From Research to Knowledge Transfer how might it actually happen in - - PowerPoint PPT Presentation

From Research to Knowledge Transfer – how might it actually happen in practice?

John Gabbay

22 July 2009

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All aboard the bandwagon…

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The KT/ KU/ KM industry

• E.g. * “KT08” conference, Banff, Canada “propositions”:

– Society expects active partnership (with KT) – Pursue KT 4 R&D or perish – Need KT “sensitivity, understanding.. & skills” throughout research – need more and better R&D on KT! – … and more training in KT – ... oh and more investment in KT – But how new is this? – Emphasis on “Mode 2” science

*= Knowledge Translation 2008:http:/ / www.uofaweb.ualberta.ca/ kusp/ pdfs/ KT08%

20Framework% 20Document% 20FINAL.pdf

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“Mode 2 science”

• Knowledge developed in the context of application
• Transdisciplinary (& not paradigm-bound)
• Diverse situations of knowledge production
• Reflexive with greater dialogue among key players
• New power-sharing in QA; wider stakeholder control

(e.g. Nowotny, Scott, Gibbons. 2001, Re-thinking science: knowledge and the public in an age of uncertainty)

“Socially distributed knowledge generation:”

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KU08 conclusions:

• LOADS more research on KT needed!!
• LOADS more KT researchers needed!!
• Mentors, training and incentives for KT
• .. and…
• vercome barriers, e.g.:

– Culture of target audience – Characteristics of knowledge – Insufficient capacity of KT/ disseminators – Human factors limiting receptivity – Systemic and cultural barriers – Not enough evaluation (i.e. research!) on KT…

http:/ / www.uofaweb.ualberta.ca/ kusp/ pdfs/ KT08_Final_Report_Dec2008.pdf

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Hmmmm… .

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More down to earth - NETSCC:

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More down to earth - NETSCC:

• KT thought through as part of the research process

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More down to earth - NETSCC:

• KT thought through as part of the research process
• Involving (i.e. really engaging) all key stakeholders
• Importance and relevance of topic to them
• Show what difference the research is going to make to them

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Who might the stakeholders be?

Professionals Purchasers/ Payors Patients Policy makers Politicians Public Physicians Producers (e.g. Pharmas) Providers Press Public health Priesthoods

P..P..P..Pretty well anyone!!

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NETSCC advice, in summary:

• KT thought through as part of the research process
• Involving (i.e. really engaging) all key stakeholders
• Importance and relevance of topic to them
• Show what difference the research is going to make to them
• Mention all this in the application!
• (NB NETSCC now m onitors Patient and Public Involvement!)

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End of Part 1 Here come the adverts.. … .? Monographs

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Lots and LOTS of Monographs!! (480 and rising) Read? Hmmmm…

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CD-ROM Searchable Up to date Comprehensive Read? Hmmmm…

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Abstracts

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Case Studies Spotlight Themed updates

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Website

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Bulletin/ email alert

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So much for the adverts: Even simple dissemination is a struggle!!

• based on an ethnography of primary care

that set out to explore the way clinicians actually use knowledge in day-to-day practice.. (JG and Andrée le May) PART II

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Design and methods

• Practice: “Lawndale”

– 8-partner GP practice plus 3 nurses and others – leading-edge practice – small UK rural seaside town

• Ethnography:

– 2 years surgeries, clinics etc; – nearly 7 years formal/ informal practice meetings – observation (participant/ non-participant) – interviews

• open/ semi-structured
• individual/ group/ multi-professional
• informal discussions / chats
• Brief “check” ethnography in an urban practice
• Thematic analysis

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Levels of knowledge translation

1 EBP / KT / Centre 2 Local policy 4 Patient 3 Clinician

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Level 1: (e.g. the “Evidence-based..” movement)

Frame a focused question Appraise the evidence for its validity & relevance Identify a client-centred problem Search thoroughly for research derived evidence Seek and incorporate users’ views Use the evidence to help solve the problem Evaluate effectiveness against planned criteria

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Gabbay, le May, Jefferson et al: Health 2003 Vol 7 283-310

Level 2: Policy group processes

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Level 3: The clinician

Patient’s view Practitioners’ “mindlines”

General Individual

Gabbay, le May, BMJ 2004;329:1013

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Mindlines are:

– internalised collectively reinforced tacit guidelines-in-the- head that clinicians use to guide their practice – one person’s mental embodiment of their knowledge-in- practice – linked socially and organisationally to other people’s mindlines

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Other worlds Clinical world Research world Socialisation Externalisation Internalisation Combination

Research based knowledge

Centre (eg DH) Patients Industry explicit knowledge tacit etc….

SECI

(Nonaka & Takeuchi 1995) explicit tacit knowledge

information

potential for use as “knowledge in practice”

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The story so far:

1 3 2 Pt EBP/ KT / Centre Local policy Clinician

Frame a focused question Appraise the evidence for its validity & relevance Identify a client-centred problem Search thoroughly for research derived evidence Seek and incorporate users’ views Use the evidence to help solve the problem Evaluate effectiveness against planned criteria

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Another finding: multiple roles of GPs, e.g.:

clinical domain managerial domain public health domain professional domain

diagnosing managing resources, personnel and logistics disease prevention keeping up to date prescribing monitoring and improving quality screening reviewing practice investigating developing the IT system health promotion teaching and training advising and explaining complying with contractual and legal requirements health education nurturing collegial networks referring handling the Primary Care Trust disease surveillance promoting general practice (e.g. ’union’ work) advocating training practice staff knowing the local district sustaining credibility

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This phase of ethnography (2005-7)

• Monthly practice meetings (multi-professional)
• Aimed at meeting requirements for new GP contract

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The GP contract to implement new research-based practice in chronic kidney disease (CKD)

For maximum remuneration for managing CKD:

• Produce a register of all their adult patients with stages 3-5
• f CKD (i.e. with an eGFR of <60ml/ min/ 1.73m2)
• >90% have record of their blood pressure
• >70% record blood pressure <140/ 85
• >80% of CKD registered patients with hypertension on

appropriate treatment or good reason why not.

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Transferring knowledge via QOF contractual arrangements (a caricature)

Commission expert review of research evidence Reduce to key performance indicators Negotiate rigour vs pragmatism Identify an area of suboptimal practice Link desired change to financial incentives Make financial reward part of new contract Monitor contract against imposed criteria

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Accept all at Stage 3 Ignore most at Stage 3 threshold

Shall we accept the evidence and change practice?

Ensuring that we identify and register all renal patients will secure QOF points and ££s Results of routine screening will unnecessarily alarm patients

Key: Key: Managerial Public health Clinical Professional

Maybe we currently fail to identify renal patients who may therefore miss

• ut on important follow-up care

We fail patients with high creatinines in ways that aren’t even mentioned in the QOF and in other guidelines (e.g. medicines management). So let’s focus on those, not just QOF items. It’s generally agreed that US basis of eGFR makes it unhelpful for elderly UK populations. And low scores in Stage 3 are especially dubious. So why comply? Our prevalence seems comparatively low – we may be missing too many renal patients Results of routine screening will overburden resources with little or no resulting health improvement We need to avoid unnecessary workload – both within practice and elsewhere (e.g. the laboratory service and hospital nephrologists) We are already giving the right care to most CKD because of the good follow up on their related illnesses It won’t be practicable to carry out all the required new tests We will become better at managing patients with renal disease With training we can find ways within the rules to recode those with eGFR 30-60 But the Practice “has only had one death from CKD in the last 10 years!”

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Conclusions

• “Knowledge in practice” = “mindlines”
• Multiple cues to amend mindlines
• Little direct “knowledge translation” (SECI cycle)
• Social, collective construction of mindlines
• Mindlines structured, shaped, sustained by contextual demands,
• pportunities, constraints
• Linkage between roles, goals, activities and knowledge-in-practice

(missed by KT)

• The roles being played influence the way the mindlines are “laid down”

amended, and used

• Research knowledge (even disease categories) interpreted and reconstructed

by this social process

Gabbay J, Le May A. In: le May A. (Ed). Com m unities of practice in health and social care

• 2009. Oxford: Blackwell.

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Implications for KT:

• Individuals tend to work and learn collectively (e.g. in

communities of practice)

• They tra nsform knowledge, not transfer or translate it, and

construct knowledge-in-practice that suits their complex, multi-role needs

• Inevitably they subvert, therefore, “top-down” KT if it doesn’t

suit those complex needs (as also happened with most top- down guidelines in our study… )

• Individuals’ use of knowledge-in-practice needs to be the

driving force of KT

• KT needs to start by understanding and working with the

recipients as active agents

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Conclusions

• Yes KT needs more (and probably different types of) research
• But what we do know is that we cannot make assumptions

about how people will react to research when needing to use it in practice

– except that we know they will transform it into something else! – and even if they don’t, their organisations almost certainly will*

• And we know that we therefore need to involve the users of the

research closely when designing, executing, interpreting and disseminating it

• KT is not easy and certainly not a bolt-on!
• *see, e.g. Van de Ven et al. 1999 The Innovation Journey

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Meanwhile, to ride the KT bandwagon successfully:

• Think of KT as an integral part of the research process

– from formulating and justifying the research question, to designing the methods and outcome measures, to executing the study, to interpreting the results, to planning and delivering the dissemination – and everything in between

• Really do engage all key stakeholders who will use the research
• Build on the relevance of the research to their actual practice/

experience of care

• Show what difference the research might make to their practice/

experience of care

• Show all this clearly in the grant application!!