A collaborative model of knowledge translation for sustainable practice change
Jennifer Baumbusch, RN, MSN, University of British Columbia
Heather McDonald, RN, MSc, University of British Columbia
Joan M. Anderson, RN, PhD, University of British Columbia
Sheryl Reimer Kirkham, RN, PhD, Trinity Western University
Koushambhi Basu Khan, PhD, University of British Columbia
Connie Blue, RN, BSN, University of British Columbia
Pat Semeniuk, RN, MA, Vancouver Coastal Health
Elsie Tan, RN, MSN, University of British Columbia
As part of a long-term research program on hospitalization and help-seeking experiences of diverse ethnocultural groups, a collaborative model of knowledge translation (KT) was developed between researchers and decision makers at a regional health authority in British Columbia. The model was based on a respectful relationship between researchers and clinical leaders, with the sharing of emerging findings in real time to inform sustainable practice changes. In addition to improvements in the practice setting, the partnership has resulted in constructive changes to the clinical research process, in recognition of the integral role practitioners and decision makers play.
The collaborative model of KT1 presented in this case study illustrates how established partnerships between researchers and leaders in the clinical environment can facilitate the uptake of research in health care settings. Developed over the past two years between researchers and health care decision makers at one of British Columbia's regional health authorities, Vancouver Coastal Health, our KT activities were part of a six-year, CIHR-funded program of research on hospitalization and help-seeking experiences of diverse ethnocultural groups.
Our approach to KT was driven by requests from clinical leaders for timely access to research findings that could inform ethically-sound decision making. Our KT model drew on both CIHR's2 and Lavis et al.'s3 frameworks, which encourage the development of take-home messages as a starting point for interactive dialogue with clinical leaders, and to use people seen as credible to clinical leaders to initiate that dialogue.
Our goal was to effect a cultural shift that would facilitate the ongoing use of research knowledge that underscores how socioeconomic, historical, and contextual factors intersect to influence patients' hospitalization and transition to home experiences. We aimed to produce sustainable transformations in practice at Vancouver Coastal Health towards more equitable, efficient and effective health services.
The KT initiative
The main components of our KT model were the development of a context that supports KT, the synthesis and use of research-based take-home messages as a point of engagement with clinical leaders and the collaborative development of specific initiatives to address research findings.
The model is underpinned by a relationship between researchers and clinical leaders grounded in accountability, reciprocity and respect for each other's knowledge. Clinical leaders act as advocates for research in the practice setting, while researchers actively participate in translating the research. Clinical partners provide input from their practices into research questions, research data are collected and analyzed concurrently and emerging findings are shared between research and clinical partners in "real time."
Various strategies were used to bring researchers and clinical leaders together in open and creative dialogue. These included holding meetings at times and locations that were conducive to the work schedules of clinical leaders; inviting leaders from across the continuum of care to talk with researchers; ensuring the gap between researchers and clinical leaders was bridged through team members with extensive experience in both academic and clinical settings; and listening carefully to and acting on issues of interest to clinical leaders. Our most effective dialogue occurred during informal breakfast meetings where we discussed emerging findings. These meetings were pivotal, as specific initiatives designed to address the research findings grew out of the collaborative discussions that took place.
Results of the KT experience
We developed initiatives that target sustainable changes in practice at both the systems level and the individual practitioner level. We have initiated a number of projects at the systems level,4 including two medical interpreter programs and a quality improvement project that uses follow-up telephone calls to discharged patients to provide continuity of care between the hospital and home. At the individual practitioner level, the team has received CIHR funding for a three-year study of cultural safety and knowledge uptake in clinical settings. This project will use "just-in-time" teaching5,6 as a strategy to translate findings into practice.
In addition to changes in the practice setting, our KT experience has also led to changes in the research process. It has demonstrated the integral role of clinical practitioners and decision makers in clinical research, in particular, how their input ensures that the results of research are relevant to the current context of health care.
For example, early in the project we were surprised to find that several patients were readmitted to hospital. A number of issues were affecting patients' experiences during the transition between hospital and home, such as the timing and quality of discharge teaching, and communication when the patient couldn't speak English. It struck us that many of these readmissions might have been preventable, as illustrated by this recounting of discharge teaching by a female Anglo-Canadian patient who was readmitted for constipation:
R: "So the information that the dietician gave you at the hospital was…?"
P: "Overwhelming…I broke into tears. Well, the stuff she told me was right; there was nothing wrong with that. It's just that you need to know where to start, when you go home."
Clinical leaders were extremely interested in this finding because they had been unaware of the high rates of hospital readmissions—patients were not necessarily readmitted to the original hospital where they had received care, and readmission rates were not tracked across health authorities. They pushed us to provide more concrete numerical data and to examine further why this was happening. The readmission data provided a strong point of focus for collaboration and resulted in the development of systems-level KT initiatives to target the issues contributing to unplanned readmissions.
One important lesson of this process is that a long-term commitment from researchers and clinical leaders is needed to effect sustainable transformations in health services. While members of our larger group have changed, particularly the clinical leaders, core team members have been working together since 1998. This ongoing relationship of trust and collaboration has proven important for the development of some of our innovative initiatives.
Researchers and clinical leaders often speak different disciplinary languages and are affected by different and sometimes competing pressures.
There have been challenges around the development and use of this approach to KT. Researchers and clinical leaders have had to shift away from their traditional roles to embrace a collaborative, dynamic and reciprocal process. Negotiating roles and responsibilities can be complicated, especially in the demanding environment of the health care system. Because the KT process requires ongoing face-to-face dialogue, protected time for clinical leaders to participate is essential. An organizational climate in the practice setting that supports KT is, therefore, crucial.
An additional challenge has been bridging the understanding gap between researchers and clinical leaders. Researchers and clinical leaders often speak different disciplinary languages and are affected by different and sometimes competing pressures. Key to bridging this gap has been the use of "credible messengers" who are well versed in both the clinical and academic worlds. Our team includes two doctoral students with strong links to practice, who are funded from both the research and practice settings.
We found that our model was especially relevant for KT with qualitative research and critical perspectives: data collection and analysis can occur concurrently, and can be flexible and responsive to priorities identified by clinical partners. Findings from such research often reveal complicated structures and social processes. Yet, researchers must be attuned to the kinds of findings that clinical leaders need to support decision making and be willing to negotiate the research agenda.
Collaborative partnership where clinical leaders have direct and real input into the research process, should be a cornerstone of research in the health care setting.
For instance, when presenting the readmission data discussed earlier, researchers were also asked to provide numerical data that could be translated into costs to the health care system. At times, requests for such "bottom-line" information conflicted with the more theoretical, contextual, and broad-based analyses that the researchers employed. The shorter time frames for taking the findings back to practice also presented a challenge for researchers used to more time for analysis. For the most part, our challenges have been successfully mediated because of our carefully cultivated collaborative relationship and the commitment of all team members to a common goal.
Conclusions and implications
Over the past three years, we have integrated the KT model into presentations of emerging findings at national conferences, public lectures, and meetings with researchers, clinical leaders and policy makers. There is widespread interest in the model's applicability in a variety of health care settings that require creative and innovative solutions to complex issues. We are careful to stress the level of commitment and resources (mostly time) needed from all participants to make the KT model work effectively, yet also celebrate the potential impact of this approach on practice within the health care arena.
Our experience, along with that of other knowledge translators, suggests that collaborative partnerships such as the one we have fostered, where clinical leaders have direct and real input into the research process, should be a cornerstone of research in the health care setting. These partnerships enable the data collection and analysis process to be responsive to the changing needs of the clinical setting, resulting in findings of immediate importance. Clinical leaders are also eager to take up the findings because of their personal investment in the research process. Effective dialogue can result in creative solutions to complex problems.
Although the funded component of this research project has now drawn to a close, our KT experience continues. We recently received three years of funding to extend and refine our model to enable KT from this program of research, as well as other research projects that similarly aim to highlight disparities in health care delivery, with front-line practitioners.
1 Baumbusch, J. L., J. M. Anderson, S. Reimer-Kirkham, K. B. Khan, H. McDonald, P. Semeniuk, and E. Tan. Manuscript in development. Pursuing common agendas: A collaborative model for knowledge translation in clinical settings.
2 Canadian Institutes of Health Research. 2004. Overview of knowledge translation.
3 Lavis, J. N., D. Robertson, J. M. Woodside, C. B. McLeod, J. Abelson, and the Knowledge Transfer Study Group. 2003. How can research organizations more effectively transfer research knowledge to decision makers? Milbank Q 81 (2): 221-48.
4 Baumbusch, J., P. Semeniuk, H. McDonald, K. B. Khan, S. Reimer-Kirkham, E. Tan, and J. M. Anderson. Manuscript in development. Easing the transition between hospital and home: Translating knowledge into action.
5 Canadian Health Services Research Foundation. 2001. Knowledge transfer: Looking beyond health. Conference report. Ottawa, ON: CHSRF.
6 Canadian Health Services Research Foundation. 2002. Knowledge transfer in health. Conference report. Ottawa, ON: CHSRF
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