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					       Knowledge translation

            Janet Curran, PhD
CIHR Postdoctoral Fellow in Knowledge Translation
      Clinical Epidemiology Program, OHRI
                University of Ottawa
• Are you currently involved/planning a
  research project?
• What do you know about knowledge
  translation ?
• What do you think about your role as
  it relates to knowledge translation?
       Objectives of this presentation

• Increase your understanding of knowledge translation
• Become more familiar with the role of the researcher in
  regards to knowledge translation
• Present different tools to guide development of an end-
  of-grant KT plan
           Knowledge translation

CIHR definition
• Knowledge translation is a dynamic and iterative process
  that includes the synthesis, dissemination, exchange and
  ethically-sound application of knowledge to improve the
  health of Canadians, provide more effective health
  services and products and strengthen the healthcare
  system.
• This process takes place within a complex system of
  interactions between researchers and knowledge users
  which may vary in intensity, complexity and level of
  engagement depending on the nature of the research
  results and on the needs of the particular knowledge
  user.
           Key terms in the definition

• Synthesis: emphasize the importance of understanding how
  the results from a single research study mesh with the larger
  body of knowledge.
• Dissemination: the communication of research results through
  a targeted approach, tailoring the message for a particular
  audience
• Exchange of knowledge: refers to the interaction between the
  research user and the research producer that results in
  mutual learning.
• Ethically sound application of knowledge: implies that the
  findings being applied are consistent with ethical principles
  and norms, social values and legal and other regulatory
  frameworks.
• Application: is used to refer to the iterative process by which
  research findings are put to use.
              KT terms encountered
applied health research           knowledge mobilization
capacity building                 knowledge transfer
co-optation - cooperation -       linkage and exchange
    competing                     popularization of research,
diffusion*                        research into practice
dissemination*                    research mediation
getting knowledge into practice   research transfer
impact                            research translation
Implementation*                   science communication
knowledge communication           teaching
knowledge cycle                   “third mission”
knowledge exchange                translational research
knowledge management              transmission
knowledge translation             utilization
                                  *cited most frequently
  Challenge of knowledge translation

• Clinical research is consistently producing new
  findings that may contribute to effective and
  efficient patient care
• The findings of such research will not change
  population outcomes unless healthcare
  professionals (and healthcare organizations)
  adopt them

                   Grimshaw, Ward, Eccles. Oxford Handbook of Public Health.
Challenge of Knowledge translation
Why do we need to think about knowledge translation?
•  Dissemination of research findings is primarily done by
   publication in peer reviewed journals
•  Consistent evidence of failure to translate research
   findings into clinical practice
  • 30-40% patients do not get treatments of proven
      effectiveness
  • 20–25% patients get care that is not needed or
      potentially harmful
                         Schuster, McGlynn, Brook (1998). Milbank Memorial Quarterly
                                                            Grol R (2001). Med Care
Knowledge for knowledge translation

Potential barriers to evidence based practice –
  knowledge management
• Over 20,000 health journals published per year
• Published research of variable quality and
  relevance
• Individual studies rarely by themselves provide
  sufficient evidence for policy or practice changes
• Individual studies are often misleading
Knowledge for knowledge translation

Potential barriers to evidence based practice –
  knowledge management
• Research users (consumers, health care
  professionals, policy makers, researchers) often
  poorly trained in critical appraisal skills
• Average time professionals have available to
  read = <1 hour/week
• What is the role of the researcher in
  the KT process ?
         Roles of the researcher
  1. Creating knowledge that is relevant
• Inform your study with previous research results and
  think about the ways in which your study can and should
  contribute to the existing body of knowledge
   • Review and appraise the literature
   • Choose the appropriate research approach and
     design
   • What about replication?
   • Choose measurement tools that will facilitate the
     synthesis of knowledge
Knowledge to action loop


                     Knowledge to
                     Action loop
                     From: Graham ID et al.
                     Lost in Knowledge
                     Translation: Time for a
                     Map? Journal of
                     Continuing Education in
                     the Health Professions,
                     2006
Knowledge for knowledge translation


                          Knowledge to
                          Action loop
                          From: Graham ID et al.
                          Lost in Knowledge
                          Translation: Time for a
                          Map? Journal of
                          Continuing Education in
                          the Health Professions,
                          2006
KT also important between researchers
              Roles of the researcher
        2. Planning the dissemination and
        communication of research results
• Expectations and guidance provided varies between funding
  agencies
• Plans developed often guided by tradition or the ISLAGIAT
  principle
• SR of organizing frameworks related to research
  dissemination
   • 33 frameworks met inclusion criteria (20 for
     dissemination activities, 13 for broader KT activities)
   • 28/33 based in part on one or more of 3 theories:
     persuasive communication, diffusion of innovation theory
     and social marketing (Wilson et al Implementation Science 2010;5:91)
Action cycle


               Knowledge to
               Action loop
               From: Graham ID et al.
               Lost in Knowledge
               Translation: Time for a
               Map? Journal of
               Continuing Education in
               the Health Professions,
               2006
  Barriers to Knowledge Translation

• Structural (e.g. financial disincentives)
• Organisational (e.g. inappropriate skill mix, lack
  of facilities or equipment)
• Peer group (e.g. local standards of care not in
  line with desired practice)
• Individual (e.g. knowledge, attitudes, skills)
• Professional - patient interaction (e.g. problems
  with information processing)
                            KT plan

• Five key questions
  • What should be transferred?
  • To whom should research knowledge be
    transferred?
  • By whom should research knowledge be
    transferred?
  • How should research knowledge be transferred?
  • With what effect should research knowledge be
    transferred?
          Lavis JN, Robertson D, Woodside JN, Mcleod CB, Abelson J (2003) Milbank Quarterly
           Targeted audiences for KT

Audience         Basic   Clinical   Health     Population
                                    Services   Health
Researchers       +++      +++         +++         +++
Professionals              +++         +++
Patients                   +++         +++
Administrators                         +++         +++
Policy Makers              +++         +++         +++
Industry          +++      +++
…..
                    KT Strategies

• Variety of different strategies
• Effectiveness varies in different context
   Examples:
     workshops
     education outreach
     distribution of printed materials
     distribution of clinical guidelines
     targetted messages
     audit and feedback
     media campaign
     opinion leaders
      Cochrane Effective Practice
 and Organisation of Care (EPOC) Group
EPOC aims to undertake systematic reviews of
  interventions to improve health care systems and health
  care delivery including:
• Professional interventions (e.g. continuing medical
  education, audit and feedback)
• Financial interventions (e.g. professional incentives)
• Organisational interventions (e.g. the expanded role of
  pharmacists)
• Regulatory interventions
 Bero, Eccles, Grilli, Grimshaw, Gruen, Mayhew, Oxman, Shepperd, Tavender, Zwarenstein (2006). Cochrane Library
http://cadth.ca/index.php/en/compus/optimal-ther-
              resources/interventions
             Research Dissemination

• Development of an END-OF-GRANT KT PLAN
  • Multiple tools are available
      • Institute for Work & Health
          • http://www.iwh.on.ca/system/files/at-
              work/kte_planning_guide_2006b.pdf
      • Developing an effective dissemination plan RUSH
          • http://www.researchutilization.org/matrix/resources/dedp/
            Dissemination.pdf
      • SickKids Fondation
          • http://www.sickkidsfoundation.com/grants/knowledge.asp
      • CHSRF Tools to help organizations create share and use
        reserach
          • http://www.chsrf.ca/keys/use_disseminating_e.php
          Roles of the researcher
    3. Assess and synthesize research
  findings to develop KT tools/products
• Getting involved in the development of:
  • Systematic reviews
  • Clinical practice guidelines
  • Decision aids
  • Web sites
  • Databases
  • Clinical care pathways
  • Electronic systems or reminders
  • Etc.
         Roles of the researcher
4. Studying the processes and outcomes
             of KT research
• Describing, predicting, evaluating professional behaviour
  change
• Assessing facilitators and barriers in different contexts
   • Characteristics of the knowledge/innovation, the
     adoptors/users and the context/environment
• Developing and testing KT interventions
• Evaluating sustainability of change
      Knowledge translation research

• Knowledge translation is a human enterprise that
  can be studied to understand and improve
  knowledge translation approaches

• Knowledge translation research is the scientific
  study of the determinants, processes and outcomes
  of knowledge translation.

• Goal is to develop a generalisable empirical and
  theoretical basis to optimize KT activities
Using Psychological Theory to Explore Use of
Canadian CT Head Rule in Emergency Practice
Objectives: 1. What factors influence emergency physicians’ use of
  the Canadian CT Head rule? 2. Can theoretical domains from the
  Michie framework assist in explaining physicians use of the
  Canadian CT Head rule?
Method: A purposive sampling technique 2-3 physicians from the
  intervention sites. One-to-one semi-structured telephone interviews
  were guided by the 12 domains identified in the Michie framework.
  Interviews were audio-recorded, transcribed and anonymised.
  Physicians were offered a $50 honorarium for their participation.
Analysis: Used Nvivo 9. Utterances classified into theoretical domains
  by two coders. Similar utterances grouped. Beliefs/themes
  generated. Relevant beliefs identified by frequency and impact on
  behaviour.
             Theoretical Domains Interview Framework
                                                                                          (Michie S,Qual Saf Health Care. 2005;14:26-33)



              Theoretical Domain                                                     Interview Questions

(1)    Knowledge                                 Do you use the Canadian CT Head rule in your practice? What do you think of the evidence
                                                 that supports the rule?
(2) Skills                                       How do you use the rule? What steps do you normally follow when using the rule? What
                                                 skills are needed to use the rule?
(3) Social/professional role and identity        Is there anything about your professional role as an ED physician that influences your use of
(Self-Standards)                                 the rule? Do your colleagues generally agree with you regarding your use of the rule?

(4) Beliefs about capabilities (Self-efficacy)   How confident do you feel in your ability to apply the rule? What problems have you
                                                 encountered when using the rule?
(5) Beliefs about consequences (Anticipated      What do you think are the consequences of using the rule? What are the specific patient,
outcomes/attitude)                               financial or provider benefits or harms that occur as a result of using the rule?

(6) Motivation and goals (Intention)             How important is the Canadian CT Head rule for managing patients with minor head injury?
                                                 Are there incentives for using the rule?
(7) Memory, attention and decision processes     How easy or difficult is it to remember the rule? Do you sometimes forget? When? What
                                                 triggers your use of the rule?
(8) Environmental context and resources          What factors in your clinical environment influence your use of the rule? Are there competing
(Environmental constraints)                      tasks or time constraints that influence your use of the rule?

(9) Social influences (Norms)                    Do other physicians in the ED influence your use of the rule? If so, how? Do physicians
                                                 outside your ED influence your use of the rule?
(10) Emotion (Emotion)                           Does using the rule ever evoke an emotional response in you? Do your patients emotions
                                                 ever affect your decision to use the rule?
(11) Behavioural regulation                      What do you think is needed to ensure you consistently use the Canadian CT Head rule?

(12)Nature of the behaviour                      How often do you see patients with minor head injury? Do you usually use the rule when
                                                 managing these patients?
                                  Preliminary Results
         Theoretical Domain                                             Sample Quotes

(4)Beliefs about capabilities (self     “the mechanism which is sometimes a little confusing, the fall from elevation
efficacy)                               always confuses me as well as some of my colleagues (Int 1). “quite
                                        confident, strongly confident (Int #6)


(5) Beliefs about consequences          “It is particularly useful when we are dealing with patients or patient’s families
(Anticipated outcomes/attitude)         who are demanding CT Heads on patients with minor head injures because
                                        then you can tell them that there is evidence-based” (Int1)


(7) Memory, attention and decision      “It’s not intuitive. I mean for me I’ve got too many things in my head already
processes                               going on, you know, when you are managing 10 patients at a time” (Int5)


(8) Environmental context and           “We are a trauma centre so sometimes patients do arrive on a spine board
resources (Environmental constraints)   and a collar and they are whisked to the trauma room so even though they
                                        may have a minor mechanism sometimes you may be biased by the location
                                        of the patient” (Int6)

(9) Social Influences                   “the only influence that would change my mind is the patient” (Int4) “there are
                                        times when I’ve stretched the rules a little bit or you know because of a
                                        patients anxiety”(int 1)
(11) Behavioural regulation             “there’s only one risk factor that gives people (trouble), mechanism of action,
                                        because people often get confused when the take a fall. Was it a fall from a
                                        height or were they just standing” (Int3)
        Roles of the researchers
  5. Getting stakeholders involved and
 studying the KT processes & outcomes
• Conducting integrated KT research
   • involves active collaboration between researchers and research
     users in all parts of the research process, including the shaping
     of the research questions, decisions about the methodology,
     involvement in the data collection and tools development,
     interpretation of the findings and dissemination and
     implementation of the research results.
   • also known by such terms as collaborative research, action-
     oriented research and co-production of knowledge.
   • research users can be other investigators from different
     disciplines, teams or countries but more often are policy and
     decision-makers, clinicians or the public.
          Replication Research: Developing a
         Framework for Knowledge Translation
            Research (CIHR Funded KS Grant 2010)
•   Abstract: Up until now, there has been little discussion of the importance of
    replication in knowledge translation (KT) that could further contribute to the quality of
    research results essential for the improvement of health care services provided to
    Canadians. The purpose of this knowledge synthesis is to develop a framework for
    promoting and conducting informative replication of KT evaluative studies. This
    framework will be developed in collaboration with a diverse group of knowledge
    users: KT researchers, policy makers, funding agency representatives and journal
    editors. The specific objectives of this review are: 1) to clarify the concept replication,
    2) to identify the consequences of and the conditions for its use, 3) to examine the
    extent and types of replication used in KT research and 4) to make recommendations
    for appropriate replication in KT research. Since this synthesis involves synthesizing
    evidence from heterogenous sources and research traditions, it will be guided by the
    principles of concept analysis and meta-narrative review. Concept analysis is a formal
    exercise that permits definition of concept attributes and critical elements and meta-
    narrative review is an interpretive method proposed to synthesize literature from a
    complex body of evidence. Investigators and knowledge users on this proposal will
    collaborate on refining the research questions, developing data collection tools and
    interpretation of findings. At the end of grant, a consensus workshop will bring
    together national and international stakeholders to elaborate recommendations and
    devise a framework for replication in KT responsive to the needs and preferences of
    the various stakeholder groups
                  Summary

• KT is about ensuring that stakeholders are
  aware of and use research evidence to inform
  their decision making
• The role of the researcher in KT varies
  depending on the project
• Knowledge to action loop provides framework
  for thinking about knowledge translation
• Different approaches likely to be needed
  depending on innovation, barriers to adoption,
  targeted stakeholders and health care system
                    Final words…….

• the intensity of knowledge translation should depend on factors
  such as the potential importance or impact of applying the
  findings, the amount and strength of the evidence supporting the
  findings (often determined by synthesis), the target audience(s),
  what is known about effective strategies to reach the
  audience(s), what is practical and feasible to do under the
  circumstances and considerations of who else should be
  involved in KT efforts

                                               (Tetroe, 2007)
Contact details


   Thank you

   Janet Curran
  jacurran@ohri.ca

				
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