This paper describes the challenges encountered by an academic team when working with clinical teams to translated knowledge for the purposes of quality improvement in multiple sites. The sites were four differing health care settings in a Northeastern US state: two acute care hospital sites (one rural, one urban), one visiting nurse service and one psychiatric specialty hospital were purposively chosen for the action research study. In conducting this study at these diverse sites the importance of developing relationships and trust, understanding the context and dealing with real world complexities were evident. We conclude with observations and recommendations on important elements for effective knowledge translation work.