Piloting knowledge brokers to promote integrated stroke care in Atlantic Canada

Renee Lyons, PhD, Atlantic Health Promotion Research Centre, Dalhousie University
Grace Warner, PhD, Atlantic Health Promotion Research Centre, Dalhousie University
Lynn Langille, MA, Atlantic Health Promotion Research Centre, Dalhousie University
Stephen J. Phillips, MBBS, Dalhousie University

The use of knowledge brokers to increase interaction between researchers and decision makers has attracted increasing attention as a knowledge translation (KT) approach. Researchers at the Atlantic Health Promotion Research Centre and Dalhousie University investigated how knowledge brokers affected decision maker uptake of best practices in integrated stroke care in the Atlantic provinces. They found that knowledge brokers can enhance partner interactions, but needed to develop effective strategies for creating partnerships and engaging participants. They also required excellent communication skills and a high level of proficiency in the subject matter.

Background

If individual and organizational change were easy, the KT process would be simple. But resistance to change is widespread1 and progress towards improving the health care system tends to be slow.2

The knowledge translation literature suggests that health system change and the creation of evidence-based policy can be enhanced by increasing interaction and communication between researchers and users of research.3 Knowledge brokering, which is defined by the Canadian Health Services Research Foundation as the human force that makes knowledge transfer more effective by bringing people together, has gained currency as one approach to help researchers and users of research work together more effectively.4

Knowledge brokers can also be described as facilitators between two communities.5 Their role is to make things easier: by building relationships, uncovering needs, sharing ideas, and promoting action.4 In 2003, the Canadian Stroke Network funded the Atlantic Health Promotion Research Centre and Dalhousie University to examine the effectiveness of using knowledge brokers for increasing exchange between stroke researchers and the users of stroke research. The goal was to increase decision maker uptake of best practices in integrated stroke care.

The KT initiative

Our primary objective was to observe and describe how knowledge brokers affected decision maker uptake of new evidence supporting changes in stroke care in four provinces: New Brunswick, Newfoundland, Nova Scotia, and Prince Edward Island. The project used work done in Ontario on integrated stroke care as a template for how an integrated stroke strategy could be created and implemented in the Atlantic provinces.

To accomplish this, we established teams of representatives from each province's department of health (who had a policy making role) and each province's Heart and Stroke Foundation branch (who, through their awareness of stroke research, acted as a resource base). Each team was then responsible for hiring a knowledge broker and articulating province-specific goals for the project. The teams drafted memoranda of agreement, decided which partner would house the knowledge broker, identified goals for the knowledge broker and outlined how the goals would be accomplished.

Prince Edward Island, New Brunswick, and Newfoundland identified the creation of provincial integrated stroke strategies as the goals for their knowledge brokers. In Nova Scotia, the Department of Health was already considering whether to implement the Heart and Stroke Foundation's recommendations for an integrated stroke strategy. The goal for the Nova Scotia knowledge broker was, therefore, to improve communication between the parties involved in implementing the strategy.

We provided the partners and the knowledge brokers with Atlantic-wide forums every six months. These forums disseminated information on best practices for stroke care, shared implementation lessons from Ontario, and provided networking time between teams. We also provided expert speakers on how telemedicine technology could be used in stroke identification and care, and supported knowledge brokers' travel to Ontario (to see a facility that had already implemented an integrated stroke strategy) and Yarmouth, Nova Scotia (to talk with researchers involved in the Yarmouth Stroke Project, an Atlantic Health Promotion Research Centre initiative to implement an integrated stroke strategy in a rural location).

We also acted as a resource and support base for the knowledge brokers. Monthly meetings or teleconferences provided an opportunity to share concerns and triumphs and to update researchers on what was going on in the provinces. In addition, the project coordinator traveled to the provinces on a regular basis. The knowledge brokers were also welcome to contact the researchers whenever they needed.

Results of the KT experience

Our project objectives were evaluated by analyzing data from key informant interviews and focus groups conducted with the knowledge brokers and the team partners. Success was judged by whether the existence of knowledge brokers increased knowledge exchange between the partners, increased decision maker uptake of new evidence supporting changes in stroke care, and helped the provinces accomplish their goals. The project formally finishes in March 2006, but improvements in partner communications and awareness of stroke care best practices have already been observed.

Prince Edward Island, New Brunswick, and Newfoundland are on schedule to complete their provincial integrated stroke strategies, which can be directly attributed to their knowledge brokers. As one interviewee said:

"I don't think without having somebody dedicated to the cause, it [the creation of an integrated stroke strategy], necessarily would have gotten off the ground this year…People who have been fighting for this kind of change for a number of years…were really feeling quite frustrated because they weren't getting the support they needed either from the Department of Health or from the Heart and Stroke Foundation because they just didn't have the resources…You really needed somebody in this position to help tie it together and to push it along."

In Nova Scotia, the provincial government has committed money to an integrated stroke strategy. Although this decision cannot be directly attributed to having a knowledge broker, their broker did increase understanding of the best practices on stroke care in the provincial health districts and, through this, generated the support that was critical for moving ahead with an implementation strategy.

The knowledge brokers facilitated communication, cleared up misunderstandings and provided a dedicated person working toward system changes in collaboration with others within the system. With much time and effort the knowledge brokers also successfully formed multi-sectoral advisory committees, consisting of researchers, administrators, policy makers, and practitioners. This was a major task of most of the knowledge brokers, and in addition to helping accomplish the partner goals, these committees had the unforeseen benefit of being a good dissemination mechanism for best practices research to individuals outside the project.

Knowledge brokers were able to identify opportunities where best practices for stroke care could be integrated into existing provincial initiatives and where training and education was needed to improve care. As a result, decision makers are more aware of best practices for stroke care and researchers have a better understanding of the context affecting decision makers' uptake of research.

Lessons learned

Knowledge brokers can enhance partner interactions, but need to develop effective strategies for creating partnerships and engaging individuals to participate.

This initiative has demonstrated that knowledge brokers can enhance partner interactions, but brokers needed to develop effective strategies for creating partnerships and engaging individuals to participate. They also needed excellent communication skills and a high level of proficiency in the subject matter to meet the diverse demands of the partners.

Establishing partnership teams took longer than expected. Despite a prior commitment from the partners to work together, it took between 9 and 14 months for each team to agree on hiring the knowledge brokers. Critical factors that contributed to this delay were political change, availability of in-kind support, confidentiality concerns and questions about possible hidden agendas among the partners.

Another obstacle was that most provinces had not identified stroke as a priority condition, and no money had been dedicated to improving stroke care. This made the government partners hesitant to commit to the partnership, because they did not have financial resources to implement health system changes in stroke care. The provincial governments did have a mandate to improve chronic disease management and they eventually examined evidence on stroke care under that framework. But there was still no guarantee that support would be available for future health system changes. While the provincial Heart and Stroke Foundations were supportive of the project, some wanted to wait until there was a firm government commitment before they agreed to actively participate. In addition to these challenges, it was difficult for the researchers to be flexible enough to set project goals collaboratively.

Even after hiring the knowledge broker, and despite jointly developed goals, the teams often struggled because the partners had divergent mandates.

The Heart and Stroke Foundations felt obligated to promote funding for better prevention and treatment of stroke in the provincial budgets. Although the Departments of Health supported evidence-based care, they had limited resources available and wanted to make sure expectations were realistic.

Conclusions and implications

Ongoing partnerships between government and non-government agencies or researchers need to be supported.

The knowledge broker role could be adapted to other situations. To date, other decision makers may not use them because of limited funds and a lack of understanding about the importance of improving communication. When finances are low, communication is usually not considered to be a priority, especially when resources barely cover the current demands on the system. But ongoing partnerships between government and non-government agencies or researchers need to be supported because governments usually do not have enough resources to scan the horizon for evidence that goes beyond their current needs. Conversely, in research, there is a continued need to understand the context in which evidence-based policy can be implemented. An increased understanding of context can help researchers identify processes to broaden government receptivity for new evidence. In the future, funding should be dedicated towards making this type of position financially sustainable because it has the potential to improve the quality of health care.


References

1 Lyons, R., and G. Warner. 2005. Demystifying knowledge translation for stroke researchers; a primer on theory and praxis. Online manuscript. Halifax, NS: Canadian Stroke Network.
2 Berwick, D. M. 2003. Improvement, trust, and the healthcare workforce. Qual Saf Health Care 12 (Suppl. no 1): i2-6.
3 Landry, R., N. Amara, and M. Lamari. 2001. Utilization of social science research knowledge in Canada. Res Policy 30:333-49.
4 Canadian Health Services Research Foundation. 2003. The theory and practice of knowledge brokering in Canada's health system. Report. Ottawa, ON: CHSRF.
5 Kitson, A., G. Harvey, and B. McCormack. 1998. Enabling the implementation of evidence based practice: A conceptual framework. Qual Health Care 7:149-58.

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