Part 3: Knowledge Translation

Learning Objectives:

This learning module is designed to achieve the following objectives:

  • Define Knowledge Translation
  • Understand the impact of knowledge translation on practice
  • Describe at least one knowledge translation action process
  • Reflect on how you can contribute to knowledge translation in your practice in educational settings

The number of high quality research studies addressing the efficacy of interventions within the scope of occupational and physical therapy and speech language pathology practice and the outcomes of interest to practitioners working in early intervention and school settings has grown exponentially over the past several decades. Despite the increasing availability of relevant research, there continues to be a significant gap between research and practice and it is widely understood that it can take up to two decades for scientific research recommendations to be accepted and implemented. Dr. Ray Kent, Professor Emeritus at in the Communication Sciences and Disorders Department at the University of Wisconsin-Madison highlight this gap in his presentation at a recent ASHA conference. Listen to his presentation here on the perspectives of a basic science researcher on closing the knowledge to practice gap.

The gap between what is known, how it is disseminated and absorbed, and what is done in practice impacts service delivery outcomes and practitioners are at risk for adopting or overusing interventions that lack sufficient evidence, providing unnecessary or contra-indicated interventions, and missing opportunities to introduce interventions that can effectively and efficiently improve client function and participation. Outcomes improved when practitioners systematically synthesize and apply research using a process known as knowledge translation.

Knowledge translation (KT) is defined by the Canadian Institutes of Health Research as a dynamic and iterative process that includes the synthesis, dissemination, exchange and ethically sound application of knowledge to improve health, provide more effective health services and products, and strengthen the health care system. Though the exact definition changes from setting to setting, the primary focus of KT is to move us away from a model that does not apply the knowledge to practice.

While this model supports the dissemination of research knowledge to those in practice it does not provided enough support on its own to ensure the use of knowledge in decision-making.  Implementation is harder than most people think! The ways in which the knowledge to practice gap is closed is described in the literature in a number of theoretical and pragmatic ways. Read the following three papers that highlight different approaches and models to KT.

As you read in these summaries, effective KT requires a diverse array of competencies to include: 1) research literacy (e.g., skills in research and evidence based practice processes, resources and dissemination methods); 2) understanding data synthesis and application across varying settings and populations (e.g., empirical research, annual, technical, and project reports, white papers, organizational documents), and 3) a lifelong commitment to collaboratively share knowledge and foster innovation in one’s unique practice context.

Many researchers suggest, however, that the development of competencies alone may not be sufficient to close the knowledge to practice gap. Barriers to the effective synthesis, dissemination, exchange and ethically sound application of knowledge in educational settings may include:

  • Availability and access to relevant research
  • Difficulty in applying available research to the specific practice settings
  • Practitioners may become entrenched in particular practice patterns
  • Specific practices are embedded in inter-disciplinary and multi-disciplinary practice contexts that may be resistant to practice change
  • Assumptions that practice is supported by the evidence

Organizational structures may help educational teams consider the application of evidence in their settings and make specific evidence informed decisions with and on behalf of the children and youth that they serve. Organizational structures may effectively structure KT practices in a way that accelerates the uptake and application of knowledge in practice. There is emerging evidence that suggests that using organizational structures to enhance KT practice may improve prognostication and lead to increased predictable client outcomes, improve client satisfaction, and eliminate ineffective service delivery. An organizational structure that has been shown to have utility in pediatric settings including early intervention and schools involves the following steps:

Knowledge Translation Example Table

One additional consideration to note is that educators may not have developed KT competencies in the same way that related service personnel have. In fact, many describe evidence based practice and knowledge translation in a different way. Many educators describe evidence-based practices (or evidence based instruction in their language) as best practices, and these practices have been generally made available to them through district wide knowledge distillation activities and dissemination centers (Explore the array of centers that offer information on evidence based instruction here.). Best practices for many educators come in the form of either high leverage practices, or those practices that show promise in the evidence for producing the best educational outcomes for learners, or they come pre-packaged as evidence based interventions or program that educators implement with fidelity in their classrooms. (Check out the array of evidence based reading intervention/programs here).

To deepen your understanding check out the evidence based practice tools and resources on your professional organizations’ website:

Discussion Questions:

1)      Now that you are familiar with these 3 models, identify similarities and differences between the models and how they differ from the model above.

2)      What are some of the barriers limiting knowledge transfer to clinical practice?

3)     What strategies could you use to resolve some of the barriers you and your colleagues posted?

 

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7 thoughts on “Part 3: Knowledge Translation

  1. There were various themes amount the models. KT is not a linear, but rather an ongoing process that requires intention and monitoring. It is a complex process that requires us to identify a problem, assess, and make adaptations. It was clear to me that KT is not something we can do passively (e.g., just read an article). It was interesting to me how the Knowledge to Action Framework/IOM Framework disused the importance of including that the end-users of the knowledge. I think it is helpful that the Framework from the IOM provided a table with the competencies needed for various roles (i.e., consumer, evaluator, reseacher, disseminator).

    Some barriers to the effective synthesis, dissemination, exchange and ethically sound application of knowledge in educational settings may include: becoming used to practicing a certain way and having a difficult time changing patterns, limited access to relevant research, challenges with applying research to practice, and assuming that practice is supported by the evidence.

    I think these issues are challenging to address. In my current fieldwork placement (even when EBP has been recently drilled into my head), I find it challenging to make the time to do research and be intentional with each my treatment sessions. Initially I spent a lot of my energy focused on the culture and current practices I observed by therapist and it took me being very intentional to begin to question. For me, it was partly lack of time/energy and there were other times when I was not really sure what to look up or did not have much luck finding relevant data for my questions. In schools, I think it would be helpful to have a meeting every month or so with the therapy team to discuss a certain article and then try to put that research into practice and reflect upon it at the next meeting and then learn something new. Having that accountability and collaboration I know would be helpful for me. I am excited to continue to learn during conferences, but I think even with these I learn information but do not always put it into practice. I am going to try to be more intentional with challenging my ideas/interventions, doing research, and being reflective and monitoring interventions.

  2. The purpose of knowledge translation (KT) is to decrease the gap between research evidence and clinical practice through diffusion, dissemination, and implementation. The Plan-Do-Study-Act Cycle approach and model of KT promotes improvement by change or recognition. For improvement projects, it all starts with three questions, “what are we trying to accomplish?”, “how will we know that a change is an improvement?, and “what change can we make that will result in improvement?”. Then it becomes a cycle, 1) Act – what changes are to be made?, 2) Plan – objectives, questions, predictions, 3) Do – carry out the plan, document, begin analysis, 4) Study – complete analysis, compare data, summarize what you learned, and finally 1) Act – what changes need to be made for the next cycle.
    The Institute of Medicine have defined a 3-stage process, 1) knowledge development, 2) translation into medical evidence, and 3) application of evidence-based care to patients. The purpose of this process is to reduce missed opportunities, waste, and harm. Both of these models. Plan-Do-Study-Act Cycle and The Institute of Medicine’s vision for clinical practice are both circular models. The elements include: create and adapt guidelines, implement EBPs, collect data, analyze practice-based evidence, and generate new knowledge. This process is done with the involvement of a variety of professionals including medical professionals, administrators, policy-makers and most the patient/family. Unlike the “Plan-Do-Study-Act Cycle, this model does not specify a beginning or an end. This discussion of this model is also geared towards the medical field.
    The third model is the knowledge-to-action framework. This model is also comprised of 3 phases similar to the other models: knowledge inquiry, synthesis of knowledge, and creation of knowledge tools. This model is two fold, as it not only has a knowledge creation cycle, but has an action or application cycle. The action/application cycle steps include: monitor knowledge use, evaluate outcomes, sustain knowledge, identify problem/identify, review, select knowledge, adapt knowledge to local context, assess barriers to knowledge use, select, tailor, and implement interventions.
    The aspects of KT that may create barriers are diffusion, dissemination, and implementation. I found the idea of “evidence-based practice, practice-based evidence, and practice-based research” from the article Knowledge Translation in Rehabilitation: A Shared Vision “ to be a concept that may be difficult to apply when transitioning to the professional world and to clinical practice. This idea affects both diffusion and implementation. In graduate school, we have talked most heavily about the implementation of evidence-based practices. However, we discussed minimal importance of practice-based research/evidence. Realistically, this is the most efficient and meaningful way to develop research and practices. Due to lack of knowledge of these concepts, I feel that this concept could become a barrier as I enter the professional and clinical field. I am looking forward to continuing my education about this topic, and how to implement this aspect of the model within the future.
    Another barrier that may be preset is how the knowledge is transferred or taught to clients, family, caregivers, community and even on the national level, like policy makers. As speech-language pathologist’s we can make sure that we educate all of these entities in a clear and thorough manner. How this can translate to the school system, is by educating the student, parents, teachers, administrators, even the occupational and physical therapists. To ensure education is clear and complete, the speech-language pathologist can also provide additional resources.

  3. Knowledge translation (KT) is not completely well-defined, but the main purpose is to apply knowledge to practice. All of the models of KT are cycles, and not just a linear process.
    The first model, science of improvement, uses The Model for Improvement plan-do-study act cycles. Plan-do-study-act consists of four steps: plan, do, study, and act. This is a fairly self-explanatory cycle. The Model for Improvement asks three main questions: 1) What are we trying to accomplish? 2) How will we know that a change is an improvement? 3) What change can we make that will result in improvement? The entire purpose of The Model for Improvement is to create changes that will head to improvement that will last within a system.
    The second model is a 3-stage process by The Institute of Medicine. This model is directly related to health care, unlike the previous model. The 3 stages are: 1) science, 2) translating science into evidence, and 3) applying the evidence to patients. Unlike the previous model, the IOM model includes what the consequences are if the model is not followed. The model illustrates that missed opportunities, waste, and harm can result from insights being poorly managed, evidence being poorly used, and experience being poorly captured.
    The third model is Knowledge-to-action framework. This model uses knowledge inquiry, synthesis, and products or tools to create knowledge. The action cycle includes 7 phases: monitoring knowledge use, evaluating outcomes, sustaining knowledge use, identifying the problem, adapting knowledge to local context, assessing barriers to knowledge use, and selecting, tailoring, and implementing interventions. This model is the lengthiest of all the KT models.

    The IOM article touched on some of the barriers that could limit knowledge transfer to clinical practice. Some of the barriers included: limited access to articles, time limitations, lack of understanding, and limited funds.

    In order to address limited access to articles, a database could be developed that would be accessibly by all clinicians. In order to address the lack of understanding, the implementation of evidence-based practices courses in a student’s graduate school curriculum could help. Evidence-based practices courses allow students to have a greater understanding of how to critically appraise evidence and then apply that evidence.

  4. As a few of you have already mentioned, each of the models have a cyclical ordering, indicating that processes need to be revisited over and over throughout knowledge translation in order for it to be effective. The Model for Improvement has a clear starting point, and highlights the forward motion that happens between each cycle, with small improvements growing into larger changes over time. I appreciated how this model and the K2A model accounted for barriers to implementation, but in differing ways. The Model for Improvement accounts for the psychology of the humans involved in the process and wanted to minimize the fear of failure by introducing small changes at a time. On the other hand, the K2A model looks at specific barriers in the field of application. Each model also includes the generation of new knowledge, however the K2A model separates out knowledge creation and application into two sequential or co-occurring processes, noting that not all “knowledge” needs to be translated.

    Barriers that limit knowledge translation into clinical practice include:
    • Communication between parties with different lenses and experiences – patients, health care professionals, policy makers
    • Long and complex process to change engrained behaviors
    • The sheer volume of research evidence currently produced, access to research evidence, time to read and the skills to appraise, understand, and apply research evidence
    • The content of evidence resources is not always enough for the needs of the end-users – the focus has been on the validity of evidence rather than its applicability
    • Inadequate management of knowledge at different levels, including the health care system (e.g., financial disincentives), the health care organization (e.g., lack of equipment), health care teams (e.g., local standards of care may not be in line with recommended practice), individual health care professionals (e.g., variations in knowledge, attitudes and skills in critically appraising and using evidence from clinical literature) and patients (e.g., low adherence to recommendations).

    I am thankful that VCU has taught us how to search for and critically appraise evidence, because this is key in knowing what knowledge is valuable for transfer and what can be dismissed as invalid or unrelated to our practice. Regularly sharing these skills with our team of providers and having times carved out where research can be brought to the table, discussed from various points of view, and an application plan made seems like a great way to break down barriers of communication and time to transfer. Framing these conversations in a way such that it is our responsibility and privilege to continuing to seek best practice as research develops and our fields change may be a step towards breaking down some engrained behaviors/beliefs/attitudes as well.

  5. As mentioned by my other colleagues, the Knowledge Transition model contains various attributes and is designed for professionals to apply knowledge into practice. KT models include the aspects of research, data synthesis, and a lifelong commitment to work collaboratively to share the knowledge and information gained from clinical practice. My colleagues have also discussed how KT is not a linear but a cyclical process. The Model for Improvement is structured around the Plan-Do-Study-Act (PDSA). This model focuses on three essential questions, what are we trying to accomplish, how will we know that a change is an improvement, and what change can we make that will result in improvement. By using these questions, the Model for Improvement works towards to make changes that will lead to the desired outcome of improvement in some way. Overall the cycle that is present in this model requires professionals to think intensely to implement the best practices. Another model is the knowledge-to-action (K2A) framework. The K2A entails the identification of the problem, assessing for potential facilitators and barriers, adaptation of evidence, monitoring, assessment of outcomes, and maintaining the practice. The Institute of Medicine (IOM) is a model that is related to health care. The IOM model works to minimize the gap in research, evidence, and clinical practice.
    IOM article discusses a few barriers that limit the ability to share information to be implemented into clinical practice. These include limited availability to articles, limited understanding of evidence application, and potential limitations on time available to find and evaluate articles.
    As discussed by my colleagues, there are a few ways we can try and address the barriers mentioned. One barrier discussed was the transferring of knowledge to others, such as those on the interdisciplinary team, clients, and their parents/caregivers. We want to take time to explain to others on our team and our clients about the information relevant to treatment. Part of our role as therapists is to ensure that we are using evidence-based practices and finding time to look at current research to make the best decisions for our clients and informing them about this information.

  6. As previously mentioned, all 3 models are cyclical or sequential in nature. However, the knowledge-to-action framework article did mention that you can go out of sequence within the 7 action steps. Each model also mentioned the importance of stakeholder input regarding relevance of knowledge. However, the IOM and knowledge-to-action framework articles discussed the importance of stakeholders to a much greater extent than the plan-do-act-study article. I like how the article on the knowledge-to-action framework specifically described the KT process as iterative, dynamic, and complex THOUGH I’m sure the creators of the other models would agree with this notion. The knowledge-to-action framework uses the word “knowledge” throughout the cycle, while the other two models switch between using: “knowledge, evidence, and data”.

    As mentioned above and in some of the articles, barriers limiting knowledge translation to clinical practice are:
    -Lack of access to relevant research
    -Resistance to change
    -Limited research literacy
    -Difficulty in applying available research to the specific practice settings–I was just discussing with someone the other day about how it is harder to get IRBs to do research based directly in the school context AND when research is out of context/needs to be translated to be applied it can sometimes be less effective in practice

    To resolve some of the barriers mentioned, we should….use the resources are professional organizations provide to us! I also just attended a conference and learned that NBCOT (who gives the OT board exam) offers all of those who pass access to a research database so they can stay current and up to date with evidence. The school system I’m in now also has monthly professional development meetings where OT and PT colleagues present on different topics to one another. This often sparks respectful and insightful discussion amongst the group. Different people will bring up questions that are puzzling to them on the topic and the group will tackle them together. Everyone typically leaves with more knowledge than they had when they walked in. As mentioned above, sometimes related service providers are more equipped to engage in the KT process than educators. Therefore, they should also be willing to share their knowledge and skills with those around them, possibly offering PD opportunities to educators at their schools or working with them 1:1.

  7. The KT model requires competencies in research literacy, data synthesis, and lifelong commitment to collaboratively share knowledge and innovation in practice context. The goal of this model is to move what we learn through research and apply it during treatment. The Model for Improvement is structured on “Plan-do-study-act” which is meant to develop changes that will lead to sustained improvements within a system. The knowledge-to-action (K2A) model is meant to expedite the implementation of EBP. The ultimate goal of these three models is to improve a “system”. For each model to be successful there needs to be the generation of new knowledge.

    As stated in the module, some of the barriers limiting knowledge transfer to clinical practice are:
    Availability and access to relevant research
    Difficulty in applying available research to the specific practice settings
    Practitioners may become entrenched in particular practice patterns
    Specific practices are embedded in interdisciplinary and multidisciplinary practice contexts that may be resistant to practice change
    Assumptions that practice is supported by the evidence

    As speech-language pathologists we could provide inservice trainings about current EBP. By doing so, this may encourage the teams to shift practices. Inservice training may also allow for those therapists/educators that are entrenched in particular practices an opportunity to learn about a new type of therapy approach; this may cause inclination for a change. This is not something that will be changed overnight. As professionals we are faced with a lot of responsibilities and tasks but, it is our duty to educate and advocate about/for better treatment practices.

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