David Aron by xiuliliaofz

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									Bridging Research and Clinical Practice
 David Aron, MD, MS; Bonnie Wakefield, PhD, RN, FAAN; Sheri Reder, PhD, MSPH



Four Questions to Consider:
   •Is bridging research and clinical practice necessary?
   •Is it possible?
   •Is it possible when it is necessary?
   •Is it necessary when it is possible?

                                                                July 13, 2010
Bridging Research and Clinical Practice
            (Operations)

•David Aron, MD, MS - Integrating Research and Practice
to Bridge the Researcher/Practitioner Divide
•Bonnie Wakefield, PhD, RN, FAAN – Building the Bridge
from Operations to Research
•Sheri Reder, PhD, MSPH – Building the Bridge from
Research to Operations
                                             July 13, 2010
                                                        Quality Enhancement
                                                         Research Initiative




Integrating Research and Practice to Bridge the
        Researcher/Practitioner Divide
               David C. Aron, MD, MS and Susan Kirsh, MD
                      Louis Stokes Cleveland DVAMC 14(W),
                     10701 East Blvd., Cleveland, OH 441061
        Case Western Reserve University School of Medicine, Cleveland, OH

with Special Thanks to Wen-Chih Wu, MD, and Tracey H. Taveira, PharmD (Providence
                  VAMC) and David Edelman, MD (Durham VAMC)
The Researcher-Practitioner Divide
                 Many suppliers and users of social
                 research are dissatisfied, the
                 former because they are not
                 listened to, the latter because they
                 do not hear much they want to
                 listen to (Lindblom & Cohen,
                 1979).

                •   Research-practice gap
                •   Science-practice gap
                •   Knowledge-practice gap
                •   Academic-Management gap
R
    Conceptualizing the Research Practice Gap as
    a Knowledge Transfer Gap: Practitioners need
    to receive the lessons of research and put them
    into practice - the Pipeline Fallacy

                                 The 17-year odyssey




                                                                        Guidelines for        Practice            -
                                                      Research          Evidence-Based     Funding; patient
                                 Publication          Synthesis         Practice           needs, demands;
                   Peer Review   Priorities &                                               local practice
                   Of Grants     Peer Review                                               circumstances;
Priorities for                                                                             professional
                                                                  Evidence-based
Research Funding                                                  Medicine                 discretion;
                             Academic appointments,               movement                 credibility & fit of
                             promotion, & tenure                                           the evidence.
                             criteria
                                                                                   Blame the practitioner
                                                                                   or blame dissemination
*Based on Green, L.W. From research to “best practices” in other settings and populations. Am J Health
Behavior 25:165-178, April-May 2001. Full text: www.ajhb.org/25-3.htm
    This is Not a New Problem: The Case of Scurvy

• 1747- Lind shows that citrus
  juice supplement eliminates
  scurvy
• 1795- British Navy
  implements citrus juice
  supplement
    History of Scurvy during World Exploration

                                                           British Board of Trade:
                                                                      Proper diets
                  Lancaster                       British Navy
Vasco da Gama England to India
                                                       Lind British Navy
Cape of Good Hope



 1497      "That which I 1593      1601               1747     1796      1865
           have seen
           most fruitfull          4 ships:
 100/160   for this          1 ship – lemon         Repeated
   dead                      juice none dead;        citrus              Ordered
           sicknesse, is
                             3 ship – no juice
           sower [sour]        110/278 dead.
                                                   observations           citrus
           oranges and                                                    diet
           lemmons." -
           Sir Richard
           Hawkins

                                                  Source: Berwick DM, JAMA 2003.
         THUMB WRESTLING




• Goal: pin your opponent as many times as
  possible in 15 seconds.
                               Julie Johnson, PhD
Sometimes we get stuck in our mental models
   following rules that don't really exist

                      “Hey! They’re lighting
                     their arrows!...Can they
                             do that?”

                     •   Our mental models become
                         the natural way of seeing and
                         explaining things
                     •   Difficult to see (“like water to
                         a fish”)
                     •   Hard to imagine any other
                         way
                     •   Filters our perception of
                         reality
     Conceptualizing the Research Practice Gap as entirely separate
     disciplines: each must develop their own answers to their own
                               problems
                 Practice                     Research

Notions of       Colloquial (Contextual)      Scientific’ (Context free)
evidence         Anything that seems          Proven empirically-rigorously p<0.05?
                 reasonable p<0.5?            Theoretically driven
                 Practice relevant
Time frames      Timely - chronophobic        As long as it takes - chronophilic
for results

Languages        Clear Message                Caveats and qualifications
for
communicati      Practitioner jargon          Research jargon
on
Work             Focus on service             Focus on strict adherence to research
environment      delivery                     rules that give objective validity to results
                 Influenced by the need       and publication of research findings
                 to respond to the            Influenced by academic achievement,
                 immediate reality of         international research reputation, sources
                 human need                   of funding
 •    Based on Davies et al. (2000); Pyra (2003); Shonkoff (2000) and Frenk (1992).
             Two separate disciplines?
   • views knowledge of theory and practice as distinct kinds of
     knowledge (not necessarily in opposition to each other;
     complementary).
      – Each reflects a different ontology (truth claim)
      – Each reflects a different epistemology (method) for
        addressing different questions.
• Aristotle distinguishes between two intellectual virtues: sophia and
  phronesis. Sophia (usually translated as “wisdom” sometimes equated
  with “science”) is the ability to think well about the nature of the world,
  and is used in our attempts to discover why the world is the way it is –
  deals with universals (Think physics)
• Phronesis is the ability to think about how and why we should act in
  order to change things, and especially to change our lives for the better
• Phronesis is about practical wisdom/judgement routed in experience
                                                                   René Kemp
All science is either physics or stamp collecting.
                                       Ernest Rutherford




                                    “Anyone who expects a source of
                                    power from the transformation of
                                    the atom is talking moonshine”
                                                        Ernest Rutherford
    More Rutherford                     Gene            A Basic
                                                     Science View

      Quotations                         RNA
                                                     of the World
                                                     Multi-OMICS
•    “The only possible                Protein

  interpretation of any                 Protein
  research whatever in the            interactions

  'social sciences' is: some do,   Protein complexes
  some don't”
                                   Network of protein
•    “If your result needs a           complexes

  statistician then you should       Tissue Organs
  design a better
  experiment”                          Organism


                                      Ecosystem
                     Project
                     is fixed     Context
                                   must
                                   adapt
                           Research
                Context
                is fixed
                                 Project
                                  must
                                 adapt
T. Greenhalgh
                            Practice
      Issue Often Framed as Rigor vs Relevance




‘As the complexity of a system increases our ability to make
a precise and yet significant statement about its behaviour
diminishes until a threshold is reached beyond which
precision and significance (or relevance) become almost
mutually exclusive characteristics.’          (Zadeh, 1965)
Internal vs. External Validity




 Precise and pointless.
           Importance of rigor and relevance
                                                        Pedantic: fastidious design and
                                                        sophisticated analysis but relevance
                                                        limited (myopic)

                                                        Pragmatic: rigor in method and
                       Pedantic         Pragmatic       relevant to organisations

                                                        Populist: insufficient
    Rigour of method




                                                        rigour/incorrect, ill
                                                        conceived/conducted studies,
                                                        populist books, inadequate
                                             Populist
                        Puerile                         refereeing

                                                        Puerile: low practical relevance,
                                                        insufficient rigour/ incorrect, ill
                                                        conceived/ conducted studies
                           Relevance to practice

Modified from MNK Saunders, Oxford Brooks Univ.
Developed from: Anderson et al. (2001)
             Viewing the gap as…
        a knowledge production problem
If the duty of the intellectual in society
 is to make a difference, the [academic]
 research community has a long way to
 go to realize its potential.
   The action steps to resolve the old
 dichotomy of theory and practice were
 often portrayed with the minimalist
 request for researchers to engage with
 practitioners through more accessible
 dissemination.
   But dissemination is too late if the
 wrong questions have been asked. A
 wider and deeper form of engagement
 between researchers and practitioners
 would entail experimentation with the        Andrew Pettigrew,
 co-funding, co-production, and co-        “Management Research After
 dissemination of knowledge.               Modernism,” Brit. J Mgmt, 2001,
                                             vol. 12, iss. SPI/1, pp. S61-S70
                                     Linking Research & Operations
                                                    Knowledge Generation




  •     Mode 1
          – Linear and often unidisciplinary
          – Developed separate from context
          – Application takes place late in the process
            of generating knowledge
  •
                                                                                                             Basic           Applied
        Mode 2                                                                                              Research         Research

           – Iterative, non-linear, and
             interdisciplinary
           – Developed in context
           – Application is incorporated early
                                                                                                  Application                     Development
           – Includes a range of stakeholders
           – Involves alliances among different
             knowledge communities
Reference: Gibbons, Michael; Camille Limoges, Helga Nowotny, Simon Schwartzman, Peter Scott, & Martin Trow (1994).   Technology
The new production of knowledge: the dynamics of science and research in contemporary societies. London: Sage.
Differences Between Inside & Outside Inquiry-A
            philosophical digression




Roger Evered & Meryl Reis Louis, Alternative perspectives in the organizational sciences:
“Inquiry from the inside” and “inquiry from the outside,” Academy of Management Review, 6, 3 (1981), p. 389.
     CLASSICAL RESEARCH: QUESTION LEADING TO RCT of INTERVENTION
                        UNCHANGED DURING THE STUDY
Interactions with clinicians took place up front; little interaction with managers.


                       Research
                         Need




                       Intervention




                                                                                Outcomes
                          Design                               Implementation
                                      Intervention              Process & Its
                          A       P
                              1                                   Context
                          S       D




                                            Barriers & Facilitators


   Data/Information    Evidence-
   From Collaborator
                         Based
                        Practice




• Results:
   – Publication in Annals of Internal Medicine (Impact Factor = 17.5)
   – As soon as research $$ dried up, intervention dropped, despite
     evidence of efficacy.
       ACTION RESEARH: CLINIC NEED LED TO INTERVENTION:
  IMPLEMENTATION PROCESS INVOLVED MULTIPLE PDSA CYCLES AND
          MODIFICATION OF INTERVENTION (TWEAKING)
             Assessed in a Quasi experimental study
                                                                             A           P

      Clinical                                                               S
                                                                                 1       D
                                                     A       P
                                                                                                         A               P
       Need                                              6                                                       2
                                                     S       D
                                                                     Intervention                        S               D



                                                     A       P
                                                                         Redesign                    A               P

                                                     S
                                                         5   D                                               3
                                                                         A           P               S               D


                                                                         S
                                                                                 4   D




      A       P

          1




                                                                                                                             Outcomes
      S       D
                  A       P

                      2
                  S       D
                              Intervention
    Intervention
       Design                                                                        Implementation
                                                                                        Process &
                                                                                       Its Context
                                                                 A       P
                                                                                     A           P
                                                                     1                       2
                                                                 S       D
                               Barriers and facilitators                             S           D
     Evidence-
       Based
      Practice




• Results
   – Publication is Qual Safety in Healthcare: impact factor = 2.8
   – Effectiveness demonstrated and the ntervention has continued for
     >5 years; more than 600 patients have participated.
                       Action Research
• a form of systematic inquiry
  intended to produce both
  change (action) and
  understanding (research)
• it involves ‘stakeholders’ in
  the research in both shaping
  and carrying out the
  research.




*Green, George, Daniel, et al., Participatory Research…Ottawa: Royal
Society of Canada, 1997. www.lgreen.net/guidelines.html
Major Activities in an Engaged Scholarship Study: Studying complex
   problems with (not for) practitioners and other stakeholders
      Study Context: Complexity, research team organization, stakeholders’ perspectives

 Research Design                                              Theory Building
 Develop variance or process                  Model           Create, elaborate & justify a theory
 model to study theory                                        by abduction, deduction & induction

 Involve methods experts & people                             Involve knowledge experts in
 providing access & information                               relevant disciplines & functions



                    Solution                                         Theory
                                             Iterate
                                              & Fit

 Problem Solving                                              Problem Formulation
 Communicate, interpret & negotiate                           Situate, ground, diagnose & infer
 findings with intended audience.                             the problem up close and from afar
                                              Reality
 Involve intended audience                                    Involve those who experience
 to interpret meanings & uses                                 & know the problem

       A. Van de Ven
          Engaged Scholarship is based on
       a Critical Realist Philosophy of Science
• There is a real world out there, but our understanding of it is limited
• All facts, observations & data are theory laden
• Social science has no absolute, universal, error-free truths or laws
• No form of inquiry can be value free & impartial; each is value full
• Knowing a complex reality demands use of multiple perspectives
• Robust knowledge is invariant (in common) across multiple models
• Models that better fit the problems they are intended to solve are
  selected, producing an evolutionary growth of knowledge.




                                                 Van de Ven
Models of Researcher-Practitioner Collaboration

 • Separate and not even talking
   (~unidisciplinary) {with         On the Impossibility of Collaborative
   Researcher hegemony}                Research – and on the Usefulness of
                                       Researchers and Practitioners
 • Separate, but at least talking      Irritating each Other.
   (~multi-disciplinary)
                                    A. Kieser and L. Leizer
 • Co-creation of knowledge
                                    Paper submitted to Special Issue on
   (~interdisciplinary and maybe       “Organization Studies as Applied
   even transdisciplinary)             Science: The Generation and Use of
    – Action Research                  Academic Knowledge about
    – Engaged Scholarship              Organizationa,” Guest Eds. P.
                                       Jarzabowski, S. Mohrman, and A.G.
    – Mode 2 Knowledge Generation      Scherer.
   Potential Benefits of Participatory Research
• Results are relevant to interests, circumstances, and needs
  of those who would apply them
• Results are more immediately actionable in local situations
  for people and/or practitioners
• Generalizable findings more credible to people,
  practitioners and policy makers elsewhere because they
  were generated in partnership with people like themselves
• Helps to reframe issues from health behavior of individuals
  to encompass system and structural issues.



                 Green LW, Mercer SL. Am J Public Health Dec. 2001.
                Bridging Research and Practice
  Improved                                                         Improved
Understanding                                                       Impact

                         Strategic
                       EDUCATIONAL
                         Supports




                      User-Inspired Research
                     Research-Inspired Reflection

                  Strategic POLICY Supports




  Existing                                                          Current
Understanding                                                      Practices

                                  Dale A. Blyth, Ph.D., U. Minn.
  The Bridge (not the Pipeline) from Research to
                Practice and Back
• If we want more evidence-based practice, we need
  more practice-based evidence.
• The importance of practitioners and policy-makers
  in shaping the research questions.
• Practitioners and their organizations represent the
  structural links (and barriers) to addressing the
  important determinants of health behavior at each
  level. Engage them, not at passive recipients, but as
  partners…

*Green, L.W. From research to “best practices” in other settings and populations. Am
J Health Behavior 25:165-178, April-May 2001. Full text: www.ajhb.org/25-3.htm.
Strategies for building relationships between the three
cultures (researchers, practitioners, and policy makers):
• Ongoing, regular communication between researchers and users: (eg,
  conduct spontaneous and planned exchanges and face to face meetings,
  partnerships, best practice demonstrations, workshops and seminars)
• Involve practitioners and decision makers early and throughout all stages
  of the research process
• Generate knowledge in a shared manner
• Allow sufficient time for people to understand fully and connect their
  needs to what is being proposed/discussed
• Utilise opportunities for researchers to ‘shadow’ policymakers and vice
  versa
• Include decision makers in the governing or consulting bodies of research
  centres

• Sources: Black & Donald (2001); Davies et al. (2000b); Fixsen et al. (2005);
  Innvaer et al. (2002); Lomas (2000); Nutbeam (2003); Percy-Smith et al.
  (2002); Pyra (2003).
                                                 KERRY LEWIG, FIONA ARNEY
                                                 AND DOROTHY SCOTT
There does not exist a category of
science to which one can give the
name applied science. There are
science and the applications of
science, bound together as the fruit
of the tree which bears it.
                   Louis Pasteur
“…the world of ideas and the world
of action are not separate…, but
inseparable parts of each other.
Ideas, in particular, are the truly
potent forces that shape the
tangible world. The man and
woman of action have no less
responsibility to know and
understand than does the scholar”
               Avedis Donabedian

								
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