programme of interventions. Together these have impacted on cognisance, capacity and capability within the professions of nursing and allied health, resulting in a growing cadre of clinical academics. These interventions, targeted at the individual level, are having some positive influence on the research culture. Wider impact and reach are however still required. Our research centre is often described in isolation to clinical research and service delivery, yet we firmly believe that we are part of a health research system supporting the development of leading researchers to work within the NHS. We have illustrated the importance of this context; solutions to build CACs must target not only individuals but also the organisation in which they work, if we are to be really ready to harness research talent in clinical practice.

| RELE VAN CE TO CLINI C AL PR AC TI CE
Our strategic approach to planning and delivery of interventions, underpinned by leadership, commitment and support, has resulted in significant success at the individual level. The achievements of individual nurses and allied health professionals indicate that with supportive infrastructure capacity, cognisance and capability are not insurmountable barriers for determined clinicians. It is early days in the development of clinical academics and the positioning of such roles within NHS organisations. We have shared some of the building blocks we have put in place to support growth, to foster 'home-grown' clinical academics, to impact on research capability and capacity within our organisation. In doing so, hopefully we have illustrated the importance of understanding context and research culture to aid sustainability and impact on clinical practice.

ACK N OWLED G EM ENTS
We would like to thank everyone who completed a survey or participated in focus groups. In particular, we would like to thank