Knowledge Translation
Evidence Based Practice and Knowledge Translation The common understanding of the term, evidence, is that it refers to knowledge produced through traditional channels of research instituted through academic or quasi-academic organizations. Knowledge produced in this manner has come to be known as Mode I knowledge (Nowotny, Scott, & Gibbons, 2003). It is produced outside of the environments in which it is intended to have impact. Step 4 of the EBP model exists to sift the evidence coming from outside practice with the context-sensitive knowledge residing inside the practice environment. Elements of such local knowledge include practitioner experience and expertise, patient preference and operational capabilities. In recent decades, a shift in perception about where and how knowledge is produced suggests that the line between the production and application of knowledge is blurring. Mode II knowledge is the term used to describe evidence produced in the context of its application (Nowotny et al., 2003). PBE methodology typifies Mode II knowledge. Recognizing both modes of knowledge production within the EBP model suggests a redrawing of steps 2-4 to show that the process of considering external evidence and the process of producing internal evidence occur in parallel, rather than in series, and are interconnected. Understanding how practitioners use knowledge is intimately related to how they produce knowledge (Estabrooks, Thompson, Lovely, & Hofmeyer, 2006). Context-driven knowledge, be it optimal or inadequate, externally or internally derived, provides the basis for action and clinical decision-making. Knowledge is never static but continually emergent (Upshur, 2000). Best practice, as previously cast, is the optimal functioning of the process of knowledge vetting and application at any given point in time. Best practice is the end point of EBP. The characteristic focus of EBP as commonly conceived has been directed toward the systematic evaluation of external evidence (Estabrooks, Derksen, Winther, Lavis, Scott, Wallin, et al., 2008) rather than toward mechanisms of implementation. This latter focus belongs to a more recent framework, Knowledge Translation (KT), which, like EBP, has intellectual roots in the knowledge utilization and diffusion of innovation theory advanced by Rogers in the last century (Estabrooks et al., 2008).KT, further, is transdisciplinary exploring and adapting its models from multiple domains such as education (Davis, 2006) and organizational and social theory (Estabrooks et al, 2006). The cyclic nature of knowledge production, application and re-evaluation is traced by both EBP and KT frameworks The production and application of knowledge are tightly related whether one is approaching knowledge from the Mode I perspective where it is “fit” to the target environment or whether one is considering the Mode II perspective where knowledge arises in context. The idea, previously developed, that production of useful knowledge in rehabilitation involves a match of research methods with patient and domain characteristics applies to knowledge translation approaches as well. Effective KT processes in rehabilitation will be those that are sensitive to its characteristic multidisciplinary and team-based patterns of practice and heterogeneous patient populations. In a National Institute on Disability and Rehabilitation Research commissioned overview of KT, Sudsawad (2007) noted that there were few studies of KT strategies applied to rehabilitation and, as a result, limited evidence of effectiveness of various approaches. As KT is a rapidly evolving field, a review of the literature was conducted to evaluate more recent findings to explore the role of KT in EBP and best practice. Supporting research questions were as follows: A. What approaches have been taken with respect to KT in rehabilitation? B. What finding from KT applications in other domains may be advisory to rehabilitation? C. What models have been advanced that may be relevant to KT in rehabilitation?
In April of 2009, a search of the peer-reviewed literature from 2006 to 2009 was conducted to uncover studies the specific focus of which was knowledge translation. Studies selected were those incorporating the term “knowledge translation” in keywords, citation or abstract. The search was replicated across three databases: ProQuest Central, CINHAL Plus and PubMed. Four hundred and three citations were returned. Of these, eighty-seven articles were non-redundant and relevant. Nine articles arose from contexts of rehabilitation care provision and service delivery (cites). Eight focused principally on the needs of individuals within the KT process(cites) and one article considered rehabilitation practice organizational and systematic mechanisms(cite). Two papers were authored from rehabilitation organizations but approached KT from a generalized clinical practice perspective(cites). The remaining articles discussed KT interventions specifically targeting occupational therapists and physical therapists, both in practice and in training(cites). One article included rehabilitation physicians in training among its study subjects in a KT effort to increase utilization of evidence-based measures of gross motor function(cites). Unique among the various disciplines publishing on KT in recent years, two papers (from the same group of rehabilitation scholars) examined the phenomenon of clinician practice style and analyzed the implications it held for use of evidence in practice(cites). Also unique to authors writing in the context of rehabilitation was exploration of empathic factors as motivators to research utilization(cites). Themes of Significance Synthesis of the nine articles originating from rehabilitation settings revealed the following themes. Most, though not all, are reprised in the KT literature produced by other healthcare domains as described below. Evidence in Context: Phase II Knowledge As described in the introduction to this section, a shift in understanding of how knowledge is produced and legitimated is a cultural phenomenon of the Information Age, which is thought to have seen light in the informatics explosion of the late 20th century (Negroponte, 1995). This perceptual shift transcends but inevitably impacts rehabilitation and the domains that support it. Nowotny et al. (p.188) point to the “democratization” of higher education as a probable contributor to the idea that channels of potentially valid evidence are broad rather than narrow. The health care marketplace demands increasing levels of preparation of its practitioners. For example, beginning in 2003, all physician applicants for spinal cord injury (SCI) subspecialty certification by the American Board of Physical Medicine and Rehabilitation were required to complete an Accreditation Council of Graduate Medical Education-sanctioned fellowship in SCI medicine following residency ( http://www.aapmr.org/hpl/sci.htm). In a similar action in 2007, the entry level of education for occupational therapist professional credentialing was raised to that of a master’s degree issued under the auspices of a program approved by the Accreditation Council for Occupational Therapy Education (ACOTE) (Coppard, B.M., Dickerson, A., & Fazio, L., 2007). As individuals increasingly receive the imprimatur conferred by passing the bars prescribed by higher education, they reasonably become increasingly confident in their own abilities to evaluate clinical situations and make decisions they believe to reflect best practice in the specific situations that confront them. Ironically, this increased sense of confidence in one’s own, schooled abilities has decreased the authority of evidence coming from (formal, academic) research conducted outside one’s local practice. This situation has its pros and cons. Rehabilitation practitioners are more competent to make decisions than they were in previous times and, at the same time, less likely to be averted from making bad clinical decisions because of their (not incorrect) perception of over-par preparation and general competence. Lencucha, Kothari, and Rouse (2007) reviewing the history of the EBP movement, recount the firestorm that occurred within the discipline of occupational therapy in the early days (1980’s) of the profession’s debate over its position vis-à-vis the EPB framework. Emphasis on the use of empirically-based evidence by the “rational” occupational therapist alienated many practitioners (p.593). According to Lencucha et al, occupational therapists (OTs) perceive their profession as an art as well as a science. OTs are strongly committed to a belief in the validity of individual clinical experiences, essentially, practice-based evidence. Clinical experience includes both that with other therapists (day-to-day and at professional gatherings) and clients/patients. Further, OT practice is validated in good part by small N and qualitative studies as well as quantitative studies (Lencucha et al., 2007). The former are not perceived as “best evidence” within the canonical EBP model (as also noted earlier in this clinical review), leaving OTs with diminished enthusiasm for incorporating the EBP model into their own practice as a result. Lencucha et al. trace a perceived evolution of EBP in recent years toward what they term a systems-level approach to research utilization that is sensitive to individuals working to apply evidence in organizational and interpersonal contexts. They characterize the emergence of the discipline of KT as a shift towards systems-level thinking in health care. Systems Theory conceives of human systems as organismic as opposed to logico-deductive (Kitson, 2009). This construct parallels the distinction between Mode I and Mode II knowledge production already described. Similarly, Doane and Varcoe (2008), writing from the same practice context (Nursing) as Kitson, question the validity of a rigid epistemological approach to KT. Reminiscent of Lencucha et al.’s description of the OT perspective t in the early days of the EBP movement,. Doane and Varcoe perceive the evaluation of options in human systems as an embodied process of ontological inquiry and action. Individuals are not compelled by evidence from external research but rather draw upon it to enlarge and imagine possibilities for action in the real contexts of their practice. Savoy (2009) in a case study of public-sector innovation processes enacted in the UK’s National Health Service noted that practice-based innovation, however, was tightly coupled to originating context and the processes and technologies supporting it. This finding suggests that Mode II knowledge may be as problematic to transfer across clinical contexts as the afore-cited authors contend Mode I knowledge to be.
Forging Closer Bonds Between Researchers, Practitioners and Practice Environments Lencucha et al. (2007) advocate development of a bi-directional relationship between researchers and therapists to find best practice utilization of knowledge from research in embodied clinical practices. This recommendation is supported by a critical review of the participatory action research literature (Cargo & Mercer, 2008) that concluded that collaboration of researchers and decision-makers resulted in a higher degree of research uptake. In all, six articles examined in the present clinical review explicitly recommended tighter bonds between researchers and practitioners to promote research use in practice. (Bambusch, Semeniuk,McDonald, Koushambhi, Reimer Kirkham, Tam & Anderson, 2007; Bambusch, Reimer Kirkham, Koushambhi, McDonald, 2007; Cargo & Mercer, 2008; Dobbins, Robeson, Ciliska, Hanna, Cameron, O'Mara, DeCorby, & Mercer, 2009; Ebner, Khan, Shademani, Compernolle, et al., 2006; Gagliardi, Wright, Grunfeld, & Davis , 2008; Hartling, Scott-Findlay, Johnson, Osmond et al, 2007; Landry, Amara., Pablos-Mendes, Shademani, & Gold, 2006) The results of researcher-nurse collaboration were reported in the context of a project designed to identify and ameliorate the difficulties encountered by ethnically-diverse patients transitioning from hospital to home post discharge. (Bambusch, Semeniuk,McDonald, Koushambhi, Reimer Kirkham, Tam & Anderson, 2007; Bambusch, Reimer Kirkham, Koushambhi, McDonald, 2007) Close collaboration between researchers and nurses led to greater awareness and sensitivity to practice context which in turn led to the design of more thoroughly executable clinical protocols. As a result of the working relationship developed with clinicians, researchers “strove to be credible messengers” (Bambusch et al., 2007a, p. 26) by communicating research findings to clinicians in a way that was context-appropriate and actionable. Likewise, because of the interaction with researchers, clinicians were sensitized to issues under research and modified practice early after release of results to create and implement action plans to address identified patient care deficiencies. Interwork of clinician and researcher in the context of practice is a core component of PBE protocols which also leverage clinician involvement in research in the practice environment. Knowledge Value Mapping Knowledge value mapping (KVM) is the process of deciding what evidence to prioritize for implementation in practice. KVM emerged as a central theme of three papers identified by the current clinical review (Ebner, Khan, Shademani, Compernolle, et al., 2006; Gagliardi, Wright, Grunfeld, & Davis, 2008; Landry, Amara, Pablos-Mendes, Shademani, & Gold, 2006). The values and perspectives held by patients are an important component of Stage 4 of the EBM model. The collaboration between researchers and nurses in the project reported by Bambusch et al. (2007a ;2007b), with its characteristic immersion of researchers in the day-to-day clinical environment, had the additional effect of incorporating the patient perspective into what aspects of the discharge process were studied and how findings were implemented. In this case, a close connection between researchers and the practice environment demonstrated an alternate and more “local” path to knowledge value mapping than that advanced by systematic KVM frameworks (Ebner et al, 2006; Gagliardi et al, 2008; Landry et al., 2006) that typically work outside of individual research projects to identify knowledge gaps. Developing a Culture of Knowledge Translation In the case of the occupational therapy, the most extensively reported rehabilitation discipline in the current review, mentorship and therapist-to-therapist validation of knowledge are pivotal to application of evidence in practice.( Lencucha et al., 2007). According to an American Occupational Therapy Association (AOTA) survey of therapists, the principal source of knowledge OTs use to guide practice derives from formal continuing education followed closely that negotiated with mentors (Philibert, Snyder, Judd & Windsor, 2003). Mentorship is a defining component of the majority of OTs’ daily work; with student supervision reported even among practitioners working 10 or fewer hours per week (AOTA, 2006). Similar orientation to practice and knowledge use were reported in surveys of physical therapists as well. (Hadouda, Laroui, Lemay, Martin, Korner-Bitensky, Menon, Storr, Asseraf-Pasin, & Ahmed, 2009; Korner-Bitensky, Menon-Nair, Thomas, Boutin, & Arafah, 2007) Mentors, or educationally influencial (EI) clinicians or opinion leaders were indicated as being considered significant in knowledge uptake in nursing and emergency medicine as well. (Doherty, 2006; Doran, & Sidani, 2007; Rowe, Diner, Camargo, Worster et al, 2007). OT and PT professional culture suggests a Community of Practice (Wenger, 1998) and situated learning (Lave & Wenger, 1991) context for knowledge translation in that discipline (Lencucha et al., 2007). Lave and Wenger’s frameworks advance the centrality of the community, as opposed to the individual, in the construction and use of knowledge. A “Learning Organization” (Senge, 2006) approach is also advocated in KT models advanced in the general context of health care, (Chunharas, 2006), home care (McWilliam, Kothari, Kloseck, Ward-Griffin, & Forbes, 2008) and emergency medicine (Dayan, Osmond, Kuppermann, Lang, et al., 2007). Of the 87 KT articles examined in the present study, 51 articles dealt with organizational strategies and 8 had a dual organizational-individual focus. Two uniquely comprehensive KT projects in rehabilitation, one in Alberta (Gross & Lowe, 2008) and the other in The Netherlands (Ketelaar, Russell, & Gorter, 2008) , both reported findings of broad awareness in their target populations of the knowledge that was the object of their translation efforts. Paradoxically, practitioners who reported a highly level of awareness also reported a low level of implementation. Organizational and work environment support factors were offered as the primary reason for not putting new knowledge into action, underscoring the importance of the work community in practice change. Individual Differences The importance of the larger community of practice not withstanding, individually-focused KT models and project were the focus of 26 of the articles appraised in this study. The issue of practice style as a touchstone of KT intervention design emerged as a focus of a group of Canadian rehabilitation investigators examining traits of individuals within therapy disciplines.(Hadouda et al., 2009; Korner-Bitensky et al., 2007). Practice styles predict how clinicians will integrate knowledge into clinical decision-making. The four identified styles are seeker, receptive, traditionalist and pragmatic. Seekers are thought most likely to seek out and use evidence in clinical practice while pragmatists are the most likely to focus on practical issues such as workload demands and patient satisfaction. It is debated whether practice style is an personality trait or an approach that can be changed through education and training. Kamwendo andTörnquist (as cited by Hadouda et al, 2009, p. 99) suggest that problem-based learning activities promote a seeker practice style. Hadouda et al. (2009) studied OTs and PTs in their second and third year of training in a program promoting problem-based learning and advancing an evidence-approach to practice. Less than 1% of subjects were seekers and most were pragmatists. The number of pragmatists increased with the years of training (which included clinical exposure) and the number of seekers diminished. Authors suggest that the clinical environment may itself discourage seeking evidence. They caution that the prevalence of pragmatically-oriented persons entering practice should be taken into account in designing KT strategies. Korner-Bitensky et al (2007) surveyed practicing OTs and PTs in stroke rehabilitation to determine if there was a relationship between practice style and choice of interventions and assessments. Seekers were marginally and insignificantly more inclined to use evidence in their decisions than were other styles, among which pragmatists were, again, the most prevalent. The most common reason given for choice of assessment was that it had “known reliability and validity, ” i.e. was well-accepted among peers. The most common reason given for choice of intervention was having learned it in professional training. Many respondents had completed training a decade previous to the survey. These results reported for therapists working in the Canadian rehabilitation care setting mirror those reported from therapists in the United States as reported by Philibert et al. (2003). The prevalence of pragmatists suggests that KT interventions may be ineffective if they presume that most clinicians are seekers and read professional journals, use electronic resources and are ready to diverge from traditional practices. Use of evidence was, however, positively associated with therapists for whom funds for continuing education were available from the practice site employer. Empathic Approaches to Motivate Change In keeping with the embodied versus logico-deductive approach to knowledge acquisition and application described by Doane and Vargo (2008) and Kitson (2009), Colantonio, Knotos, Gilbert, Rossiter, Gray, & Keightley (2008) investigated the effectiveness of embedding focus group-derived traumatic brain injury (TBI) patient perspectives and evidence-based (TBI) best practice guidelines for health practitioners and care givers in a theatrical production. Reception of the KT intervention was positive as reported by a Likert-scale survey of audience members post-performance. Engagement and impact was rated highly. The effect of the intervention on practice, however, was not evaluated. A model advanced by another team of rehabilitation authors supports the theoretical underpinning the TBI intervention just described. Kontos and Poland (2009) articulate a Critical Realism and the Arts Research Utilization Model (CRARUM). Authors contend that arts-based KT methodologies are under-explored and have “educational potential to foster critical awareness, encourage adopters to envision new possibilities, and affect change.” (p. 2). An analogous effort to use scenario-based learning in clinical learning is the simulated (or standardized) patient (SP). SPs are real human beings who receive special training and present with specified health and personal conditions in clinical learning scenarios. They have been shown to be particularly effective in helping clinicians improve communications and interpersonal skills (Van Zanten, Boulet, & McKinley, 2007). Staged Approach to KT Ketelaar et al. (2008) describe the staged approach to KT employed in trying to increase use of gross motor function and classification measures in clinical practice in The Netherlands. Authors modeled their efforts on Grol’s Stages of Change Model (2002) and demonstrated that different strategies may be appropriate at different phases of knowledge uptake as defined by the model. Grol’s model is a synthesis of previous models and distinguishes capacity and performance, “can do” and “does do.” Capacity (knowing) and performance (acting) are addressed by different interventions. Capacity is individual and performance depends on organizational facilitation. Goals of the capacity-building phase include orientation, insight and acceptance of the knowledge being communicated. Goals of the performance stage are actually practice change and maintenance of change. Strategies were implemented successively: dissemination via peer-reviewed publications, posting of pamphlets on professional web sites, dissemination in the context of professional training programs, and interactive workshops. Simple dissemination did not effect practice change. Workshops were more effective, but there remained an evident gap between knowledge and practice. As previously stated, this outcome was very similar to the one reported in a similar study (Gross & Lowe, 2008). In this latter study of a KT program aimed at shifting PTs’ approach to work disability therapy from impairment-based to function based. Investigators devised a four-part approach to KT that sought to accommodate PT practice styles and environments. An evidence-based “toolkit” was developed and promoted through a network of identified EI clinicians and academic faculty. Seminars were held and the toolkit was integrated with formal academic curriculum in the province. A third of responding PTs who received the materials never read them. Organizational culture was posited as the overriding cause by investigators. Pointed Facilitation and Knowledge Brokering The experiences of the Alberta and Netherlands projects seem to point to the fact that EIs, though important are not enough. Armstrong, Waters, Crockett and Keleher, (date?) studying EBP resource utilization observed that there was no knowledge uptake without a knowledge management process to engage intended practitioners. A Knowledge Broker (KB), as opposed to an individual in the practice setting who is admired and respected, takes on the role of explicitly championing uptake of knowledge and is charged with pointed facilitation. The role of the KB in a randomized controlled trial of three KT interventions was examined, however, and found, generally, to not be particularly effective. (Dobbins, Robeson, Ciliska, Hanna, Cameron, O'Mara, DeCorby, & Mercer 2009). The exception to this trend, however, occurred in organizations where use of evidence in decision-making had not previously been highly valued. Technological Facilitation Uses of the Web and Information Technology Rehabilitation and chronic care-centered KT reports use of the web for dissemination of materials and follow-up surveys of study participants (Green, Fortin, Maclure, Macgregor, & Robinson,year?; Gross & Lowe, 2008; Ketelaar et al. , 2008;MacDermid, Solomon, Law, Russell, & Stratford, 2006). The discipline is otherwise silent on use of informatics, in sharp contrast to emergency medicine (add cites), intensive (including neonatal) care(add cites) and nursing (add cites) where decision time is perhaps more often critical to outcome. Web-based information delivery and health informatics have a potential to facilitate use of evidence from multiple sources. Computer-based clinical support systems (CDSS) can play a role in fit of evidence to individual patient decisions. Integration of Traditional Learning Channels and KT Ok, I am going to send this to you. I have material to discuss this, but it is only tangentially related to rehab. Emergency Medicine has published a bit about effecting KT Programs through their residency program.
Knowledge Translation
Evidence Based Practice and Knowledge Translation The common understanding of the term, evidence, is that it refers to knowledge produced through traditional channels of research instituted through academic or quasi-academic organizations. Knowledge produced in this manner has come to be known as Mode I knowledge (Nowotny, Scott, & Gibbons, 2003). It is produced outside of the environments in which it is intended to have impact. Step 4 of the EBP model exists to sift the evidence coming from outside practice with the context-sensitive knowledge residing inside the practice environment. Elements of such local knowledge include practitioner experience and expertise, patient preference and operational capabilities. In recent decades, a shift in perception about where and how knowledge is produced suggests that the line between the production and application of knowledge is blurring. Mode II knowledge is the term used to describe evidence produced in the context of its application (Nowotny et al., 2003). PBE methodology typifies Mode II knowledge. Recognizing both modes of knowledge production within the EBP model suggests a redrawing of steps 2-4 to show that the process of considering external evidence and the process of producing internal evidence occur in parallel, rather than in series, and are interconnected. Understanding how practitioners use knowledge is intimately related to how they produce knowledge (Estabrooks, Thompson, Lovely, & Hofmeyer, 2006). Context-driven knowledge, be it optimal or inadequate, externally or internally derived, provides the basis for action and clinical decision-making. Knowledge is never static but continually emergent (Upshur, 2000). Best practice, as previously cast, is the optimal functioning of the process of knowledge vetting and application at any given point in time. Best practice is the end point of EBP. The characteristic focus of EBP as commonly conceived has been directed toward the systematic evaluation of external evidence (Estabrooks, Derksen, Winther, Lavis, Scott, Wallin, et al., 2008) rather than toward mechanisms of implementation. This latter focus belongs to a more recent framework, Knowledge Translation (KT), which, like EBP, has intellectual roots in the knowledge utilization and diffusion of innovation theory advanced by Rogers in the last century (Estabrooks et al., 2008).KT, further, is transdisciplinary exploring and adapting its models from multiple domains such as education (Davis, 2006) and organizational and social theory (Estabrooks et al, 2006). The cyclic nature of knowledge production, application and re-evaluation is traced by both EBP and KT frameworks The production and application of knowledge are tightly related whether one is approaching knowledge from the Mode I perspective where it is “fit” to the target environment or whether one is considering the Mode II perspective where knowledge arises in context. The idea, previously developed, that production of useful knowledge in rehabilitation involves a match of research methods with patient and domain characteristics applies to knowledge translation approaches as well. Effective KT processes in rehabilitation will be those that are sensitive to its characteristic multidisciplinary and team-based patterns of practice and heterogeneous patient populations. In a National Institute on Disability and Rehabilitation Research commissioned overview of KT, Sudsawad (2007) noted that there were few studies of KT strategies applied to rehabilitation and, as a result, limited evidence of effectiveness of various approaches. As KT is a rapidly evolving field, a review of the literature was conducted to evaluate more recent findings to explore the role of KT in EBP and best practice. Supporting research questions were as follows: A. What approaches have been taken with respect to KT in rehabilitation? B. What finding from KT applications in other domains may be advisory to rehabilitation? C. What models have been advanced that may be relevant to KT in rehabilitation?
In April of 2009, a search of the peer-reviewed literature from 2006 to 2009 was conducted to uncover studies the specific focus of which was knowledge translation. Studies selected were those incorporating the term “knowledge translation” in keywords, citation or abstract. The search was replicated across three databases: ProQuest Central, CINHAL Plus and PubMed. Four hundred and three citations were returned. Of these, eighty-seven articles were non-redundant and relevant. Nine articles arose from contexts of rehabilitation care provision and service delivery (cites). Eight focused principally on the needs of individuals within the KT process(cites) and one article considered rehabilitation practice organizational and systematic mechanisms(cite). Two papers were authored from rehabilitation organizations but approached KT from a generalized clinical practice perspective(cites). The remaining articles discussed KT interventions specifically targeting occupational therapists and physical therapists, both in practice and in training(cites). One article included rehabilitation physicians in training among its study subjects in a KT effort to increase utilization of evidence-based measures of gross motor function(cites). Unique among the various disciplines publishing on KT in recent years, two papers (from the same group of rehabilitation scholars) examined the phenomenon of clinician practice style and analyzed the implications it held for use of evidence in practice(cites). Also unique to authors writing in the context of rehabilitation was exploration of empathic factors as motivators to research utilization(cites). Themes of Significance Synthesis of the nine articles originating from rehabilitation settings revealed the following themes. Most, though not all, are reprised in the KT literature produced by other healthcare domains as described below. Evidence in Context: Phase II Knowledge As described in the introduction to this section, a shift in understanding of how knowledge is produced and legitimated is a cultural phenomenon of the Information Age, which is thought to have seen light in the informatics explosion of the late 20th century (Negroponte, 1995). This perceptual shift transcends but inevitably impacts rehabilitation and the domains that support it. Nowotny et al. (p.188) point to the “democratization” of higher education as a probable contributor to the idea that channels of potentially valid evidence are broad rather than narrow. The health care marketplace demands increasing levels of preparation of its practitioners. For example, beginning in 2003, all physician applicants for spinal cord injury (SCI) subspecialty certification by the American Board of Physical Medicine and Rehabilitation were required to complete an Accreditation Council of Graduate Medical Education-sanctioned fellowship in SCI medicine following residency ( http://www.aapmr.org/hpl/sci.htm). In a similar action in 2007, the entry level of education for occupational therapist professional credentialing was raised to that of a master’s degree issued under the auspices of a program approved by the Accreditation Council for Occupational Therapy Education (ACOTE) (Coppard, B.M., Dickerson, A., & Fazio, L., 2007). As individuals increasingly receive the imprimatur conferred by passing the bars prescribed by higher education, they reasonably become increasingly confident in their own abilities to evaluate clinical situations and make decisions they believe to reflect best practice in the specific situations that confront them. Ironically, this increased sense of confidence in one’s own, schooled abilities has decreased the authority of evidence coming from (formal, academic) research conducted outside one’s local practice. This situation has its pros and cons. Rehabilitation practitioners are more competent to make decisions than they were in previous times and, at the same time, less likely to be averted from making bad clinical decisions because of their (not incorrect) perception of over-par preparation and general competence. Lencucha, Kothari, and Rouse (2007) reviewing the history of the EBP movement, recount the firestorm that occurred within the discipline of occupational therapy in the early days (1980’s) of the profession’s debate over its position vis-à-vis the EPB framework. Emphasis on the use of empirically-based evidence by the “rational” occupational therapist alienated many practitioners (p.593). According to Lencucha et al, occupational therapists (OTs) perceive their profession as an art as well as a science. OTs are strongly committed to a belief in the validity of individual clinical experiences, essentially, practice-based evidence. Clinical experience includes both that with other therapists (day-to-day and at professional gatherings) and clients/patients. Further, OT practice is validated in good part by small N and qualitative studies as well as quantitative studies (Lencucha et al., 2007). The former are not perceived as “best evidence” within the canonical EBP model (as also noted earlier in this clinical review), leaving OTs with diminished enthusiasm for incorporating the EBP model into their own practice as a result. Lencucha et al. trace a perceived evolution of EBP in recent years toward what they term a systems-level approach to research utilization that is sensitive to individuals working to apply evidence in organizational and interpersonal contexts. They characterize the emergence of the discipline of KT as a shift towards systems-level thinking in health care. Systems Theory conceives of human systems as organismic as opposed to logico-deductive (Kitson, 2009). This construct parallels the distinction between Mode I and Mode II knowledge production already described. Similarly, Doane and Varcoe (2008), writing from the same practice context (Nursing) as Kitson, question the validity of a rigid epistemological approach to KT. Reminiscent of Lencucha et al.’s description of the OT perspective t in the early days of the EBP movement,. Doane and Varcoe perceive the evaluation of options in human systems as an embodied process of ontological inquiry and action. Individuals are not compelled by evidence from external research but rather draw upon it to enlarge and imagine possibilities for action in the real contexts of their practice. Savoy (2009) in a case study of public-sector innovation processes enacted in the UK’s National Health Service noted that practice-based innovation, however, was tightly coupled to originating context and the processes and technologies supporting it. This finding suggests that Mode II knowledge may be as problematic to transfer across clinical contexts as the afore-cited authors contend Mode I knowledge to be.
Forging Closer Bonds Between Researchers, Practitioners and Practice Environments Lencucha et al. (2007) advocate development of a bi-directional relationship between researchers and therapists to find best practice utilization of knowledge from research in embodied clinical practices. This recommendation is supported by a critical review of the participatory action research literature (Cargo & Mercer, 2008) that concluded that collaboration of researchers and decision-makers resulted in a higher degree of research uptake. In all, six articles examined in the present clinical review explicitly recommended tighter bonds between researchers and practitioners to promote research use in practice. (Bambusch, Semeniuk,McDonald, Koushambhi, Reimer Kirkham, Tam & Anderson, 2007; Bambusch, Reimer Kirkham, Koushambhi, McDonald, 2007; Cargo & Mercer, 2008; Dobbins, Robeson, Ciliska, Hanna, Cameron, O'Mara, DeCorby, & Mercer, 2009; Ebner, Khan, Shademani, Compernolle, et al., 2006; Gagliardi, Wright, Grunfeld, & Davis , 2008; Hartling, Scott-Findlay, Johnson, Osmond et al, 2007; Landry, Amara., Pablos-Mendes, Shademani, & Gold, 2006) The results of researcher-nurse collaboration were reported in the context of a project designed to identify and ameliorate the difficulties encountered by ethnically-diverse patients transitioning from hospital to home post discharge. (Bambusch, Semeniuk,McDonald, Koushambhi, Reimer Kirkham, Tam & Anderson, 2007; Bambusch, Reimer Kirkham, Koushambhi, McDonald, 2007) Close collaboration between researchers and nurses led to greater awareness and sensitivity to practice context which in turn led to the design of more thoroughly executable clinical protocols. As a result of the working relationship developed with clinicians, researchers “strove to be credible messengers” (Bambusch et al., 2007a, p. 26) by communicating research findings to clinicians in a way that was context-appropriate and actionable. Likewise, because of the interaction with researchers, clinicians were sensitized to issues under research and modified practice early after release of results to create and implement action plans to address identified patient care deficiencies. Interwork of clinician and researcher in the context of practice is a core component of PBE protocols which also leverage clinician involvement in research in the practice environment. Knowledge Value Mapping Knowledge value mapping (KVM) is the process of deciding what evidence to prioritize for implementation in practice. KVM emerged as a central theme of three papers identified by the current clinical review (Ebner, Khan, Shademani, Compernolle, et al., 2006; Gagliardi, Wright, Grunfeld, & Davis, 2008; Landry, Amara, Pablos-Mendes, Shademani, & Gold, 2006). The values and perspectives held by patients are an important component of Stage 4 of the EBM model. The collaboration between researchers and nurses in the project reported by Bambusch et al. (2007a ;2007b), with its characteristic immersion of researchers in the day-to-day clinical environment, had the additional effect of incorporating the patient perspective into what aspects of the discharge process were studied and how findings were implemented. In this case, a close connection between researchers and the practice environment demonstrated an alternate and more “local” path to knowledge value mapping than that advanced by systematic KVM frameworks (Ebner et al, 2006; Gagliardi et al, 2008; Landry et al., 2006) that typically work outside of individual research projects to identify knowledge gaps. Developing a Culture of Knowledge Translation In the case of the occupational therapy, the most extensively reported rehabilitation discipline in the current review, mentorship and therapist-to-therapist validation of knowledge are pivotal to application of evidence in practice.( Lencucha et al., 2007). According to an American Occupational Therapy Association (AOTA) survey of therapists, the principal source of knowledge OTs use to guide practice derives from formal continuing education followed closely that negotiated with mentors (Philibert, Snyder, Judd & Windsor, 2003). Mentorship is a defining component of the majority of OTs’ daily work; with student supervision reported even among practitioners working 10 or fewer hours per week (AOTA, 2006). Similar orientation to practice and knowledge use were reported in surveys of physical therapists as well. (Hadouda, Laroui, Lemay, Martin, Korner-Bitensky, Menon, Storr, Asseraf-Pasin, & Ahmed, 2009; Korner-Bitensky, Menon-Nair, Thomas, Boutin, & Arafah, 2007) Mentors, or educationally influencial (EI) clinicians or opinion leaders were indicated as being considered significant in knowledge uptake in nursing and emergency medicine as well. (Doherty, 2006; Doran, & Sidani, 2007; Rowe, Diner, Camargo, Worster et al, 2007). OT and PT professional culture suggests a Community of Practice (Wenger, 1998) and situated learning (Lave & Wenger, 1991) context for knowledge translation in that discipline (Lencucha et al., 2007). Lave and Wenger’s frameworks advance the centrality of the community, as opposed to the individual, in the construction and use of knowledge. A “Learning Organization” (Senge, 2006) approach is also advocated in KT models advanced in the general context of health care, (Chunharas, 2006), home care (McWilliam, Kothari, Kloseck, Ward-Griffin, & Forbes, 2008) and emergency medicine (Dayan, Osmond, Kuppermann, Lang, et al., 2007). Of the 87 KT articles examined in the present study, 51 articles dealt with organizational strategies and 8 had a dual organizational-individual focus. Two uniquely comprehensive KT projects in rehabilitation, one in Alberta (Gross & Lowe, 2008) and the other in The Netherlands (Ketelaar, Russell, & Gorter, 2008) , both reported findings of broad awareness in their target populations of the knowledge that was the object of their translation efforts. Paradoxically, practitioners who reported a highly level of awareness also reported a low level of implementation. Organizational and work environment support factors were offered as the primary reason for not putting new knowledge into action, underscoring the importance of the work community in practice change. Individual Differences The importance of the larger community of practice not withstanding, individually-focused KT models and project were the focus of 26 of the articles appraised in this study. The issue of practice style as a touchstone of KT intervention design emerged as a focus of a group of Canadian rehabilitation investigators examining traits of individuals within therapy disciplines.(Hadouda et al., 2009; Korner-Bitensky et al., 2007). Practice styles predict how clinicians will integrate knowledge into clinical decision-making. The four identified styles are seeker, receptive, traditionalist and pragmatic. Seekers are thought most likely to seek out and use evidence in clinical practice while pragmatists are the most likely to focus on practical issues such as workload demands and patient satisfaction. It is debated whether practice style is an personality trait or an approach that can be changed through education and training. Kamwendo andTörnquist (as cited by Hadouda et al, 2009, p. 99) suggest that problem-based learning activities promote a seeker practice style. Hadouda et al. (2009) studied OTs and PTs in their second and third year of training in a program promoting problem-based learning and advancing an evidence-approach to practice. Less than 1% of subjects were seekers and most were pragmatists. The number of pragmatists increased with the years of training (which included clinical exposure) and the number of seekers diminished. Authors suggest that the clinical environment may itself discourage seeking evidence. They caution that the prevalence of pragmatically-oriented persons entering practice should be taken into account in designing KT strategies. Korner-Bitensky et al (2007) surveyed practicing OTs and PTs in stroke rehabilitation to determine if there was a relationship between practice style and choice of interventions and assessments. Seekers were marginally and insignificantly more inclined to use evidence in their decisions than were other styles, among which pragmatists were, again, the most prevalent. The most common reason given for choice of assessment was that it had “known reliability and validity, ” i.e. was well-accepted among peers. The most common reason given for choice of intervention was having learned it in professional training. Many respondents had completed training a decade previous to the survey. These results reported for therapists working in the Canadian rehabilitation care setting mirror those reported from therapists in the United States as reported by Philibert et al. (2003). The prevalence of pragmatists suggests that KT interventions may be ineffective if they presume that most clinicians are seekers and read professional journals, use electronic resources and are ready to diverge from traditional practices. Use of evidence was, however, positively associated with therapists for whom funds for continuing education were available from the practice site employer. Empathic Approaches to Motivate Change In keeping with the embodied versus logico-deductive approach to knowledge acquisition and application described by Doane and Vargo (2008) and Kitson (2009), Colantonio, Knotos, Gilbert, Rossiter, Gray, & Keightley (2008) investigated the effectiveness of embedding focus group-derived traumatic brain injury (TBI) patient perspectives and evidence-based (TBI) best practice guidelines for health practitioners and care givers in a theatrical production. Reception of the KT intervention was positive as reported by a Likert-scale survey of audience members post-performance. Engagement and impact was rated highly. The effect of the intervention on practice, however, was not evaluated. A model advanced by another team of rehabilitation authors supports the theoretical underpinning the TBI intervention just described. Kontos and Poland (2009) articulate a Critical Realism and the Arts Research Utilization Model (CRARUM). Authors contend that arts-based KT methodologies are under-explored and have “educational potential to foster critical awareness, encourage adopters to envision new possibilities, and affect change.” (p. 2). An analogous effort to use scenario-based learning in clinical learning is the simulated (or standardized) patient (SP). SPs are real human beings who receive special training and present with specified health and personal conditions in clinical learning scenarios. They have been shown to be particularly effective in helping clinicians improve communications and interpersonal skills (Van Zanten, Boulet, & McKinley, 2007). Staged Approach to KT Ketelaar et al. (2008) describe the staged approach to KT employed in trying to increase use of gross motor function and classification measures in clinical practice in The Netherlands. Authors modeled their efforts on Grol’s Stages of Change Model (2002) and demonstrated that different strategies may be appropriate at different phases of knowledge uptake as defined by the model. Grol’s model is a synthesis of previous models and distinguishes capacity and performance, “can do” and “does do.” Capacity (knowing) and performance (acting) are addressed by different interventions. Capacity is individual and performance depends on organizational facilitation. Goals of the capacity-building phase include orientation, insight and acceptance of the knowledge being communicated. Goals of the performance stage are actually practice change and maintenance of change. Strategies were implemented successively: dissemination via peer-reviewed publications, posting of pamphlets on professional web sites, dissemination in the context of professional training programs, and interactive workshops. Simple dissemination did not effect practice change. Workshops were more effective, but there remained an evident gap between knowledge and practice. As previously stated, this outcome was very similar to the one reported in a similar study (Gross & Lowe, 2008). In this latter study of a KT program aimed at shifting PTs’ approach to work disability therapy from impairment-based to function based. Investigators devised a four-part approach to KT that sought to accommodate PT practice styles and environments. An evidence-based “toolkit” was developed and promoted through a network of identified EI clinicians and academic faculty. Seminars were held and the toolkit was integrated with formal academic curriculum in the province. A third of responding PTs who received the materials never read them. Organizational culture was posited as the overriding cause by investigators. Pointed Facilitation and Knowledge Brokering The experiences of the Alberta and Netherlands projects seem to point to the fact that EIs, though important are not enough. Armstrong, Waters, Crockett and Keleher, (date?) studying EBP resource utilization observed that there was no knowledge uptake without a knowledge management process to engage intended practitioners. A Knowledge Broker (KB), as opposed to an individual in the practice setting who is admired and respected, takes on the role of explicitly championing uptake of knowledge and is charged with pointed facilitation. The role of the KB in a randomized controlled trial of three KT interventions was examined, however, and found, generally, to not be particularly effective. (Dobbins, Robeson, Ciliska, Hanna, Cameron, O'Mara, DeCorby, & Mercer 2009). The exception to this trend, however, occurred in organizations where use of evidence in decision-making had not previously been highly valued. Technological Facilitation Uses of the Web and Information Technology Rehabilitation and chronic care-centered KT reports use of the web for dissemination of materials and follow-up surveys of study participants (Green, Fortin, Maclure, Macgregor, & Robinson,year?; Gross & Lowe, 2008; Ketelaar et al. , 2008;MacDermid, Solomon, Law, Russell, & Stratford, 2006). The discipline is otherwise silent on use of informatics, in sharp contrast to emergency medicine (add cites), intensive (including neonatal) care(add cites) and nursing (add cites) where decision time is perhaps more often critical to outcome. Web-based information delivery and health informatics have a potential to facilitate use of evidence from multiple sources. Computer-based clinical support systems (CDSS) can play a role in fit of evidence to individual patient decisions. Integration of Traditional Learning Channels and KT Ok, I am going to send this to you. I have material to discuss this, but it is only tangentially related to rehab. Emergency Medicine has published a bit about effecting KT Programs through their residency program.