Knowledge translation frameworks: Narrowing the gap between evidence and practice

There is a large gap between what we know and what we practice and the way to narrow that gap is not always clear, especially in the context of clinical practice where clinical guidelines are often ignored by healthcare professionals. There is often considerable time that elapses before research findings are transferred to common practice.

Various strategies are used to try and bring about a movement towards evidence-based practice and associated change in practitioners’ behaviour. These include Continuing Medical Education (CME), Continous Professional Development (CPD) and Knowledge Translation (KT). KT has been positioned as a construct that subsumes and builds upon CME and CPD, minimising the limitations of those approaches, as well as offering new insights into behavioural change (Davis, et al., 2003). See pg. 34 of Davis, et al. (2003) for a table comparing the basic characteristics of CME, CPD and KT.

For example, workshops are often suggested as possible ways to help implement change by inviting stakeholders and getting them to participate in discussion around the change. However, workshops in the context of CME and CPD are either teacher- or learner-focused and relatively rarely include the patient or health systems context. In addition, change is a process and not an event, which may be another reason for why workshops often don’t work in this context. It seems clear that logic and pragmatism are not necessarily the best way to implement and drive change in clinical practice and knowledge translation frameworks show some promise as potentially useful tools to help guide the process.

The effectiveness of strategies that aim to bring about behavioural change is highly variable and dependent on the setting, and success is often determined by whether or not the strategies have been appropriately tailored to the unique context of the setting (Santesso & Tugwell, 2006). The Ottawa Model of Research Use (OMRU) is one example of a KT framework that incorporates this concept, as well as having an interdisciplinary focus. It consists of six elements:

  1. Setting the stage
  2. Specify the innovation
  3. Assess the innovation, potential adopters and the environment for barriers and facilitators
  4. Select and monitor the knowledge translation strategies
  5. Monitor innovation adoption
  6. Evaluate outcomes of the innovation

Underlying the OMRU model is the idea that success rests with tailoring the KT strategies to the relative barriers and supports that are found within the setting in which behavioural change is sought (Santesso & Tugwell, 2006).

Knowledge translation encourages the integration of insights and experiences from many disciplines, including informatics, social and educational psychology, organisational theory, and patient and public education. This means that the approach incorporates a range of perspectives beyond what healthcare professionals are able to provide on their own, with the possibility for more diverse and creative solutions to arise. This seems prudent since the most effective strategies for behavioural change tend to be those that are more active in nature, and which incorporate multiple interventions (Davis, et al., 2003).

Graham et al., (2006, pg. 22) offer the following practice points regarding KT:

  1. Knowledge translation is about turning knowledge into action and encompasses the process of both knowledge creation and knowledge application.
  2. Knowledge translation subsumes and builds on continuing education and continuing professional development.
  3. Healthcare professionals need to learn about planned-action theories and frameworks so as to be able to understand and influence change in their practice settings.
  4. Continuing education should be based on the best available knowledge, whether in the form of knowledge tools (e.g. practice guidelines), knowledge syntheses, or primary knowledge enquiries.
  5. Continuing education should apply strategies known to be effective at transferring knowledge.

It should be noted that, while KT seems to show some promise for changing clinician behaviour when it comes to adopting evidence-based practices in healthcare, there are some limitations to the approach, including the fact that the approach remains largely intuitive and untested in large-scale, rigorous studies (Davis, et al., 2003).

Resources and references

Twitter Weekly Updates for 2011-07-04

  • U.N. Report Declares Internet Access a Human Right | Threat Level | Wired.com http://bit.ly/ivNke2 #
  • #saahe2011 officially over. It was a wonderful conference made possible by the participation of health educators from all over the country #
  • Papert http://bit.ly/mggi6R. Being a revolutionary means seeing far enough ahead to know that there is going to be a fundamental change #
  • Papert http://bit.ly/le70h7. The impact of paper in education has led to the exclusion of those who don’t think in certain ways #
  • @dkeats When people are “experts” in a domain they can be blinded to great ideas in other fields and so miss opportunities to drive change #
  • @dkeats Agreed. I’ve had to work really hard to convince people in my dept that I’m not the “computer guy”, I’m the “education guy” #
  • Innovation is about linking concepts from different fields to solve problems, its not about doing the same thing with more efficiency #
  • “How do you learn enough of the words to make sense of the discipline?” #saahe2011 #
  • Presentation by David Taylor on the use of adult learning theories #saahe2011 #
  • Jack Boulet speaking about the challenges and opportunities in simulation-based assessment #saahe2011 #
  • Mendeley Desktop 1.0 Development Preview Released http://ow.ly/1ueXSs #
  • Social media is inherently a system of peer evaluation and is changing the way scholars disseminate their research http://ow.ly/1ueXMA #
  • @dkeats Wonder if the problem has to do with the fact that much “ed tech” is designed by Comp Scientists, rather than Social Sci? #
  • @dkeats Also, people have the idea that LMSs have something to do with T&L, & then struggle when it can’t do what they need it to #
  • @dkeats To qualify, the problem isn’t resistance, its misunderstanding. The conversation always ends up being about technology #
  • There’s a huge difference between “learning” & “studying”, not in terms of the process but ito motivation & objectives #
  • @thesiswhisperer conf is for health educators, mostly clinicians, many of whom are amazing teachers but for whom tech is misunderstood #
  • In a workshop with David Taylor, looking at using adult learning theories #saahe2011 #
  • Blackboard is a course management system, it has little to do with learning. Use it for what its designed for #saahe2011 #
  • Trying to change perception that technology-mediated teaching & learning isn’t about technology. Not going well #saahe2011 #
  • Just gave my presentation on the use of social networks to facilitate clinical & ethical reasoning in practice contexts #saahe2011 #
  • Deborah Murdoch Eaton talks about the role of entrepreneurship to innovate in health education #saahe2011 #
  • Social accountability is relevant for all health professions (healthsocialaccountability.org) #saahe2011 #
  • Charles Boelen talks about social accountability at #saahe2011 keynote, discusses its role in meeting society’s health needs #
  • First day of #saahe2011 over. Lots of interesting discussion and some good research being done in health science education #
  • Concept mapping workshop turned out OK. Got a CD with loads of useful information…a first for any workshop I’ve attended #saahe2011 #
  • Many people still miss the point when it comes to technology-mediated teaching & learning. Your notes on an LMS is not teaching or learning #
  • At a workshop on concept mapping, lots of content being delivered to me, not much practical yet #saahe2011 #
  • Noticed a trend of decreasing satisfaction from 1-4 year, even though overall scores were +. Implications for teaching? #saahe2011 #
  • Banjamin van Nugteren: do medical students’ perceptions of their educational environment predict academic performance? #saahe2011 #
  • Selective assignment as an applied education & research tool -> gain research exp, improve knowledge & groupwork #saahe2011 #
  • Reflective journaling: “as we write conscious thoughts, useful associations & new ideas begin to emerge” #saahe2011 #
  • Change paradigm from “just-in-case” learning to “just-in-time” learning #saahe2011 #
  • Benefits of EBP are enhanced when principles are modelled by clinicians #saahe2011 #
  • EBP less effective when taught as a discrete module. Integration with clinical practice shows improvements across all components #saahe2011 #
  • Students have difficulty conducting appraisals of online sources <- an enormous challenge when much content is accessed online #saahe2011 #
  • Looking around venue at #saahe2011 10 open laptops, 2 visible iPads (lying on desk, not being used), about 350 participants…disappointing #
  • EBP isn’t a recipe (or a religion), although that is a common misconception #saahe2011 #
  • Prof. Robin Watts discusses EBP and facilitating student learning. EBP isn’t synonymous with research #saahe2011 #
  • “A lecture without a story is like an operation without an anaesthetic” Athol Kent, #saahe2001 #
  • Kent drawing heavily on Freni et al, 2010, Health professionals for a new century, Lancet. #
  • #saahe2001 has begun. Prof. Athol Kent: the future of health science education #
  • Portfolios and Competency http://bit.ly/jfFpfU. Really interesting comments section. Poorly implemented portfolios aren’t worth much #
  • @amcunningham I think that portfolios can demonstrate competence and be assessed but it needs a change in mindset to evaluate them #
  • @amcunningham will comment on the post when I’m off the road #
  • @amcunningham Can’t b objective as I haven’t used NHS eportfolio. Also, its hard 2 structure what should be personally meaningful experience #
  • @amcunningham Portfolios must include reflection, not just documentation. Reflection = relating past experience to future performance #
  • @amcunningham Your delusion question in the link: practitioners / students not shown how to develop a portfolio with objectives #
  • @amcunningham Also spoke a lot about competency-based education and strengths / limitations compared to apprentice-based model #
  • @amcunningham Very much. Just finished a 4 day workshop that included the use of portfolios as reflective tools in developing competence #
  • Final day of #safri 2011 finished. Busy with a few evaluations now. Spent some time developing the next phase of my project. Tired… #
  • Last day of #safri today, short session this morning, then leaving for #saahe2011 conference in Potchefstroom. It’s been an intense 5 days #
  • Papert: Calling yourself some1 who uses computers in education will be as ridiculous as calling yourself some1 who uses pencils in education #
  • Daily Papert http://bit.ly/jKlVmn. 10 years ago, Papert warned against the “computers in education” specialist. How have we responded? #
  • Daily Papert http://bit.ly/m7rfYY. Defining yourself as someone who uses computers in education, is to subordinate yourself #
  • YouTube – Augmented Reality Brain http://bit.ly/kcZWXy. When this is common in health education, things are going to get crazy #
  • @rochellesa Everyone needs some downtime, especially at 10 at night when you’re out with your wife 🙂 Seems like a nice guy, very quiet #
  • @rochellesa The large policeman he’s with isn’t keen tho. Mr Nzimande has asked 2 not b disturbed. Understandable when u want to chill out #
  • I’m sitting in a hotel in Jo’burg & Minister of Higher Education Blade Nzimande walks in and sits down next to me. Any1 have any questions? #

SAAHE conference, 2011 – day 1

Introduction by Dr. Lionel Green-Thompson

A country whose health is fragile

The future of health science education: 2020 vision by Prof. Athol Kent

“After an introduction like that I can’t wait to hear myself speak”

It’s not the strongest or fittest who survive but the ones who are most adaptable to change

  • Who will our students be?
  • How many of them will we need?
  • Who will their teachers be?
  • What will we teach them?
  • How will we teach them?

They will be smarter, better prepared, more IT literate, more women, more black students

We need far more than are currently graduated, more from rural areas, more mid-level workers, clinical assistants

“Innovation through diversity”

Why do health professionals leave? Political, security, working conditions, financial reasons

Makes reference to Freni, et al, Health Professionals for a new century, The Lancet

30% of all posts are unfilled

Need to increase intake & satellite campuses must evolve

All service posts should have a teaching component

Doctors who want part-time work (e.g. mothers) can be integrated as clinical teachers

Generalists who teach as opposed to specialists

Peer teaching should become a core, significant component of clinical teaching (“the mark you get will be the same mark your students get”)

Syllabus will change from curative to preventative → PHC, lifelong learning, less factual, more core and process orientated (“we can’t possibly teach all the facts”, “teach how to learn”)

“The world is flat” → information is everywhere

Move from university → centres → health/education system-based

Teach students HOW to learn

Move from assessment of learning → assessment for learning

“A lecture without a story is like an operation without an anaesthetic”

800 specialised language forms in O&G alone ← imagine what this must look like to a new clinical student

Is the gap between secondary education and health science education going to increase?

The content we give students today is based on work that was done 5 years ago. In 10 years time that content will be less valuable even than today. For all intents and purposes, the content is irrelevant. We need to give students the tools to identify gaps in their own knowledge, and the skills to find the answers to the questions that will help fill those gaps.


Evidence-based practice: how can we facilitate student learning? by Prof. Robin Watts

Practice = EBP is nothing if concepts are not implemented in clinical practice

Evidence-informed practice? More inclusive in that it implies that evidence isn’t the only factor in clinical decision-making, and that practice knowledge is an important component to take into account

Different language roots have an impact on how EBP is understood by people from different parts of the world

EBP steps:

  • Asking (Population, phenomenon of Interest, Context, Outcome)
  • Acquiring
  • Appraising (levels of evidence – hard for students to conduct appraisals of online sources)
  • Applying
  • Assessing

Is evidence derived from medical research directly generalisable to other health disciplines? Should be be modified? Avoid making assumptions of transferability

Springer, “7 pillars of information literacy”

Discrete subject (EBP separate from other modules), or integrated throughout and within other modules? Standalone courses appear to be less effective than integrated. Discrete modules found improvement in basic knowledge, but no impact on appraisal ability. It integrated into clinical practice, improvements occur throughout. Integration should be well-designed.

Content in EBP module should be sequenced, building on previous content / components

Benefits of EBP enhanced when modelled by clinicians

Integrating EBP into the curriculum requires a culture and mindset change

 

Morning POEMs (Patient Oriented Evidence that Matters) – Teaching Point-of-care, patient centred, evidence-based medicine by Dr. Eamon C. Armstrong

Patient presentation followed by real-time internet search for best available evidence → discussion of patient management using those sources

EBM triad:

  • good clinical expertise
  • best external evidence
  • patient values and expectations

POEM = valid:

  • information that patient will care about i.e. has positive patient outcomes
  • addresses a common problem
  • should require a change in practice

How do you brindge the growing knowledge “chasm”

Change the paradigm from “just-in-case” (learn everything in case it comes up) to “just-in-time” (learn what you need, when you need it)

Negotiate common ground around medical decision-making

Prior to the introduction of POEMs, use of electronic sources was scant (study done in US hospital)

Led to fundamental change in prevailing teaching and learning practice

 

The use of reflective journaling in the training of play therapy students by Isabella Jacobs

Reflection used to raise personal awareness, and integrate theory into practice

Students find that ideas become clearer when they write them down, they have to declare concepts in concrete form

Existential dialogue = ways of being, reflective journal may help to implement

Students must receive guidance regarding expectations for jounnaling i.e. must be structured

Role of the self in patient encounters

Journals not assessed, although a random selection of journals were analysed

Students not informed prior to journaling that the journals would be researched, so as not to influence their responses. Informed consent obtained from students after assignments were completed

Students initially reluctant to participate in journaling, but awareness of self began to emerge over time

“as we write conscious thoughts, useful associations and new ideas begin to emerge” (Miller, in Moon, 2006)

“regain my balance by losing my mind” (student quote)

“I do not want to be in unawareness anymore” (student quote)

Some students referred to the process as “a life changing experience”

 

Selective alignment as an applied education and research tool by Sophia Fourie

Assingment which served as an educational tool and research project

Students gained research experience, improved knowledge, and encountered principles of rational drug prescription

 

Do emergency medical care student’s perceptions of their educational environment predict academic performance? by Benjamin van Nugteren

Role of the academic environment in student success?

Identify areas of student dissatisfaction / satisfaction

Used the DREEM questionnaire: 50 statements based on 5 point Likert scale

Looked at:

  • perceptions of learning
  • perceptions of teachers
  • academic self-perception
  • atmosphere
  • social self-perception

Associated above outcomes with academic performance

Noticed a trend of decreasing satisfaction in all of the above components from 1st – 4th year medical students, even though overall satisfaction was reasonably high. What are the implications considering these students are going straight into clinical practice? Is burnout beginning already?

When the data is connected relative to final exams / other stressors might make a difference to student perceptions

 

Workshop: Concept maps and cognition by Dr. Stephen Walsh

Here’s the basic concept map I made during the short workshop:

 

Reflective blogging in an Evidence-based practice module

During 2010 a colleague and I studied the use of blogging to facilitate reflection among postgraduate physiotherapy students as it related to the process of learning evidence-based practice. We’re in the last stages of writing the article and have developed a poster that will be presented at the World Congress of Physical Therapy in Amsterdam during June.

Here’s the poster:

Frantz & Rowe – Blogging to Facilitate Reflection in EBP

Developing clinical reasoning and critical thinking

“Clinical reasoning is a process in which the therapist, interacting with the patient and significant others (e.g. family and other health-care team members), structures meaning, goals and health management strategies based on clinical data, client choices and professional judgment and knowledge (Higgs & Jones, 2000).

Clinical reasoning is difficult, if not impossible to “teach” (if anything is actually possible to teach [Game & Metcalfe, 2009]) but can be developed indirectly through careful course design. I’m trying to move my teaching from helping students to answer the simple Who, What, Where and When questions, to answering the more complex How and Why questions. Instead of memorising content, which is how most of my students prefer to study, I’m trying to help them see the value in developing a deeper understanding of the topic. To use the content as a framework around which we can use critical thinking to apply our understanding of theory, to practice. In other words, to develop clinical reasoning.

I’ve started to change the types of assignments I give to my students, to try and integrate some form of critical thinking. I’ve uploaded and shared the last assignment handout on Google Docs (unfortunately I only have the PDF…seem to have deleted to ODT version), and would love suggestions or feedback on the process. The feedback from students has been great and the quality of the work they produce has been of a very high standard. I’ve found that the feedback from the drafting process (a requirement of the assignment) really helps to give direction to the students, and although they are initially resistant to the idea (they want to submit work that is perfect), they see the value when they get their scripts back and have the opportunity to refine their arguments.

The research and evidence-based practice component is something that we’re trying to incorporate into all of our modules, but which currently is covered only superficially. Students don’t understand how to extract relevant information from academic publications, probably because they lack the specific academic literacies required in higher education. Once we establish that they need only identify the main conclusion of the study (this is at a second year undergraduate level), and use that conclusion to construct an argument, they manage just fine.

Game, A., & Metcalfe, A. (2009). Dialogue and team teaching. Higher Education Research & Development, 28(1), 45-57. doi: 10.1080/07294360802444354

Higgs, J. & Jones, M. (2000). Clinical reasoning in the health professions. In Clinical Reasoning in the Health Professions, 2nd edition (J. Higgs & M. Jones, eds), pg. 3-14

Physiopedia: awesome physiotherapy reference site

I came across Physiopedia when the site creator, Rachael Lowe, followed me on Twitter.  Physiopedia is a free (to access, not edit) physiotherapy reference that has a great emphasis on being evidence based.  You must be a registered physiotherapist to get an account that enables you to contribute, which is how the site maintains quality control.  A quick overview of the articles reveals that this is indeed a high quality resource for physiotherapy clinicians, educators and students.  Perhaps the best thing about each article is not only the concise information it presents, but the reference list it provides for each article, pointing the reader to original resources.  It’s a very impressive effort.

You may wonder why I’m mentioning Physiopedia since my own site, OpenPhysio, is an attempt to be the same thing…a free physiotherapy resource for clinicians, educators and students.  There are however, some differences that I think are worth pointing out, the main one of which is the issue of licensing.  All the content published on OpenPhysio is specifically released under this Creative Commons license, which allows anyone to take that content and share, distribute and adapt the work, so long as they provide attribution to the original source, don’t make any money from it, and agree to share it under the same conditions.  I think this is an important distinction that in itself, is enough to differentiate the two projects.  Not that Physiopedia is using some heinous license, it’s just that it’s not specifically open.  The other thing that stands out immediately is the clean aesthetic and writing style of Physiopedia.

I think that there’s a lot of work that needs to be done on OpenPhysio if it’s going to participate in a field with such high quality content, but that’s the whole point isn’t it?  As long as there are people pushing this agenda, the future of free and open content is looking good.  At the end of the day, the more information that’s available for physiotherapists and students, the stronger we’ll become as a profession.

Note (06/04/09): I just received an email from Rachael stating that Physiopedia used the GFDL, a great license for promoting open content.

HESS conference: a summary of my thoughts

OK, so I’ve been back for a few weeks now and have had a little bit of time to gather my thoughts regarding the HESS conference, and thought I’d make a note of some of the highlights from my limited perspective.  If anyone from the conference feels that I’m way off the mark, feel free to drop me a line.

One of the key themes that emerged was the idea that research should be taken down off of it’s pedestal and integrated into the curriculum as a functional, useful and exciting aspect of teaching and learning.  Dr Angela Brew established this idea in the first keynote of the first day.  That research should not be seen purely as a series of steps to be undertaken in the lofty towers of higher education, but should rather be seen as an integral part of teaching and learning.  The phrases “research-based learning” and “inquiry-based learning” cropped up regularly over the three days.

This idea that research should become part of the curriculum, rather than something tacked on, moved the conversation into another strong theme, that of the “scholarship of teaching and learning”.  In order to teach in your field, it’s no longer enough to merely know your subject.  The move towards evidence-based practice doesn’t only apply to our own niche fields, but should be applied equally strongly in how we approach the way we teach.  The concept of “communities of practice” came through strongly in this realm.

Martin Oliver’s keynote negotiated the fine line between technology in education as an all-powerful saviour, and a potentially misleading mindset that puts the technology, rather than pedagogy, first.  While e-learning was generally lauded as a powerful tool, enthusiasm should be tempered with optimistic caution.  With technology changing so quickly, it seems that a predominant focus on the tools themselves, rather than pedagogy, will be met with failure.

There were a few presentations I attended that urged educators to become more aware of students social lives, which came with evidence of the fact that they are not always as we imagine them to be.  Realising that students often have significant difficulties in almost every aspect of their personal lives can (and should) change how we relate to them.  As educators, we should understand that not only do we bring our own personalities and quirks into the higher education space, but so do our students.

Here are the notes I took while at HESS 2008:

Summary of HESS 2008 (OpenDocument format)
Summary of HESS 2008 (MS Word format)

Clinical guidelines: should we be using them?

I attended a lecture a few days ago by Karen Grimmer-Somers, a professor at the University of South Australia and Director of the Centre for Allied Health Evidence (CAHE). An adjunct professor at the University of Stellenbosch, she visits Cape Town every year or so and this year we were fortunate enough to have her visit our physiotherapy department. She gave a great talk about the emerging use of clinical guidelines in healthcare, as well as the standards around their development and discussed why we should be looking to these guidelines in our practice.

Traditionally, clinical guidelines have been viewed with suspicion by anyone interested in working from the evidence base, as “guidelines” were often little more than one individual’s personal opinion. Over the past 5 years however, the approach to producing clinical guidelines has radically changed, with vast amounts of time and resources being poured into their development.

Nowadays, a clinical guideline focuses on the current understanding of a particular condition and makes use of a diverse range of academic literature to establish an approach to best practices, based on the outcomes of a large number of the studies available. They also inform the reader what level of evidence has been used to establish “best practice”, from systematic reviews of the literature (Level A) to expert clinical opinion (Level D). This allows the clinician to make up their own mind about how solid is the foundation upon which the guideline is built and how much weight to allocate it.

Here are a few links to some of the organisations responsible for developing guidelines (in no particular order). Since different organisations are tasked with developing different guidelines, you might have to look around until you find what you’re looking for. You should also bear in mind that not only are new guidelines being developed all the time but old ones are typically reviewed every 2-3 years, so you need to make sure you have the latest version.

And an article looking at both sides of the use of clinical guidelines:

With the international movement in healthcare towards evidence-based practice, it seems logical to make use of any tools available that would assist us in this regard.