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Developing Partnerships in Mental Health to Bridge the Research–Practitioner GapJan Horsfall, PhD, Michelle Cleary, RN, PhD, and Glenn E. Hunt, PhD Jan Horsfall, PhD, is a Research Officer, Research Unit, Concord Centre for Mental Health, Sydney South West Area Mental Health Service, Concord Hospital, Sydney, New South Wales, Australia; Michelle Cleary, RN, PhD, is an Associate Professor in Nursing (Mental Health), School of Nursing and Midwifery, University of Western Sydney, Penrith South DC, New South Wales, Australia; and Glenn E. Hunt, PhD, is a Senior Research Fellow, Discipline of Psychiatry, University of Sydney, and Research Unit, Concord Centre for Mental Health, Sydney South West Area Mental Health Service, Concord Hospital, Sydney, New South Wales, Australia. Search terms: Collaborative research, community-based research, consumer research participation, evidence-based practice, mental health, research–practice gap Author contact: [email protected], with a copy to the Editor: [email protected] First Received December 2, 2009; Revision received January 19, 2010; Accepted for publication January 22, 2010. doi: 10.1111/j.1744-6163.2010.00265.x PURPOSE: An overview of approaches used in contemporary mental health research to consider when coordinating research agendas is presented. Connections between the research–practice gap and evidence-based practice are explored. Col- laboration, as a key concept and practice, is investigated particularly in relation to community and consumer participation in mental health research. CONCLUSIONS: Non-commensurate belief systems, inadequate infrastructure, and institutional tendencies maintain the status quo and constitute significant impediments to widespread planned and integrated research programs. PRACTICE IMPLICATIONS: Communication and trust building between researchers and practitioners is central to developing effective collaborations that can deliver more effective health care. As 14% of global health burden is attributed to mental disor- ders, strategies to coordinate appropriate targets and research agendas are urgently needed to improve consumer outcomes. The imbalance between mental illness burden and the resources devoted to dealing with them (the 10/90 gap), and the fact that effective and cost-saving interventions are not always taken up on a large scale are cause for concern world- wide (Proctor et al., 2009; Tomlinson et al., 2009; Wells, Miranda, Bruce,Alegria, & Wallerstein, 2004). Improvements in public health require cooperation among individual, social, and economic factors to create change.This article provides an overview of a number of approaches for consideration when planning and coordinating mental health research agendas at various levels (e.g., area, state, and national). Specific topics discussed include the implementation of evidenced-based ser- vices, approaches to mental health research, considerations before collaboration, principles for community collaboration, and partnerships with consumers in mental health research. It is proposed that developing strong relationships between researchers and practitioners using evidenced-based methods will result in better,cost-effective delivery of mental health care to consumers in practice settings. Implementation of Evidence-Based Services Given the international efforts to address mental health research with a particular concern for developing nations, it is important to acknowledge that in more developed countries, the awareness of evidence-based practice (EBP) exceeds its take-up by far (Proctor et al., 2009; Sullivan et al., 2005; Wells et al., 2004). In the United States, it is noted that the determi- nation of EBP and its implementation at the system level remain two entirely different matters (Proctor et al., 2009). Researchers, therefore, distinguish among diffusion, dissemi- nation, and implementation. Diffusion is the passive spread of information about innovation and evidence; dissemina- tion involves the active and planned effort to make evidence available to clinicians and to persuade target groups to adopt EBPs; and implementation is the use of strategies to introduce or change practice using an evidence base (Proctor et al., 2009). Proctor and colleagues, in promoting implementation research to develop strategies and processes to conduct EBP, conclude that mental health services cannot continue to accept ad hoc approaches to an issue as pivotal as the research–practice gap. Perspectives in Psychiatric Care ISSN 0031-5990 6 Perspectives in Psychiatric Care 47 (2011) 6–12 © 2010 Wiley Periodicals, Inc.

Developing Partnerships in Mental Health to Bridge the Research–Practitioner Gap

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Developing Partnerships in Mental Health to Bridge theResearch–Practitioner Gapppc_265 6..12

Jan Horsfall, PhD, Michelle Cleary, RN, PhD, and Glenn E. Hunt, PhD

Jan Horsfall, PhD, is a Research Officer, Research Unit, Concord Centre for Mental Health, Sydney South West Area Mental Health Service, ConcordHospital, Sydney, New South Wales, Australia; Michelle Cleary, RN, PhD, is an Associate Professor in Nursing (Mental Health), School of Nursing andMidwifery, University of Western Sydney, Penrith South DC, New South Wales, Australia; and Glenn E. Hunt, PhD, is a Senior Research Fellow,Discipline of Psychiatry, University of Sydney, and Research Unit, Concord Centre for Mental Health, Sydney South West Area Mental Health Service,Concord Hospital, Sydney, New South Wales, Australia.

Search terms:Collaborative research, community-basedresearch, consumer research participation,evidence-based practice, mental health,research–practice gap

Author contact:[email protected], with a copy to theEditor: [email protected]

First Received December 2, 2009; Revisionreceived January 19, 2010; Accepted forpublication January 22, 2010.

doi: 10.1111/j.1744-6163.2010.00265.x

PURPOSE: An overview of approaches used in contemporary mental healthresearch to consider when coordinating research agendas is presented. Connectionsbetween the research–practice gap and evidence-based practice are explored. Col-laboration, as a key concept and practice, is investigated particularly in relation tocommunity and consumer participation in mental health research.CONCLUSIONS: Non-commensurate belief systems, inadequate infrastructure,and institutional tendencies maintain the status quo and constitute significantimpediments to widespread planned and integrated research programs.PRACTICE IMPLICATIONS: Communication and trust building betweenresearchers and practitioners is central to developing effective collaborations thatcan deliver more effective health care.

As 14% of global health burden is attributed to mental disor-ders, strategies to coordinate appropriate targets and researchagendas are urgently needed to improve consumer outcomes.The imbalance between mental illness burden and theresources devoted to dealing with them (the 10/90 gap), andthe fact that effective and cost-saving interventions are notalways taken up on a large scale are cause for concern world-wide (Proctor et al., 2009; Tomlinson et al., 2009; Wells,Miranda, Bruce, Alegria, & Wallerstein, 2004). Improvementsin public health require cooperation among individual, social,and economic factors to create change.This article provides anoverview of a number of approaches for consideration whenplanning and coordinating mental health research agendas atvarious levels (e.g., area, state, and national). Specific topicsdiscussed includethe implementationof evidenced-basedser-vices, approaches to mental health research, considerationsbefore collaboration,principles for community collaboration,and partnerships with consumers in mental health research. Itis proposed that developing strong relationships betweenresearchers and practitioners using evidenced-based methodswill result inbetter,cost-effectivedeliveryof mentalhealthcareto consumers in practice settings.

Implementation of Evidence-Based Services

Given the international efforts to address mental healthresearch with a particular concern for developing nations, it isimportant to acknowledge that in more developed countries,the awareness of evidence-based practice (EBP) exceeds itstake-up by far (Proctor et al., 2009; Sullivan et al., 2005; Wellset al., 2004). In the United States, it is noted that the determi-nation of EBP and its implementation at the system levelremain two entirely different matters (Proctor et al., 2009).Researchers, therefore, distinguish among diffusion, dissemi-nation, and implementation. Diffusion is the passive spreadof information about innovation and evidence; dissemina-tion involves the active and planned effort to make evidenceavailable to clinicians and to persuade target groups to adoptEBPs; and implementation is the use of strategies to introduceor change practice using an evidence base (Proctor et al.,2009). Proctor and colleagues, in promoting implementationresearch to develop strategies and processes to conduct EBP,conclude that mental health services cannot continue toaccept ad hoc approaches to an issue as pivotal as theresearch–practice gap.

Perspectives in Psychiatric Care ISSN 0031-5990

6 Perspectives in Psychiatric Care 47 (2011) 6–12 © 2010 Wiley Periodicals, Inc.

The research–practice gap within mental health may bemore of a chasm, and implementation research dealing withtop-down changes will have to broach multiple factors involv-ingmanysystemlevels (Ganju,2006),despite that theNationalAdvisoryMentalHealthCouncil in theUnitedStateshascalledfor bridge building for over a decade (Garland, Plemmons, &Koontz,2006).Health systems and hospitals are complex hier-archical organizations that are intended to fulfill a range ofcompeting goals, and they cannot be regarded as permeablesettings receptive to implementing significant changes, nomatter how rational (Rosenheck, 2001). In this regard,Garland and colleagues (2006) claimed that the traditionaldisciplines of psychiatry and psychology lagged behind neigh-boring fields such as public health, health promotion, andnursing,conceptually and practically.They go so far as to claimthat EBP is the wedge creating the research–practice gap(Garland et al., 2006). Thus, researchers are stereotyped aspromoters of randomized controlled trials (RCTs) as thesource of evidence par excellence, and mental health practitio-ners are characterized as believing EBP to be impractical andthat their skills are not amenable to empirical analysis(Garland et al., 2006).

However, Rosenheck (2001) deems this split arises in partfrom “the protected environment in which research takesplace and the complex heavily contested field in which theresults are eventually applied” (p. 1609). Nevertheless,Garland and colleagues (2006) consider that the time forbridge building rhetoric has passed, and researchers and prac-titioners need to collaboratively explore“structural and inter-personal factors essential in building and sustainingpartnerships and [a] systematic study of partnership pro-cesses and outcomes” (p. 526).

Approaches to Mental Health Research

In the mental health research literature, the options availablefor clinical research range from complex macro-level strate-gies, via RCTs, pragmatic trials, mixed quantitative–qualitative methods, to community-based, consumer needs-based, and consumer-focused action research. A few of theseapproaches will now be reviewed. Given criticisms of ideal-type efficacy research, some researchers are advocating agreater focus on effectiveness in real-life settings (McMillen,Lenze, Hawley, & Osborne, 2009). McMillen and colleaguesexplored the possibilities of mental health practice-basedresearch networks that consisted of a group of practices(public and/or private) working together to generate researchknowledge from clinical settings. These collaborationsderived information from ordinary settings, rather than thoseset up specifically for research purposes; the networks aimedto be long-term and, therefore, go beyond one project; leader-ship is shared by practitioners and researchers; and, even if thenetwork uses academic consultants, funding, or infrastruc-

ture, the research is practice focused (McMillen et al., 2009).Any research method, from interviews and observation tosurveys and clinical trials, can be used across the platform.

McMillen and colleagues (2009) outlined six major chal-lenges for practice-based research networks: developingadequate team relationships; gaining ongoing financial andinfrastructure support; maintaining productivity and sharinginformation beyond the network; managing time,money,andresearch training; aiming for representativeness; and ensuringvalidity. They also suggested several mental health researchtopics that needed to be addressed: What do practitionersactually do?; Are evidence-based interventions transferable?;What are the barriers to new policy, practice guidelines, andEBP implementation?; How can clinician behavior bechanged to improve outcome quality?; When implemented,how do policy changes affect everyday practice? (McMillenet al., 2009). Neither the challenges nor the questions are con-fined to practice-based research networks; however, it is clearthat there is much research to be done in mental healthdomains, and platform networks are one ambitious approachto addressing this on a wide scale.

The proclaimed advantages of practice-based researchnetworks are: flexibility; efficiency; realistic research; and afocus on clinician-determined practice, questions, and pri-orities (McMillen et al., 2009). Research question selectionmay seem straightforward, but researchers highlight differ-ent types of questions depending on whether the studymode is that of practical clinical, efficacy, effectiveness, dis-semination trial, or practice research (March et al., 2005). Aswell, there is the quantitative–qualitative schism where ques-tions about the rationales, relevance, and conflicting resultshave to be addressed (Robins et al., 2008). Across variousresearch methods, there are also decisions to be maderegarding what processes are needed and who determinesthe research question, how it relates to clinical practice, andits significance from public health or disease-burden per-spectives (Tansella, Thornicroft, Barbui, Cipriani, &Saraceno, 2006).

Reference population, sample characteristics, settings, thesimplicity–complexity and fidelity of the experimental inter-vention, treatment as usual or placebo as control, data collec-tion methods, sample size for the requisite statistical power todifferentiate between groups, and the practicality of resultsmeasurement protocols are some of the routine aspects ofclinical trials that have to be addressed (March et al., 2005;Tansella et al., 2006). Within these, more detailed consider-ations impact on research rigor, including organizationalfactors associated with communication, audit trails, and con-tingency plans; staff practicalities regarding time, support,training, and motivation; and patient factors such as verbal orwritten skills, understanding protocol requirements, andadded support/advocacy demands on staff (Oestrich, Austin,& Tarrier, 2007). Key issues regardless of research method are:

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bias, recruitment strategies, narrowness–breadth of diagno-sis, efficacy vis-à-vis effectiveness, cost-effectiveness, rel-evance to clinical practice, and consumer acceptability.Among all of these facets of research, issues surrounding col-laboration arise between organizations and across profes-sional groupings, and with consumers and family members.

Considerations Before Collaboration

Research partnership models have been conceptualized as acontinuum ranging from consultation with clinical expertsand consumers via cooperation,participation,and full controlby practitioners (Oliver et al., 2008; Rose, 2003; Sullivan et al.,2005). However, other researchers have indicated that they donot form a continuum as the underlying epistemology, foreach type is distinct (Baker, Homan, Schonhoff, & Kreuter,1999; Garland et al., 2006; Nastasi & Hitchcock, 2009; Robinset al., 2008; Wells et al., 2004). Cooperation involves clinicianinput and advice,but with no commitment to taking these intoaccount, whereas participation means equal input and powersharing regarding question determination, research modality,design, data collection, and overall aims. Participatory or col-laborative research is likely to increase commitment, enhancetherelevanceof theprocessesandoutcomesforthose involved,encourage long-term sustainability, and provide opportuni-ties for peer learning, thus increasing community capacity(Baker et al., 1999; Oliver et al., 2008; Trickett & RyersonEspino, 2004; Weiss, Anderson, & Lasker, 2002; Wells et al.,2004).

Overall, proponents of collaboration consider that thepartnerships will be at least complementary and can be evengreater than the sum of their parts, and by combining knowl-edge and skills, improved innovative and sustainable healthprograms will result (Weiss et al., 2002). These are goodreasons for research collaboration with other professionals,consumers, and carers within or across organizations toimprove the quality of mental healthcare provision.

Weiss and colleagues (2002) explored comparative contri-butions of leadership, administration and management, effi-ciency, nonfinancial resources, collaborative challenges andcommunity challenges to partnership functioning, and cre-ativity through 66 extant health partnerships across theUnited States. They found that partnership productivity wasmost closely associated with two factors: leadership and effi-ciency. Leadership and the personal qualities and sophisti-cated skills involved in developing trust, and othercollaboration preconditions, were also deemed central byTrickett and Ryerson Espino (2004). Effective leaders brokerauthentic engagement between partners by “bridging diversecultures, sharing power, facilitating open dialogue, andrevealing and challenging assumptions that limit thinkingand action” (Weiss et al., p. 693). The important contribu-tions of efficiency in the productivity of the partnerships

involved practical matters such as assigning roles and respon-sibilities to partners that draw on their strengths and exper-tise, and use their time well. As leadership and efficiencyare key characteristics for enhanced health collaboration,it is likely that similar qualities are central to researchpartnerships.

In their comprehensive literature review of collaborationand community research, Trickett and Ryerson Espino (2004)organized key issues under three headings: reasons for col-laboration, models of collaboration, and key concepts. Theremust be good and clear reasons for inviting any group to col-laborate in research in the first place (Trivedi & Wykes, 2002).Rationales for community participation must be solid on atleast the grounds of practicality, potential contributions, andoutcomes from various stakeholder perspectives. Collabora-tion models must focus on the community development endof the partnership spectrum with a focus on different kinds ofaction research, branching into program evaluation.

Key collaboration concepts are: sustainability, utility, andvalidity of information (cf. Nastasi & Hitchcock, 2009). Sus-tainability, “a slippery and evolving concept” (Trickett &Ryerson Espino, 2004, p. 30), has various meanings and cer-tainly indicates a longer time frame than required for onetrial, project, or implementation. Utility is viewed fromconsumer/community angles and has instrumental, persua-sive, and knowledge components that lead to questioning thetraditional assumption that research topics, methods, andprocesses are the sole responsibility of the researchers. Like-wise, validity has to be considered from contextual and localperspectives (Baker et al., 1999). Thus, when viewed closely,there are very few aspects of community research or collabo-ration that are straightforward.

Drawing on the understandings of collaboration and com-munity development outside traditional health research,authors such as Weiss and colleagues (2002), and Trickett andRyerson Espino (2004) elaborated on these ideas and prac-tices, and made it clear that collaboration is not a simple deci-sion and the community is not merely a place. Theirdiscussions also remind mental health researchers that con-sumers and carers are commonly omitted from a wide rangeof research models. Hohmann and Shear (2002), for example,address this more explicitly when they challenge both thedemand for research generalizability, and the premises ofEBP by stating that the question clinicians should ask in thepractice setting is: “What should I do for this specific persongiven what I know about the person?” rather than “What onaverage works best for this disorder?” (Hohmann & Shear,p. 204).

Among concerns about EBP utilization in mental healthpractice, consumers, policy makers, administrators, research-ers, and clinicians have articulated the following:• Randomized clinical trials omit the complexities of con-

sumer experience

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• Basic and desired social needs are not met by narrow formsof treatment• Some EBPs are not acceptable across all ethnic groups and

settings• An EBP emphasis will siphon funds from other relevant

approaches• Treatment algorithms based on EBP may diminish

patient-centered care• Researchers and consumers frequently seek different

treatment outcomes• Consumer power and influence will diminish further• Data become more important than individual and

community values• Implementation of EBPs often require start-up money

from limited resources• EBP ignores in situ provider groups’ (hospitals, unions,

specialists, health insurers, pharmaceutical industry) powerto resist change (Essock et al., 2003).

As a rider to this abridged but daunting list of challenges toEBP implementation, Essock and colleagues (2003) feltobliged to state their credentials regarding their active com-mitment to and involvement in EBP research and implemen-tation. By way of conclusion and leading toward the future,they declared that “respecting and valuing the emphases of allstakeholder groups may be [the] quicker route to reforms thatwill improve services” (Essock et al., p. 937), and to do this,authentic community (multiple stakeholder) collaborationwill be required (cf. Nastasi & Hitchcock, 2009).

Principles for Community Collaboration

One potential barrier to real collaboration across sectorswhether they are academic, research, service provider, practi-tioner, community, mental health consumer, family, or differ-ent health professions is beliefs about who is an expert andwhat constitutes research expertise. Traditionally, practitio-ners and researchers are immersed in their own professionalknowledge base and research approach, without concomitantskills of reflection and critique of the premises and assump-tions built into their discipline and training.

Community members, carer groups, and consumer orga-nizations often have no formal research knowledge and mayhave misguided ideas about research from media informa-tion, or have poor previous experiences with research (Chris-topher, Watts, McCormick, & Young, 2008; Horsfall, Cleary,Walter, & Malins, 2007; Linhorst & Eckert, 2002; Robins et al.,2008). However, academics, professional researchers, medicalspecialists, and mental health practitioners may have limitedunderstandings of real-life issues that confront consumers ona daily basis, or the overlapping but different worries experi-enced by carers and family members. Neither professionalsnor consumers and carers necessarily have good workingfamiliarity with the local community and its strengths,

resources, or collective struggles—this is the domain of somecommunity members and grassroots workers. Thus, allcommunity-based participants have different perspectivesand can make complementary contributions to all phases ofresearch planning and implementation (Christopher et al.,2008).

If community contexts and the vagaries of individuals andgroup are ignored, this will contribute to EBP either not beingtaken up or not realizing expected improvements. At the etio-logical level, an analogy is that schizophrenia is not caused bygenes alone: Multilayered real-world contingencies contrib-ute to mental health problems as well as their amelioration. Inthe research domain, confounding factors that may muddythe waters of RCTs are intrinsic aspects of life and clinicalpractice, and, therefore, should be constructively addressedup front for interventions to be feasible, effective, andsustainable.

Partnership development and sustainability principlesinclude the following:• Develop working principles with locals to establish inclu-

sivity at the outset• Allow all participant perspectives to be heard and

addressed—from research question determination throughto interpretation and results dissemination• Allow time for consumers, carers, and lay community

members to develop an adequate understanding of theresearch brief and their capacity to influence it• Develop trust, mutual respect, and clear two-way commu-

nication• Incorporate consumer and community values and needs

into the project• Train all participants for teamwork and support nonpro-

fessionals throughout• Acknowledge and accept different partner agendas• Take a multidisciplinary approach• Be aware of partnership development and transition

stressors• Ensure research processes and outcomes benefit the

community• Use methods and evaluation processes consistent with

local needs• Invest in partners for the future as well as the present

(Baker et al., 1999; Christopher et al., 2008; Horsfall et al.,2007; Oliver et al., 2001; Trivedi & Wykes, 2002).

Baker and colleagues (1999) warned that research partner-ship principles constitute the whole fabric of the researchproject, and cannot be cherry-picked and still retain the in-tegrity of the community collaboration. Other realists suchas Green and Mercer (2001) pointed out that, although inits infancy: “The happy confluence of mutual interestsand action that can be achieved through participatoryresearch remains the exception rather than the rule”(p. 1927). Community-based participatory research requires

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leadership, coalition building, facilitation, well-developedcommunication skills, and, at times, third-party mediation.Ultimately, such projects must demonstrate relevant commu-nity changes in illness prevention, addressing unmet needs, orthe provision of, and adherence to, more effective treatments(Wells et al., 2004). In other words, given the time, personnel,and sophisticated skills investments, outcomes need to dem-onstrate appropriate changes to improve on present quality ofcare and level of mental health consumer satisfaction.

Partnerships With Consumers in MentalHealth Research

From a U.K. national base, Oliver and colleagues (2001) out-lined the steps and processes they drew on to incorporategrassroots health consumers into needs-led research pro-grams. Consumers were involved in: identifying importantresearch questions, prioritizing the research agenda on sixadvisory panels set up for specific health illness conditionsand issues, peer reviewing for research commissioning, andcommenting on draft reports. These processes were evalu-ated, and the primary advantage, above those for consumersper se and the purposeful focus of the research questions andmethods, was peer learning. Esoteric language, acronyms, andthe subsequent time and resources required to overcomeimpediments and facilitate multifaceted skills development,along with organizational resistance, were the major barriersconfronted.

Trivedi and Wykes (2002) pointed out that even though theHealth Department and funding bodies in the UnitedKingdom have developed guidelines for partnerships withmental health consumers, researchers have little informationat the practical level. As well as outlining practical questionsfor collaborators to consider from planning through to resultsdissemination, they developed a short, clear contract for con-sumer and research partners. This document addresses issuessuch as: inclusiveness throughout the project; ethics andinformed consent; support, supervision, and reimbursementfor consumer researchers; and acknowledgment of consumerinput in all ensuing verbal and written presentations aboutthe project (Trivedi & Wykes, 2002).

Dealing with more down-to-earth practicalities, Dadichand Muir (2009) explicated the challenges they encounteredand strategies they used as non-mental health-trained com-munity housing evaluators interviewing people with severelong-term mental illness, as well as caseworkers and accom-modation support workers. The community housing agen-cies were characterized by limited resources, complexadministrative procedures, demanding employment condi-tions, and consequent high staff turnover, particularly ofdirect care workers. Interviewing residents involved detailedpreparation, patience, and responsiveness to individual signsof discomfort or distress. To begin rapport development with

interviewees, they worked via support providers who kneweach resident well. In meeting with these intermediaries, theydiscussed suitable times, interview locations, verbal commu-nication skills, intrusive psychotic symptoms, managingclient suspicion, and their own safety. Residents needed to beguided through the informed consent processes; intervieweesset the pace; interview questions were often rephrased orrepeated; and open-ended questions were often left empty asthey were considered too demanding to complete. Beforefollow-up interviews, researchers re-read their original fieldnotes to access details of client idiosyncrasies that had to betaken into account for an effective interview (Dadich & Muir,2009).

Research targeting people with severe and persistentmental illness is thus even more demanding of time, commu-nication skills, and flexible methods than other communityresearch. These clients are not entirely unique; Christopherand colleagues’ (2008) work with indigenous people in theUnited States necessitated significant researcher learningabout history, unique cultural belief systems, disenfranchise-ment, as well as the complexities of building trust and viablerelationships. Partnerships between researchers and practi-tioners can also have significant challenges, given differentperspectives, preconceptions, and possible prejudices(Garland et al., 2006; Horsfall et al., 2007). Development oftrust, mutual respect, and sophisticated interpersonal skillsare again central to the effectiveness of the collaborativeenterprise, especially if it is to continue over time.

Implications for Nursing Practice

As EBP seems rational and reasonable, so does the idea ofplanning, prioritizing, and integrating local, regional, andnational mental health research agendas. Having reviewed theliterature addressing some macro- and micro-level researchapproaches, it is evident that non-commensurate beliefsystems, inadequate infrastructure, and institutional tenden-cies to maintain the status quo constitute significant impedi-ments to widespread planned and integrated researchprograms. However, there are notable examples of cross-sectoral research and evaluation in health showing thatleadership, authentic collaboration, commitment from allparticipant groups, as well as adaptability can facilitatesustainable partnerships, resulting in mutual learning andimproved consumer outcomes.

The EBP approach is not without criticism as there areother important aspects that need to be considered such asclient-centered practice and perspectives on recovery. Inmental health, resources, expertise, and the preferences ofpatients may be different to those recruited into RCTs, leadingto questions about applicability and validity of the researchevidence in individual practice settings. Fisher and Happell(2009) stated: “What counts as evidence in mental health

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nursing practice must incorporate patient values, characteris-tics, and circumstances, as well as the expertise and skills ofthe practitioner”(p. 183). Communication and trust buildingamong researchers, practitioners, and stakeholders are centralto developing effective collaborations that can reduce thepresent research gap to deliver more effective health care topatients and carers.

Available Web Sites• Web site for partnership for workplace mental health, a

program of the American Psychiatric Foundation to advanceeffective employer approaches to mental health: http://www.workplacementalhealth.org/• Web site for Partnerships in Care is the largest independent

provider of secure mental health facilities across the UnitedKingdom: http://www.partnershipsincare.co.uk/• Web site for Rainbow Health Ontario works on building

partnerships with researchers, funders, and policy makersin order to promote EBP and improved public policy inmental health: http://www.rainbowhealthontario.ca/research/researchPartnerships.cfm• Web site for the Alberta Addiction and Mental Health

Research Partnership is committed to improving addictionand mental health outcomes, and to finding innovativesolutions that make a difference: http://www.mentalhealthresearch.ca/About/Pages/default.aspx

Acknowledgements

The authors report no conflicts of interest. The authors aloneare responsible for the content and writing of the article.

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