CanJPsychiatry 2014;59(3):160–169
Review Paper
A Narrative Review of Recent Developments in Knowledge Translation and Implications for Mental Health Care Providers Elliot M Goldner, MD, MHSc, FRCPC1; Emily K Jenkins, RN, MPH (PhD Candidate)2; Benedikt Fischer, MA, PhD3 1
Professor, Centre for Research in Mental Health and Addiction (CARMHA), Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia. Correspondence: CARMHA, Faculty of Health Sciences, Simon Fraser University, 2400–515 West Hastings Street, Vancouver, BC V6B 5K3; [email protected].
2
Doctoral Student, School of Nursing, University of British Columbia, Vancouver, British Columbia.
3
Professor, Centre for Research in Mental Health and Addiction (CARMHA), Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia; Senior Scientist, Social and Epidemiological Research, Centre for Addiction and Mental Health, Toronto, Ontario; Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario.
Key Words: knowledge translation, mental health, knowledge exchange, implementation, health care, dissemination Received March 2013, revised, and accepted October 2013.
Objective: Attention to knowledge translation (KT) has increased in the health care field in an effort to improve uptake and implementation of potentially beneficial knowledge. We provide an overview of the current state of KT literature and discuss the relevance of KT for health care professionals working in mental health. Method: A systematic search was conducted using MEDLINE, PsycINFO, and CINAHL databases to identify review articles published in journals from 2007 to 2012. We selected articles on the basis of eligibility criteria and then added further articles deemed pertinent to the focus of our paper. Results: After removing duplicates, we scanned 214 review articles for relevance and, subsequently, we added 46 articles identified through hand searches of reference lists or from other sources. A total of 61 papers were retained for full review. Qualitative synthesis identified 5 main themes: defining KT and development of KT science; effective KT strategies; factors influencing the effectiveness of KT; KT frameworks and guides; and relevance of KT to health care providers. Conclusions: Despite limitations in existing evidence, the concept and practice of KT holds potential value for mental health care providers. Understanding of, and familiarity with, effective approaches to KT holds the potential to enhance providers’ treatment approaches and to promote the use of new knowledge in practice to enhance outcomes. WWW
Une revue narrative des récents développements du transfert des connaissances et des implications pour les prestataires de soins de santé mentale Objectif : L’attention portée au transfert des connaissances (TC) s’est accrue dans le domaine des soins de santé, dans une tentative d’améliorer l’assimilation et l’application de connaissances potentiellement bénéfiques. Nous présentons un aperçu de l’état actuel de la littérature sur le TC et discutons de la pertinence du TC pour les professionnels de la santé œuvrant en santé mentale. Méthode : Une recherche systématique a été menée dans les bases de données MEDLINE, PsycINFO, et CINAHL afin de relever les articles de synthèse publiés dans les revues de 2007 à 2012. Nous avons choisi des articles selon des critères d’admissibilité, puis nous en avons ajouté d’autres jugés pertinents pour le propos de notre article. Résultats : Après avoir éliminé les doubles, nous avons scanné 214 articles de synthèse pour en vérifier la pertinence et, subséquemment, nous avons ajouté 46 articles issus d’une recherche manuelle de bibliographies ou d’autres sources. En tout, 61 articles ont été retenus pour un examen complet. Une synthèse qualitative a dégagé 5 thèmes principaux : définition du TC et
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A Narrative Review of Recent Developments in Knowledge Translation and Implications for Mental Health Care Providers
développement de la science du TC; stratégies efficaces du TC; facteurs influençant l’efficacité du TC; cadres et guides du TC; et pertinence du TC pour les prestataires de soins de santé. Conclusions : Malgré les limitations des données probantes existantes, le concept et la pratique du TC ont une valeur potentielle pour les prestataires de soins de santé mentale. La compréhension et l’apprivoisement des approches de TC efficaces offrent le potentiel d’améliorer les approches du traitement des prestataires et de promouvoir l’utilisation de nouvelles connaissances dans la pratique pour de meilleurs résultats.
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ithin health care, there has been a rapid growth of interest in KT. This growth has been triggered by the realization that clinicians, patients, and decision makers do not pick up many potentially beneficial research findings and discoveries, that is, the new knowledge does not get translated into action or does so only after a lengthy lag time.1–8 Moreover, many promising discoveries and health interventions fail to achieve their maximum potential and (or) reach the people most in need.3,9,10 Researchers are dissatisfied with the prospect of their findings being disregarded and health care providers want to ensure good access to the best quality and most up-to-date findings about specific health care questions—not only for themselves, but for patients, family members, and decision makers.11 In our paper, we review developments in KT and consider the implications for health care practitioners working in mental health.
Methods Search Strategy
We used a multi-faceted approach to obtain relevant material for review of developments in KT to address the challenges inherent in search strategies that seek to examine publications about KT.12–15 We initiated our search using MEDLINE, PsycINFO, and CINAHL electronic databases, and, given the limitations that have been noted with the use of standard MESH terms to identify articles on KT,15 we instead used 3 of the most widely used KT-relevant terms as identified by Graham et al3: KT, knowledge exchange, and knowledge transfer. We limited our search to reviews and meta-analyses published in the English language between 2007 and 2012. Our decision to limit our search to reviews and meta-analyses was based on our need to reduce the very large volume of publications that address KT to manageable numbers, and the focus of our review, which seeks to provide an up-to-date overview of developments in KT, particularly those relevant to mental health care providers. The search Abbreviations CIHR
Canadian Institutes of Health Research
I2I
Innovation to Implementation
KT
knowledge translation
PARIHS Promoting Action on Research Implementation in Health Services
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Clinical Implications •
Awareness of KT concepts and approaches among mental health treatment providers may enhance the uptake and use of best evidence.
•
Incorporating KT approaches into clinical encounters may enhance quality of care and health outcomes.
•
Contributing to the practice-based research evidence base holds the potential to establish research evidence that is relevant to clinicians and thus benefits patients.
Limitations •
The systematic search procedure included only review papers and identified only a portion of documents considered to be relevant. The papers that were reviewed should not be considered to be comprehensive.
•
The discussion regarding the applicability of KT concepts to health care providers is not exhaustive but, rather, is meant to illustrate important ways in which these concepts are relevant to clinical practice.
•
Discussion of KT frameworks is limited, however, reference to an appropriate resource for further guidance is provided.
terms and filtering procedures we used are summarized in Figure 1. Using an iterative process, we subsequently added papers through hand searching of the citations contained within publications identified through the systematic search process. The results of a recently conducted review of the KT literature were also drawn on to identify publications judged to be relevant to our review.14
Eligibility Criteria and Selection Process
All abstracts identified in the search procedure were reviewed and publications that focused on the application of KT to specific areas of health care practice that were not directly relevant to mental health (such as dermatology, surgery, or oncology) were eliminated. Publications that addressed general and nonspecific issues of KT and those that focused on any aspect of mental health care were retained for full review and were made available to all authors, who also added publications that were considered to be germane to our review, including those that were published before 2007 and those that were identified in reviewing the publications (and references contained within) that had been obtained through the structured search procedures. When including papers that had not been identified in the systematic search The Canadian Journal of Psychiatry, Vol 59, No 3, March 2014 W 161
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Figure 1 Search procedures
Articles identified through online database searches, n = 230: MEDLINE (n = 139), PsycINFO (n = 47) and CINAHL (n = 44)
Additional articles identified through hand searches of reference lists and identification of relevant papers by authors, n = 46 Duplicates n = 16
Records remaining (n = 260) titles and abstracts screened for relevance Articles excluded n = 199 Articles assessed for eligibility, n = 61 No further articles excluded Articles included in qualitative synthesis, n = 61
procedure, we aimed to identify either seminal papers that were considered to have shaped the evolution of the KT field, papers that held particular relevance to the focused topic of review, or articles that provided valuable information related to the themes that were identified through analysis. This latter component used a snowball search procedure described by Contandriopoulos et al13 in their review of knowledge exchange processes. We did not apply an evidence evaluation process as we surmised that such a process produced a narrow type of analysis, potentially eliminating valuable insights from this type of narrative review.13
Data Abstraction and Synthesis
Qualitative analysis of the publications was undertaken to identify key themes relevant to the topic of our paper. Two of the authors read through selected reviews and produced a coding template to identify and categorize the review data into themes identified within this literature. An iterative process was used throughout the analysis process and, when we considered themes to be inadequately covered by the literature that was obtained, additional efforts were made to identify peer-reviewed papers that could further develop 162 W La Revue canadienne de psychiatrie, vol 59, no 3, mars 2014
and articulate thematic areas. Summaries of thematic areas were produced by 2 of the authors and then circulated among all 3 authors for review. Our approach to synthesizing the large volume of material was to use an iterative process in which major concepts were first added and then reorganized to diminish the number of thematic areas to a minimum number that retained each of the key areas identified by the reviewing authors. Following qualitative synthesis, the themes were collated and consensus obtained among us to produce the following results.
Results
After removing duplicates, we scanned 214 articles for relevance. An additional 46 articles were added through hand searches of reference lists or identification and agreement by the authors. A total of 61 articles were retained for full review. The following 5 themes were identified and each is discussed under a separate heading: defining KT and development of KT science; effective KT strategies; factors influencing the effectiveness of KT; KT frameworks and guides; and relevance of KT to health care providers. www.LaRCP.ca
A Narrative Review of Recent Developments in Knowledge Translation and Implications for Mental Health Care Providers
Table 1 Effective KT strategies for influencing health care providers and allied professionals Strategy
Definition
Sample evidence
Educational outreach
This strategy (also known as academic detailing) refers to personal visits by a trained, credible person to health professionals in their own settings in which evidence-based, tailored information is provided for the purposes of influencing specific practice behaviours.
Grimshaw et al8; O’Brien et al34
Audit and feedback
Refers to the provision of information to health care providers about their own clinical performance, allowing comparison of their performance with that of their peers. Often, such information is collected through clinical databases and fed back through individualized reports and summaries.
Grimshaw et al8; Boaz et al10; Jamtvedt et al35
Use of opinion leaders
Opinion leaders are influential members of a community or field of practice whom other health care providers often turn to for advice, opinions, and clinical direction.
Grimshaw et al8; Boaz et al10; O’Brien et al34
Reminders and prompts
These include various formats (for example, paper reminders in patient charts, computerized decision support, algorithms, or electronic health records) that help clinicians optimize evidencebased protocols and practices at the point of care.
Grimshaw et al8; Grol and Grimshaw37
Interactive educational meetings
These include courses, workshops, and seminars that are more effective when they use multiple interventions, 2-way communications, printed and graphic materials in person, and locally respected health personnel as educators.
Grimshaw et al8; O’Brien et al34; Forsetlund et al38
Theme 1: Defining KT and Development of KT Science
Despite being described as closing the gap between what we know and what we do,16 it has been difficult to settle on a clear and consistent definition of KT.17 Numerous overlapping terms, such as knowledge transfer, knowledge exchange, knowledge mobilization, research utilization, dissemination, and implementation are used in varying ways by different groups.2,3,5,18,19 The CIHR uses the following definition of KT, now widely adopted in the field of health care: [A] dynamic and iterative process that includes synthesis, dissemination, exchange and ethicallysound application of knowledge to improve the health of Canadians, provide more effective health services and products and strengthen the health care system. This process takes place within a complex system of interactions between researchers and knowledge users . . .20, p 1 According to Tetroe: It [KT] encompasses all steps between the creation of new knowledge and its application to yield beneficial outcomes for society.20, p 2 The concept of KT is thus an umbrella term that includes many activities, such as technology transfer, knowledge management, knowledge use, continuing education, consensus guideline development, and translational research.5 In this definition, KT constitutes a broad concept and various theoretical perspectives have been applied to explain the processes of KT.13,21–23 www.TheCJP.ca
The KT process often brings knowledge that has been produced through scientific research into contact with knowledge developed through other means.23 Other forms of knowledge can be gained through the experience people have accumulated by living with a certain health problem, through encounters as a close family member or friend of someone with a health problem, through providing treatment as a health care provider to various people with the health problem, or by being involved with cultural, policy, educational, or political processes that address health care issues.13,24–26 Naturally, scientists are keen to apply scientific methods, including systematic observation, data collection, and hypothesis testing, and are often uncomfortable accepting other forms of knowledge unless they have been put through scientific filters. Conversely, nonscientists often feel that their knowledge, often gained through years of experience, should be recognized without the impediment of detailed scientific study.11,27 These conflicting perspectives may cause tensions within the KT process, however, this can be a creative tension; it is often through the interplay among these perspectives that highly valuable knowledge is created and moved into action.4,13,23,25,28 In describing the processes of KT, Lomas29 identifies 3 steps in moving research into action. Diffusion refers to relatively passive and horizontal (that is, among peers) activities, such as publishing findings in journals, presenting papers at academic meetings, or posting information on websites. Despite their limitations as means of effective KT, diffusion activities remain important and form a foundation for the development of more action-oriented KT efforts and opportunities that exist to improve the likelihood that The Canadian Journal of Psychiatry, Vol 59, No 3, March 2014 W 163
Review Paper
Table 2 Effective KT strategies for influencing patients and the general public Strategy
Definition
Sample evidence
Mass media campaigns
These are determined efforts used to promote health behaviour through television, radio, Internet, and print or other media.
Wakefield et al39; Jepson et al40
Social marketing approaches
These strategies aim to improve the welfare of people and society through applying commercial marketing technologies and techniques. For example, social marketing efforts often undertake consumer research to understand consumer values and needs and subsequently use segmentation variables to tailor interventions for use with specific segments of the population.
Gordon et al41
Community mobilization
Community-wide efforts to address a health or social issue that may bring together local, provincial, and federal governments; professional groups; religious groups; businesses; and individual community members. The process includes mobilizing necessary resources, disseminating information, generating support, and fostering cooperation across public and private sectors in the community to bring about changes in relevant health behaviours.
Jepson et al40; Roussos and Fawcett42
Laws and regulations
These have been applied by governments to achieve substantial public health achievements, such as tobacco control laws, that have reduced rates of many chronic illnesses and laws addressing the operation of motor vehicles under the influence of alcohol that have reduced accident-related fatalities and injuries. The effectiveness of regulatory and legal tools to address some health-related behaviours, such as substance abuse, is a complex area and must carefully take into account the relative harms that may be created through inappropriate criminalization of people in society.
Moulton et al43
Financial incentives and disincentives
The use of bonuses or exemptions as inducements (incentives) or excise taxes and pricing burdens (disincentives) to change health-related behaviours, such as reduction of tobacco and alcohol use, among members of the general public.
Chaloupka et al44
Self-management
Seeks to enhance a person’s ability to manage the symptoms, treatment, physical and psychological consequences, and lifestyle changes associated with a health condition. May be undertaken when people obtain tools, resources, or guidebooks through their own initiative or with the prompting and support of health care providers (that is, supported self-management).
Lorig and Holman45
diffused knowledge will reach relevant users. Dissemination delivers messages that are tailored to the target audience and uses effective delivery channels.2,29,30 Such efforts include the development and distribution of materials formatted to match the needs of particular stakeholder groups and may consist of briefings, educational sessions, media communications, and other activities that are designed for specific target audiences. Implementation is described by Lomas29 as the most active process in KT and one that is undertaken primarily at a local level, where barriers to the use of new knowledge can be effectively addressed and overcome. In general, effective implementation requires persistent and multi-faceted efforts that may be directed through various routes and means.2 KT strategies are often divided into those that either push or pull knowledge.24,30 Push strategies involve efforts to enhance the movement of knowledge from those who generate knowledge outward to those who may be able to benefit from its use. It often involves gathering, synthesizing, and funnelling high-quality information, and efforts at distribution and promotion. In health care, push 164 W La Revue canadienne de psychiatrie, vol 59, no 3, mars 2014
strategies may involve scientific publications, reports, systematic reviews, guidelines, online materials, conference presentations, courses, webinars, educational outreach, prompts, social marketing efforts, financial incentives, and media campaigns. By contrast, pull strategies are those instigated by people seeking to obtain new knowledge,24,30 such as when health care providers, policy makers, or patients seek out the knowledge that is needed to guide their actions. Such efforts can be facilitated by effective search tools that can locate high-quality information, access to knowledge syntheses and databases, training in the identification and application of research findings in decision making, critical appraisal skill development, and creation of rapid response units and government–university liaisons.
Theme 2: Effective KT Strategies
A theme was identified within the published literature that focuses on specific strategies and approaches that have been shown to be effective in KT efforts.8,10,19,31–46 These can be usefully divided into groups of strategies that can www.LaRCP.ca
A Narrative Review of Recent Developments in Knowledge Translation and Implications for Mental Health Care Providers
Table 3 Effective KT strategies for influencing decision makers Strategy
Definition
Sample evidence
Targeted and tailored dissemination of research knowledge to decision makers
Efforts to deliver messages to decision makers that are designed to be accessed and used easily, through creating information that uses language and formats that are comfortable, familiar, and comprehensible to the audience. Also involves delivering the information via effective delivery channels.
Dobbins et al46
Linkage of researchers and decision makers
Creating a means for sustained dialogue between researchers and decision makers.
Orton et al33
Capability building of both researchers and decision makers
Concerted efforts and programs to increase researchers’ abilities to create and disseminate evidence geared to decision makers’ needs and improve decision makers’ abilities to appraise and interpret research.
Orton et al33
Fostering culture of evidence-informed decision making
Changing the culture within which decision makers work to increase the value placed on the use of research evidence.
Orton et al33
be successfully applied with each of the following 3 key stakeholder groups: 1) health care providers and allied professionals (such as teachers and social service providers); 2) patients and the general public; and 3) decision makers (particularly those working in government and health sector decision-making roles).8 Tables 1, 2, and 3 summarize the findings for each of these groups, respectively. Although there is a substantial body of knowledge regarding KT strategies that are effective for the first 2 groups,10,31 there remains a paucity of knowledge regarding effective KT strategies to influence decision makers.8,13,33 In various areas, there remains limited evidence regarding the effectiveness of KT in producing clinically significant outcomes.
Theme 3: Factors Influencing the Effectiveness of KT
Numerous factors have been found to influence the effectiveness of KT interventions.2,5,19,30,32,47 KT is more effective when addressing topics that are perceived by knowledge users to be relatively simple and when tools (for example, guidebooks and decision aids) are in place to support the intended behavioural changes.48 Factors associated with better uptake of evidence-based innovations by organizations include larger size, decentralized decision making, greater resourcing, and closer proximity to urban centres, however, these account for a relatively small degree of variance.49 A learning organizational culture promotes absorptive capacity and facilitates the identification, capture, sharing, reorientation, and implementation of evidencebased knowledge.49,50 Organizational characteristics that contribute to good capacity include clear vision and strong leadership, workforce and skills development, ability www.TheCJP.ca
to access research (library services), fiscal investments, acquisition and development of technological resources, a knowledge management strategy, effective communication, a receptive organizational culture, and a focus on change management.2,30,47,51
Theme 4: KT Frameworks and Guides
KT scholars have developed frameworks and tools to describe and guide the KT process in an effort to minimize the research-practice gap.3,47,52–55 Given the abundance of KT frameworks and methods proposed over the last few decades,53 the National Collaborating Centre for Methods and Tools has established an online registry, cataloguing these frameworks and providing a valuable resource for those interested in incorporating KT approaches into their work.56 Here, we briefly describe 2 KT frameworks that have figured prominently in KT research and practice, and 1 guide that aims to support the practice of KT in mental health care settings. Among the most prominent KT frameworks is the Knowledge to Action Process devised by Graham et al.3 This framework, which has been adopted by Canada’s federal health research funding agency, the CIHR, consists of 2 components: 1) knowledge creation (which is conceptualized as the development of scientific evidence), and 2) action steps. Although this model presents the KT process as consisting of 2 distinct activities, the authors acknowledge that, in the real world, the process would be much more complex and dynamic with blurring between these 2 concepts, and activities within each of these components occurring simultaneously. At the centre of this model lies the knowledge creation funnel, depicting the different The Canadian Journal of Psychiatry, Vol 59, No 3, March 2014 W 165
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Figure 2 The I2I55 is a practical guide that describes 7 steps to achieving successful KT in health care settings.
1. State purpose
7. Evaluate
6. Implement
5. Design strategy
2.2.SelecƟon Select anan InnovaƟon innovaƟon
3. Specify actors and acƟons
4. IdenƟfy agents of change
Permission to reproduce the figure and the graphic was provided by the Mental Health Commission of Canada.
phases of knowledge creation that become more focused and actionable as the funnel narrows. The broadest form of knowledge is described as first-generation knowledge (for example, primary studies), leading to more refined second-generation knowledge (for example, systematic reviews and meta-analyses), which is ultimately distilled into third-generation knowledge (for example, knowledge tools and practice guidelines), which has been developed into user-friendly formats to enhance use. In addition to the knowledge creation component, this model outlines numerous action steps necessary to move knowledge into practice, including: identifying a problem and selecting knowledge or evidence relevant to addressing the issue; adapting knowledge to the local context; assessing barriers to knowledge use; selecting and tailoring interventions to promote knowledge use; monitoring change; evaluating outcomes; and sustaining change.3,5,20 While the KT framework developed by Graham et al3 is primarily focused on supporting and promoting the implementation of scientific research evidence, Kitson et al57 propose that 4 types of knowledge are necessary for effective KT interventions: research evidence, practitioners’ knowledge, patient experience, and knowledge of the local context. This broader conceptualization of knowledge is championed by KT scholars who argue that scientific evidence alone, which is often comprised of data from small, homogenous populations, may not meet the needs of health care practitioners who provide care to diverse client 166 W La Revue canadienne de psychiatrie, vol 59, no 3, mars 2014
populations.50,58,59 The widely studied and used framework, entitled the PARIHS framework, conceptualizes successful implementation as a function of the interaction of 3 core factors: evidence, context, and facilitation.52 Each of these 3 factors are viewed as lying along a continuum from high to low, with the most effective implementation efforts arising in environments that are high evidence (that is, a strong evidence base that is consistent with practitioners’ values), high context (that is, effective leadership and willingness to change), and high facilitation (that is, support from internal or external change facilitators). Thus this framework provides guidance for practitioners to assess whether their setting is strong or weak in these 3 critical areas, helping identify opportunities to strengthen elements that could impede the knowledge implementation or the utilization process. For example, Owen and Milburn60 describe how the PARIHS framework was applied in the United Kingdom to guide meaningful and sustained improvements in services to women with serious and enduring mental health problems. The I2I is a step-by-step guide to undertaking KT in health care settings55 developed for the Mental Health Commission of Canada. The I2I encompasses an inclusive view of knowledge and relevant KT stakeholder groups that is particularly resonant in the field of mental health. It highlights the importance of bringing a wide range of participants to the table and promotes a process by which knowledge is jointly identified, created, or applied. www.LaRCP.ca
A Narrative Review of Recent Developments in Knowledge Translation and Implications for Mental Health Care Providers
The I2I also emphasizes the importance of incorporating various knowledge perspectives. Seven steps are described: identifying the purpose of an intervention; selecting the innovation to be promoted; specifying the actors or stakeholders to engage; identifying agents of change; designing the KT strategy; implementing the intervention or change approach; and evaluating the outcomes (Figure 2). Examples are provided for each stage of the process to support those involved in KT efforts in developing and executing an effective KT strategy.
Theme 5: Relevance of KT to Health Care Providers In identification of a theme that addresses the relevance of KT to health care providers, 3 subthemes were specified: 1) KT as applied by health care providers in their clinical activities;8,60 2) KT activities that seek to influence the behaviour of health care providers3,9,10,31,51,52,57,58; and 3) KT activities in which health care providers contribute to research, policy, and advocacy.8 As a central component of clinical care is the sharing of knowledge between clinicians and patients, much of clinical practice can be construed to be KT.8 Effective health care provision demands that clinicians use sound means of communicating with patients and their families or caregivers.61 Health care providers must target and tailor key messages and be receptive to knowledge from patients, family members, and caregivers that could influence care and improve outcomes.8 As health care providers are credible and valued sources of knowledge to patients, family members, and caregivers, a health care provider’s capability to assist patients in applying the increasingly sophisticated tools and resources for self-management can optimize patient outcomes.45 Health care providers can play an important role in supporting their patients’ efforts to pull and use valuable knowledge relevant to their own health care needs. The second subtheme recognizes that health care providers are the targets of many of the KT efforts within health care.3,52,59 The wide range of modalities used to achieve KT, with variable success, includes conferences, workshops, Telehealth, dissemination of practice guidelines and highquality review sources (such as Cochrane systematic reviews), academic detailing, and financial incentives. A good understanding of KT, including attention to skills in pulling knowledge from high-quality sources can ensure that health practitioners optimize the use of best evidence and improve the quality of care provided to clients. Findings about the effectiveness of various KT approaches can also inform the training and continuing education of health professionals.6,9 For example, courses, workshops, and seminars have been shown to be more effective at transmitting knowledge and promoting changes in clinical practice when they use multiple interventions, 2-way communications, and locally respected health personnel as educators.10,38 www.TheCJP.ca
The third subtheme addresses circumstances in which KT becomes useful to health care providers who wish to have an influence on research, policy, decision making, and advocacy. The unique and valuable knowledge that is gained through delivering clinical care in real-world settings has the potential to advance research and policy and to bring about beneficial change.24 Although the concept of evidence-based practice is well known, critiques in recent years suggest there is also a need for practicebased evidence, that is, evidence with greater applicability and generalizability to real-world experience that draws on the tacit knowledge and expertise of health care providers and patients.50,52,54,59,62–68
Discussion
In our review of general literature on KT, we identified a series of prominent themes and, here, we address issues that hold specific implications for mental health care providers. As it has been noted that gaps between science and practice are great in the field of mental health,2,27,69 KT strategies may hold particular value. More so than in other areas of health care, mental health is an area in which detrimental and stigmatizing misinformation is widespread and resistant to modification, both among the general public65 and health care providers.66,67 Moreover, the diverse ethnocultural composition of modern societies bring a multiplicity of cultural and historical beliefs and practices regarding mental health and illness.70 Consequently, effective approaches to KT may be particularly important to facilitate exchange and uptake of high quality knowledge related to mental health. Regarding the effectiveness of KT efforts to foster innovation and improvement in mental health programs, various authors have emphasized the importance of organizational culture and attitudes of health care providers.2,9,69 Within the cultures in which mental health care providers operate, particular value is often placed on tacit knowledge, that is, knowledge that is developed from direct experience and action, highly pragmatic and situation-specific, and often understood and applied subconsciously and thus difficult to articulate or codify.68 Tacit knowledge is often distinguished from explicit knowledge, which follows logic, can be codified, written down, and effectively communicated to others.68 In comparison to many other areas of health care in which explicit scientific knowledge is favoured, tacit knowledge may be of particular importance in the field of mental health. Goering et al50 have described how the successful application of psychotherapies depends prominently on the qualitative and tacit knowledge that is exchanged between clinician and patient.
Conclusions
Developments in both the conceptual understanding and effective practice of KT may be of value to health care providers working in mental health and the definition of KT is broad enough to be relevant to their day-to-day practice. Awareness of effective approaches to KT may help health The Canadian Journal of Psychiatry, Vol 59, No 3, March 2014 W 167
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care providers to optimize their treatment approaches and become adept at locating, using, disseminating, and implementing valuable new knowledge while supporting their patients’ efforts to do so as well. Frameworks, tools, and resources have been developed that may be useful to health care providers in applying effective KT practices.
Acknowledgements
Financial support for conducting this review was provided to Emily Jenkins through a CIHR Canadian Graduate Scholarship Doctoral Award and a Fellowship through Knowledge Translation Canada. Dr Fischer acknowledges research and salary support from a CIHR–Public Health Agency of Canada Applied Public Health Chair.
References
1. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington (DC): National Academy Press; 2001. 2. Gotham HJ. Diffusion of mental health and substance abuse treatments: development, dissemination, and implementation. Clin Psychol. 2004;11(2):160–176. 3. Graham ID, Logan J, Harrison MB, et al. Lost in knowledge translation: time for a map? J Contin Educ Health Prof. 2006;26:13–24. 4. McGrath PJ, Lingley-Pottie P, Emberly DJ, et al. Integrated knowledge translation in mental health: family help as an example. J Can Acad Child Adolesc Psychiatry. 2009;18(1):30–37. 5. Straus SE, Tetroe JM, Graham ID. Knowledge translation is the use of knowledge in health care decision making. J Clin Epidemiol. 2011;64(1):6–10. 6. Curran JA, Grimshaw JM, Hayden JA, et al. Knowledge translation research: the science of moving research into policy and practice. J Contin Educ Health Prof. 2011;31(3):174–180. 7. Morris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. J R Soc Med. 2011;104(12):510–520. 8. Grimshaw JM, Eccles MP, Lavis JN, et al. Knowledge translation of research findings. Implement Sci. 2012;7:50. 9. Barwick MA, Schachter HM, Bennett LM, et al. Knowledge translation efforts in child and youth mental health: a systematic review. J Evid Based Soc Work. 2012;9(4):369–395. 10. Boaz A, Baeza J, Fraser A. Effective implementation of research into practice: an overview of systematic reviews of the health literature. BMC Res Notes. 2011;4:212. 11. Walsh K, Kitson A, Cross W, et al. A conversation about practice development and knowledge translation as mechanisms to align the academic and clinical contexts for the advancement of nursing practice. Collegian. 2012;19(2):67–75. 12. Lokker C, McKibbon KA, Wilczynski NL, et al. Finding knowledge translation articles in CINAHL. Stud Health Technol Inform. 2010;160(Pt 2):1179–1183. 13. Contandriopoulos D, Lemire M, Denis J-L, et al. Knowledge exchange processes in organizations and policy arenas: a narrative systematic review of the literature. Milbank Q. 2010;288(4):444–448. 14. Goldner EM, Jeffries V, Bilsker, D, et al. Knowledge translation in mental health: a scoping review. Healthc Policy. 2011;7(2):83–98. 15. McKibbon KA, Lokker C, Wilczynski NL. Search filters can find some but not all knowledge translation articles in MEDLINE: an analytic survey. J Clin Epidemiol. 2012;65:651–659. 16. Graham ID, Tetroe JM. Getting evidence into policy and practice: perspective of a health research funder. J Can Acad Child Adolesc Psychiatry. 2009;218(1):46–50. 17. Aita M, Richer M, Heon M. Illuminating the processes of knowledge transfer in nursing. Worldviews Evid Based Nurs. 2007;4(3):146–155.
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18. Tetroe JM, Graham ID, Foy R, et al. Health research funding agencies’ support and promotion of knowledge translation: an international study. Milbank Q. 2008;86(1):125–155. 19. Pentland D, Forsyth K, MacIver D, et al. Key characteristics of knowledge transfer and exchange in healthcare: integrative literature review. J Adv Nurs. 2011;67(7):1408–1425. 20. Tetroe J. Knowledge translation at the Canadian Institutes of Health Research: a primer. National Center for the Dissemination of Disability Research. Technical brief. 2007;18:1–8. 21. Colquhoun HL, Letts LJ, Law MC, et al. A scoping review of the use of theory in studies of knowledge translation. Can J Occup Ther. 2010;77(5):270–279. 22. Doane GH, Varcoe C. Knowledge translation in everyday nursing: from evidence-based to inquiry-based practice. Adv Nurs Sci. 2008;31(4):283–295. 23. Davis D, Evans M, Jadad A, et al. The case for knowledge translation: shortening the journey from evidence to effect. BMJ. 2003;327:33–35. 24. Baumbusch JL, Kirkham SR, Khan KB, et al. Pursuing common agendas: a collaborative model for knowledge translation between research and practice in clinical settings. Res Nurs Health. 2008;31(2):130–140. 25. Bowen S, Martens P, The Need to Know Team. Demystifying knowledge translation: learning from the community. J Health Serv Res Policy. 2005;10(4):203–211. 26. Browne AJ, Varcoe C, Smye V, et al. Cultural safety and the challenges of translating critically oriented knowledge in practice. Nurs Philos. 2009;10(3):167–179. 27. Stirman SW, Crits-Christoph P, DeRubeis RJ. Achieving successful dissemination of empirically supported psychotherapies: a synthesis of dissemination theory. Clin Psychol. 2004;11:343–359. 28. Montague T. Patient–provider partnerships in healthcare: enhancing knowledge translation and improving outcomes. Healthc Pap. 2006;7(2):53–61. 29. Lomas J. Diffusion, dissemination and implementation: who should do what? Ann N Y Acad Sci. 1993;703:226–235. 30. Gagnon ML. Moving knowledge to action through dissemination and exchange. J Clin Epidemiol. 2011;64(1):25–31. 31. Bero LA, Grilli R, Grimshaw JM, et al. Closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. BMJ. 1998;317:465–468. 32. Mitton C, Adair CE, McKenzie E, et al. Knowledge transfer and exchange: review and synthesis of the literature. Milbank Q. 2007;85(4):729–768. 33. Orton L, Lloyd-Williams F, Taylor-Robinson D, et al. The use of research evidence in public health decision making processes: systematic review. PLOS ONE. 2011;6(7):e21704. doi: 10.1371/ journal.pone.0021704. Epub 2011 Jul 26. Review. 34. O’Brien MA, Rogers S, Jamtvedt G, et al. Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews. 2007;17(4):CD000409. 35. Jamtvedt G, Young JM, Kristoffersen DT, et al. Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews. 2006;19(2):CD000259. 36. O’Brien MA, Oxman AD, Haynes RB, et al. Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews. 1999;(1):CD000125. 37. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet. 2003;362(9391):1225–1230. 38. Forsetlund L, Bjørndal A, Rashidian A, et al. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews. 2009;2:CD003030. 39. Wakefield MA, Loken B, Hornik RC. Use of mass media campaigns to change health behavior. Lancet. 2010;376(9748):1261–1271. 40. Jepson RG, Harris, FM, Platt S. The effectiveness of interventions to change six health behaviours: a review of reviews. BMC Public Health. 2010;10:538. www.LaRCP.ca
A Narrative Review of Recent Developments in Knowledge Translation and Implications for Mental Health Care Providers 41. Gordon R, McDermott L, Stead M, et al. The effectiveness of social marketing interventions for health improvement: what’s the evidence? Public Health. 2006;120(12):1133–1139. 42. Roussos ST, Fawcett SB. A review of collaborative partnerships as a strategy for improving community health. Annu Rev Public Health. 2000;21:369–402. 43. Moulton AD, Mercer SL, Popovic T, et al. The scientific basis for law as a public health tool. Am J Public Health. 2009;99(1):17–24. 44. Chaloupka FJ, Straif K, Leon ME. Effectiveness of tax and price policies in tobacco control. Tob Control. 2011;20(3):235–238. 45. Lorig KR, Holman H. Self-management education: history, definition, outcomes, and mechanisms. Ann Behav Med. 2003;26(1):1–7. 46. Dobbins M, Hanna SE, Ciliska D, et al. A randomized controlled trial evaluating the impact of knowledge translation and exchange activities. Implement Sci. 2009;4:61. 47. Damschroder LJ, Aron DC, Keith RE, et al. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009;4:50. 48. Titler MG. Translation science and context. Res Theory Nurs Pract. 2010;24(1):35–55. 49. Greenhalgh T, Robert G, Macfarlane F, et al. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 2004;82(4):581–629. 50. Goering P, Boydell KM, Pignatellio A. The relevance of qualitative research for clinical programs in psychiatry. Can J Psychiatry. 2008;53(3):145–151. 51. Peirson L, Ciliska D, Dobbins M, et al. Building capacity for evidence informed decision making in public health: a case study of organizational change. BMC Public Health. 2012;20(12):137. 52. Rycroft-Malone J. The PARIHS framework: a framework for guiding the implementation of evidence-based practice. J Nurs Care Qual. 2004;19(4):297–304. 53. Ward V, House A, Hamer S. Developing a framework for transferring knowledge into action: a thematic analysis of the literature. J Health Serv Res Policy. 2009;14(3):156–164. 54. Meier M. Knowledge management in strategic alliances: a review of empirical evidence. Int J Manag Rev. 2011;13(1):1–23. 55. Mental Health Commission of Canada (MHCC). Innovation to Implementation (I2I): a practical guide to knowledge translation in healthcare [Internet]. Calgary (AB): MHCC; 2012 [cited 2013 Mar 14]. Available from: http://www.sfu.ca/carmha/projects/i2i.html. 56. National Collaborating Centre for Methods and Tools (NCCMT). Registry of methods and tools [Internet]. Hamilton (ON): NCCMT;
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2013 [cited 2013 Mar 10]. Available from: http://www.nccmt.ca/ registry/index-eng.html. 57. Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based practice: a conceptual framework. Qual Health Care. 1998;7(3):149–158. 58. Rycroft-Malone J, Seers K, Titchen A, et al. What counts as evidence in evidence-based practice? J Adv Nurs. 2004;47(1):81–90. 59. Goldenberg M. On evidence and evidence-based medicine: lessons from the philosophy of science. Soc Sci Med. 2006;62:2621–2632. 60. Owen S, Milburn C. Implementing research findings into practice: improving and developing services for women with serious and enduring mental health problems. J Psychiatr Ment Health Nurs. 2001;8:221–231. 61. Coulter A, Ellins J. Effectiveness of strategies for informing, educating, and involving patients. BMJ. 2007;335:24–27. 62. Kitson AL. The need for systems change: reflections on knowledge translation and organizational change. J Adv Nurs. 2009;65(1):217–228. 63. Green LW, Glasgow RE. Evaluating the relevance, generalization, and applicability of research: issues in external validation and translation methodology. Eval Health Prof. 2006;29:126–153. 64. Green LW. Public health asks of systems science: to advance our evidence-based practice, can you help us get more practice-based evidence? Am J Public Health. 2006;96(3):406–409. 65. Angermeyer MC, Dietrich S. Public beliefs about and attitudes towards people with mental illness: a review of population studies. Acta Psychiatr Scand. 2006;113(3):163–179. 66. Ross CA, Goldner EM. Stigma, negative attitudes and discrimination towards mental illness within the nursing profession: a review of the literature. J Psychiatr Ment Health Nurs. 2009;16(6):558–567. 67. Mental Health Commission of Canada (MHCC). Opening Minds program overview [Internet]. Calgary (AB): MHCC; 2013 [cited 2013 May 19]. Available from: http://www.mentalhealthcommission.ca/English/ node/5233?terminitial=39. 68. Kothari A, Rudman D, Dobbins M, et al. The use of tacit and explicit knowledge in public health: a qualitative study. Implement Sci. 2012;20:7. 69. Williams V, Oades LG, Deane FB, et al. Improving implementation of evidence-based practice in mental health service delivery: protocol for a cluster randomized quasi-experimental investigation of staff-focused values interventions. Implement Sci. 2013;8:75. 70. Becker A, Kleinman A. Mental health and the global agenda. N Engl J Med. 2013;369:66–73.
The Canadian Journal of Psychiatry, Vol 59, No 3, March 2014 W 169
Review Paper
A Narrative Review of Recent Developments in Knowledge Translation and Implications for Mental Health Care Providers Elliot M Goldner, MD, MHSc, FRCPC1; Emily K Jenkins, RN, MPH (PhD Candidate)2; Benedikt Fischer, MA, PhD3 1
Professor, Centre for Research in Mental Health and Addiction (CARMHA), Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia. Correspondence: CARMHA, Faculty of Health Sciences, Simon Fraser University, 2400–515 West Hastings Street, Vancouver, BC V6B 5K3; [email protected].
2
Doctoral Student, School of Nursing, University of British Columbia, Vancouver, British Columbia.
3
Professor, Centre for Research in Mental Health and Addiction (CARMHA), Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia; Senior Scientist, Social and Epidemiological Research, Centre for Addiction and Mental Health, Toronto, Ontario; Professor, Department of Psychiatry, University of Toronto, Toronto, Ontario.
Key Words: knowledge translation, mental health, knowledge exchange, implementation, health care, dissemination Received March 2013, revised, and accepted October 2013.
Objective: Attention to knowledge translation (KT) has increased in the health care field in an effort to improve uptake and implementation of potentially beneficial knowledge. We provide an overview of the current state of KT literature and discuss the relevance of KT for health care professionals working in mental health. Method: A systematic search was conducted using MEDLINE, PsycINFO, and CINAHL databases to identify review articles published in journals from 2007 to 2012. We selected articles on the basis of eligibility criteria and then added further articles deemed pertinent to the focus of our paper. Results: After removing duplicates, we scanned 214 review articles for relevance and, subsequently, we added 46 articles identified through hand searches of reference lists or from other sources. A total of 61 papers were retained for full review. Qualitative synthesis identified 5 main themes: defining KT and development of KT science; effective KT strategies; factors influencing the effectiveness of KT; KT frameworks and guides; and relevance of KT to health care providers. Conclusions: Despite limitations in existing evidence, the concept and practice of KT holds potential value for mental health care providers. Understanding of, and familiarity with, effective approaches to KT holds the potential to enhance providers’ treatment approaches and to promote the use of new knowledge in practice to enhance outcomes. WWW
Une revue narrative des récents développements du transfert des connaissances et des implications pour les prestataires de soins de santé mentale Objectif : L’attention portée au transfert des connaissances (TC) s’est accrue dans le domaine des soins de santé, dans une tentative d’améliorer l’assimilation et l’application de connaissances potentiellement bénéfiques. Nous présentons un aperçu de l’état actuel de la littérature sur le TC et discutons de la pertinence du TC pour les professionnels de la santé œuvrant en santé mentale. Méthode : Une recherche systématique a été menée dans les bases de données MEDLINE, PsycINFO, et CINAHL afin de relever les articles de synthèse publiés dans les revues de 2007 à 2012. Nous avons choisi des articles selon des critères d’admissibilité, puis nous en avons ajouté d’autres jugés pertinents pour le propos de notre article. Résultats : Après avoir éliminé les doubles, nous avons scanné 214 articles de synthèse pour en vérifier la pertinence et, subséquemment, nous avons ajouté 46 articles issus d’une recherche manuelle de bibliographies ou d’autres sources. En tout, 61 articles ont été retenus pour un examen complet. Une synthèse qualitative a dégagé 5 thèmes principaux : définition du TC et
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A Narrative Review of Recent Developments in Knowledge Translation and Implications for Mental Health Care Providers
développement de la science du TC; stratégies efficaces du TC; facteurs influençant l’efficacité du TC; cadres et guides du TC; et pertinence du TC pour les prestataires de soins de santé. Conclusions : Malgré les limitations des données probantes existantes, le concept et la pratique du TC ont une valeur potentielle pour les prestataires de soins de santé mentale. La compréhension et l’apprivoisement des approches de TC efficaces offrent le potentiel d’améliorer les approches du traitement des prestataires et de promouvoir l’utilisation de nouvelles connaissances dans la pratique pour de meilleurs résultats.
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ithin health care, there has been a rapid growth of interest in KT. This growth has been triggered by the realization that clinicians, patients, and decision makers do not pick up many potentially beneficial research findings and discoveries, that is, the new knowledge does not get translated into action or does so only after a lengthy lag time.1–8 Moreover, many promising discoveries and health interventions fail to achieve their maximum potential and (or) reach the people most in need.3,9,10 Researchers are dissatisfied with the prospect of their findings being disregarded and health care providers want to ensure good access to the best quality and most up-to-date findings about specific health care questions—not only for themselves, but for patients, family members, and decision makers.11 In our paper, we review developments in KT and consider the implications for health care practitioners working in mental health.
Methods Search Strategy
We used a multi-faceted approach to obtain relevant material for review of developments in KT to address the challenges inherent in search strategies that seek to examine publications about KT.12–15 We initiated our search using MEDLINE, PsycINFO, and CINAHL electronic databases, and, given the limitations that have been noted with the use of standard MESH terms to identify articles on KT,15 we instead used 3 of the most widely used KT-relevant terms as identified by Graham et al3: KT, knowledge exchange, and knowledge transfer. We limited our search to reviews and meta-analyses published in the English language between 2007 and 2012. Our decision to limit our search to reviews and meta-analyses was based on our need to reduce the very large volume of publications that address KT to manageable numbers, and the focus of our review, which seeks to provide an up-to-date overview of developments in KT, particularly those relevant to mental health care providers. The search Abbreviations CIHR
Canadian Institutes of Health Research
I2I
Innovation to Implementation
KT
knowledge translation
PARIHS Promoting Action on Research Implementation in Health Services
www.TheCJP.ca
Clinical Implications •
Awareness of KT concepts and approaches among mental health treatment providers may enhance the uptake and use of best evidence.
•
Incorporating KT approaches into clinical encounters may enhance quality of care and health outcomes.
•
Contributing to the practice-based research evidence base holds the potential to establish research evidence that is relevant to clinicians and thus benefits patients.
Limitations •
The systematic search procedure included only review papers and identified only a portion of documents considered to be relevant. The papers that were reviewed should not be considered to be comprehensive.
•
The discussion regarding the applicability of KT concepts to health care providers is not exhaustive but, rather, is meant to illustrate important ways in which these concepts are relevant to clinical practice.
•
Discussion of KT frameworks is limited, however, reference to an appropriate resource for further guidance is provided.
terms and filtering procedures we used are summarized in Figure 1. Using an iterative process, we subsequently added papers through hand searching of the citations contained within publications identified through the systematic search process. The results of a recently conducted review of the KT literature were also drawn on to identify publications judged to be relevant to our review.14
Eligibility Criteria and Selection Process
All abstracts identified in the search procedure were reviewed and publications that focused on the application of KT to specific areas of health care practice that were not directly relevant to mental health (such as dermatology, surgery, or oncology) were eliminated. Publications that addressed general and nonspecific issues of KT and those that focused on any aspect of mental health care were retained for full review and were made available to all authors, who also added publications that were considered to be germane to our review, including those that were published before 2007 and those that were identified in reviewing the publications (and references contained within) that had been obtained through the structured search procedures. When including papers that had not been identified in the systematic search The Canadian Journal of Psychiatry, Vol 59, No 3, March 2014 W 161
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Figure 1 Search procedures
Articles identified through online database searches, n = 230: MEDLINE (n = 139), PsycINFO (n = 47) and CINAHL (n = 44)
Additional articles identified through hand searches of reference lists and identification of relevant papers by authors, n = 46 Duplicates n = 16
Records remaining (n = 260) titles and abstracts screened for relevance Articles excluded n = 199 Articles assessed for eligibility, n = 61 No further articles excluded Articles included in qualitative synthesis, n = 61
procedure, we aimed to identify either seminal papers that were considered to have shaped the evolution of the KT field, papers that held particular relevance to the focused topic of review, or articles that provided valuable information related to the themes that were identified through analysis. This latter component used a snowball search procedure described by Contandriopoulos et al13 in their review of knowledge exchange processes. We did not apply an evidence evaluation process as we surmised that such a process produced a narrow type of analysis, potentially eliminating valuable insights from this type of narrative review.13
Data Abstraction and Synthesis
Qualitative analysis of the publications was undertaken to identify key themes relevant to the topic of our paper. Two of the authors read through selected reviews and produced a coding template to identify and categorize the review data into themes identified within this literature. An iterative process was used throughout the analysis process and, when we considered themes to be inadequately covered by the literature that was obtained, additional efforts were made to identify peer-reviewed papers that could further develop 162 W La Revue canadienne de psychiatrie, vol 59, no 3, mars 2014
and articulate thematic areas. Summaries of thematic areas were produced by 2 of the authors and then circulated among all 3 authors for review. Our approach to synthesizing the large volume of material was to use an iterative process in which major concepts were first added and then reorganized to diminish the number of thematic areas to a minimum number that retained each of the key areas identified by the reviewing authors. Following qualitative synthesis, the themes were collated and consensus obtained among us to produce the following results.
Results
After removing duplicates, we scanned 214 articles for relevance. An additional 46 articles were added through hand searches of reference lists or identification and agreement by the authors. A total of 61 articles were retained for full review. The following 5 themes were identified and each is discussed under a separate heading: defining KT and development of KT science; effective KT strategies; factors influencing the effectiveness of KT; KT frameworks and guides; and relevance of KT to health care providers. www.LaRCP.ca
A Narrative Review of Recent Developments in Knowledge Translation and Implications for Mental Health Care Providers
Table 1 Effective KT strategies for influencing health care providers and allied professionals Strategy
Definition
Sample evidence
Educational outreach
This strategy (also known as academic detailing) refers to personal visits by a trained, credible person to health professionals in their own settings in which evidence-based, tailored information is provided for the purposes of influencing specific practice behaviours.
Grimshaw et al8; O’Brien et al34
Audit and feedback
Refers to the provision of information to health care providers about their own clinical performance, allowing comparison of their performance with that of their peers. Often, such information is collected through clinical databases and fed back through individualized reports and summaries.
Grimshaw et al8; Boaz et al10; Jamtvedt et al35
Use of opinion leaders
Opinion leaders are influential members of a community or field of practice whom other health care providers often turn to for advice, opinions, and clinical direction.
Grimshaw et al8; Boaz et al10; O’Brien et al34
Reminders and prompts
These include various formats (for example, paper reminders in patient charts, computerized decision support, algorithms, or electronic health records) that help clinicians optimize evidencebased protocols and practices at the point of care.
Grimshaw et al8; Grol and Grimshaw37
Interactive educational meetings
These include courses, workshops, and seminars that are more effective when they use multiple interventions, 2-way communications, printed and graphic materials in person, and locally respected health personnel as educators.
Grimshaw et al8; O’Brien et al34; Forsetlund et al38
Theme 1: Defining KT and Development of KT Science
Despite being described as closing the gap between what we know and what we do,16 it has been difficult to settle on a clear and consistent definition of KT.17 Numerous overlapping terms, such as knowledge transfer, knowledge exchange, knowledge mobilization, research utilization, dissemination, and implementation are used in varying ways by different groups.2,3,5,18,19 The CIHR uses the following definition of KT, now widely adopted in the field of health care: [A] dynamic and iterative process that includes synthesis, dissemination, exchange and ethicallysound application of knowledge to improve the health of Canadians, provide more effective health services and products and strengthen the health care system. This process takes place within a complex system of interactions between researchers and knowledge users . . .20, p 1 According to Tetroe: It [KT] encompasses all steps between the creation of new knowledge and its application to yield beneficial outcomes for society.20, p 2 The concept of KT is thus an umbrella term that includes many activities, such as technology transfer, knowledge management, knowledge use, continuing education, consensus guideline development, and translational research.5 In this definition, KT constitutes a broad concept and various theoretical perspectives have been applied to explain the processes of KT.13,21–23 www.TheCJP.ca
The KT process often brings knowledge that has been produced through scientific research into contact with knowledge developed through other means.23 Other forms of knowledge can be gained through the experience people have accumulated by living with a certain health problem, through encounters as a close family member or friend of someone with a health problem, through providing treatment as a health care provider to various people with the health problem, or by being involved with cultural, policy, educational, or political processes that address health care issues.13,24–26 Naturally, scientists are keen to apply scientific methods, including systematic observation, data collection, and hypothesis testing, and are often uncomfortable accepting other forms of knowledge unless they have been put through scientific filters. Conversely, nonscientists often feel that their knowledge, often gained through years of experience, should be recognized without the impediment of detailed scientific study.11,27 These conflicting perspectives may cause tensions within the KT process, however, this can be a creative tension; it is often through the interplay among these perspectives that highly valuable knowledge is created and moved into action.4,13,23,25,28 In describing the processes of KT, Lomas29 identifies 3 steps in moving research into action. Diffusion refers to relatively passive and horizontal (that is, among peers) activities, such as publishing findings in journals, presenting papers at academic meetings, or posting information on websites. Despite their limitations as means of effective KT, diffusion activities remain important and form a foundation for the development of more action-oriented KT efforts and opportunities that exist to improve the likelihood that The Canadian Journal of Psychiatry, Vol 59, No 3, March 2014 W 163
Review Paper
Table 2 Effective KT strategies for influencing patients and the general public Strategy
Definition
Sample evidence
Mass media campaigns
These are determined efforts used to promote health behaviour through television, radio, Internet, and print or other media.
Wakefield et al39; Jepson et al40
Social marketing approaches
These strategies aim to improve the welfare of people and society through applying commercial marketing technologies and techniques. For example, social marketing efforts often undertake consumer research to understand consumer values and needs and subsequently use segmentation variables to tailor interventions for use with specific segments of the population.
Gordon et al41
Community mobilization
Community-wide efforts to address a health or social issue that may bring together local, provincial, and federal governments; professional groups; religious groups; businesses; and individual community members. The process includes mobilizing necessary resources, disseminating information, generating support, and fostering cooperation across public and private sectors in the community to bring about changes in relevant health behaviours.
Jepson et al40; Roussos and Fawcett42
Laws and regulations
These have been applied by governments to achieve substantial public health achievements, such as tobacco control laws, that have reduced rates of many chronic illnesses and laws addressing the operation of motor vehicles under the influence of alcohol that have reduced accident-related fatalities and injuries. The effectiveness of regulatory and legal tools to address some health-related behaviours, such as substance abuse, is a complex area and must carefully take into account the relative harms that may be created through inappropriate criminalization of people in society.
Moulton et al43
Financial incentives and disincentives
The use of bonuses or exemptions as inducements (incentives) or excise taxes and pricing burdens (disincentives) to change health-related behaviours, such as reduction of tobacco and alcohol use, among members of the general public.
Chaloupka et al44
Self-management
Seeks to enhance a person’s ability to manage the symptoms, treatment, physical and psychological consequences, and lifestyle changes associated with a health condition. May be undertaken when people obtain tools, resources, or guidebooks through their own initiative or with the prompting and support of health care providers (that is, supported self-management).
Lorig and Holman45
diffused knowledge will reach relevant users. Dissemination delivers messages that are tailored to the target audience and uses effective delivery channels.2,29,30 Such efforts include the development and distribution of materials formatted to match the needs of particular stakeholder groups and may consist of briefings, educational sessions, media communications, and other activities that are designed for specific target audiences. Implementation is described by Lomas29 as the most active process in KT and one that is undertaken primarily at a local level, where barriers to the use of new knowledge can be effectively addressed and overcome. In general, effective implementation requires persistent and multi-faceted efforts that may be directed through various routes and means.2 KT strategies are often divided into those that either push or pull knowledge.24,30 Push strategies involve efforts to enhance the movement of knowledge from those who generate knowledge outward to those who may be able to benefit from its use. It often involves gathering, synthesizing, and funnelling high-quality information, and efforts at distribution and promotion. In health care, push 164 W La Revue canadienne de psychiatrie, vol 59, no 3, mars 2014
strategies may involve scientific publications, reports, systematic reviews, guidelines, online materials, conference presentations, courses, webinars, educational outreach, prompts, social marketing efforts, financial incentives, and media campaigns. By contrast, pull strategies are those instigated by people seeking to obtain new knowledge,24,30 such as when health care providers, policy makers, or patients seek out the knowledge that is needed to guide their actions. Such efforts can be facilitated by effective search tools that can locate high-quality information, access to knowledge syntheses and databases, training in the identification and application of research findings in decision making, critical appraisal skill development, and creation of rapid response units and government–university liaisons.
Theme 2: Effective KT Strategies
A theme was identified within the published literature that focuses on specific strategies and approaches that have been shown to be effective in KT efforts.8,10,19,31–46 These can be usefully divided into groups of strategies that can www.LaRCP.ca
A Narrative Review of Recent Developments in Knowledge Translation and Implications for Mental Health Care Providers
Table 3 Effective KT strategies for influencing decision makers Strategy
Definition
Sample evidence
Targeted and tailored dissemination of research knowledge to decision makers
Efforts to deliver messages to decision makers that are designed to be accessed and used easily, through creating information that uses language and formats that are comfortable, familiar, and comprehensible to the audience. Also involves delivering the information via effective delivery channels.
Dobbins et al46
Linkage of researchers and decision makers
Creating a means for sustained dialogue between researchers and decision makers.
Orton et al33
Capability building of both researchers and decision makers
Concerted efforts and programs to increase researchers’ abilities to create and disseminate evidence geared to decision makers’ needs and improve decision makers’ abilities to appraise and interpret research.
Orton et al33
Fostering culture of evidence-informed decision making
Changing the culture within which decision makers work to increase the value placed on the use of research evidence.
Orton et al33
be successfully applied with each of the following 3 key stakeholder groups: 1) health care providers and allied professionals (such as teachers and social service providers); 2) patients and the general public; and 3) decision makers (particularly those working in government and health sector decision-making roles).8 Tables 1, 2, and 3 summarize the findings for each of these groups, respectively. Although there is a substantial body of knowledge regarding KT strategies that are effective for the first 2 groups,10,31 there remains a paucity of knowledge regarding effective KT strategies to influence decision makers.8,13,33 In various areas, there remains limited evidence regarding the effectiveness of KT in producing clinically significant outcomes.
Theme 3: Factors Influencing the Effectiveness of KT
Numerous factors have been found to influence the effectiveness of KT interventions.2,5,19,30,32,47 KT is more effective when addressing topics that are perceived by knowledge users to be relatively simple and when tools (for example, guidebooks and decision aids) are in place to support the intended behavioural changes.48 Factors associated with better uptake of evidence-based innovations by organizations include larger size, decentralized decision making, greater resourcing, and closer proximity to urban centres, however, these account for a relatively small degree of variance.49 A learning organizational culture promotes absorptive capacity and facilitates the identification, capture, sharing, reorientation, and implementation of evidencebased knowledge.49,50 Organizational characteristics that contribute to good capacity include clear vision and strong leadership, workforce and skills development, ability www.TheCJP.ca
to access research (library services), fiscal investments, acquisition and development of technological resources, a knowledge management strategy, effective communication, a receptive organizational culture, and a focus on change management.2,30,47,51
Theme 4: KT Frameworks and Guides
KT scholars have developed frameworks and tools to describe and guide the KT process in an effort to minimize the research-practice gap.3,47,52–55 Given the abundance of KT frameworks and methods proposed over the last few decades,53 the National Collaborating Centre for Methods and Tools has established an online registry, cataloguing these frameworks and providing a valuable resource for those interested in incorporating KT approaches into their work.56 Here, we briefly describe 2 KT frameworks that have figured prominently in KT research and practice, and 1 guide that aims to support the practice of KT in mental health care settings. Among the most prominent KT frameworks is the Knowledge to Action Process devised by Graham et al.3 This framework, which has been adopted by Canada’s federal health research funding agency, the CIHR, consists of 2 components: 1) knowledge creation (which is conceptualized as the development of scientific evidence), and 2) action steps. Although this model presents the KT process as consisting of 2 distinct activities, the authors acknowledge that, in the real world, the process would be much more complex and dynamic with blurring between these 2 concepts, and activities within each of these components occurring simultaneously. At the centre of this model lies the knowledge creation funnel, depicting the different The Canadian Journal of Psychiatry, Vol 59, No 3, March 2014 W 165
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Figure 2 The I2I55 is a practical guide that describes 7 steps to achieving successful KT in health care settings.
1. State purpose
7. Evaluate
6. Implement
5. Design strategy
2.2.SelecƟon Select anan InnovaƟon innovaƟon
3. Specify actors and acƟons
4. IdenƟfy agents of change
Permission to reproduce the figure and the graphic was provided by the Mental Health Commission of Canada.
phases of knowledge creation that become more focused and actionable as the funnel narrows. The broadest form of knowledge is described as first-generation knowledge (for example, primary studies), leading to more refined second-generation knowledge (for example, systematic reviews and meta-analyses), which is ultimately distilled into third-generation knowledge (for example, knowledge tools and practice guidelines), which has been developed into user-friendly formats to enhance use. In addition to the knowledge creation component, this model outlines numerous action steps necessary to move knowledge into practice, including: identifying a problem and selecting knowledge or evidence relevant to addressing the issue; adapting knowledge to the local context; assessing barriers to knowledge use; selecting and tailoring interventions to promote knowledge use; monitoring change; evaluating outcomes; and sustaining change.3,5,20 While the KT framework developed by Graham et al3 is primarily focused on supporting and promoting the implementation of scientific research evidence, Kitson et al57 propose that 4 types of knowledge are necessary for effective KT interventions: research evidence, practitioners’ knowledge, patient experience, and knowledge of the local context. This broader conceptualization of knowledge is championed by KT scholars who argue that scientific evidence alone, which is often comprised of data from small, homogenous populations, may not meet the needs of health care practitioners who provide care to diverse client 166 W La Revue canadienne de psychiatrie, vol 59, no 3, mars 2014
populations.50,58,59 The widely studied and used framework, entitled the PARIHS framework, conceptualizes successful implementation as a function of the interaction of 3 core factors: evidence, context, and facilitation.52 Each of these 3 factors are viewed as lying along a continuum from high to low, with the most effective implementation efforts arising in environments that are high evidence (that is, a strong evidence base that is consistent with practitioners’ values), high context (that is, effective leadership and willingness to change), and high facilitation (that is, support from internal or external change facilitators). Thus this framework provides guidance for practitioners to assess whether their setting is strong or weak in these 3 critical areas, helping identify opportunities to strengthen elements that could impede the knowledge implementation or the utilization process. For example, Owen and Milburn60 describe how the PARIHS framework was applied in the United Kingdom to guide meaningful and sustained improvements in services to women with serious and enduring mental health problems. The I2I is a step-by-step guide to undertaking KT in health care settings55 developed for the Mental Health Commission of Canada. The I2I encompasses an inclusive view of knowledge and relevant KT stakeholder groups that is particularly resonant in the field of mental health. It highlights the importance of bringing a wide range of participants to the table and promotes a process by which knowledge is jointly identified, created, or applied. www.LaRCP.ca
A Narrative Review of Recent Developments in Knowledge Translation and Implications for Mental Health Care Providers
The I2I also emphasizes the importance of incorporating various knowledge perspectives. Seven steps are described: identifying the purpose of an intervention; selecting the innovation to be promoted; specifying the actors or stakeholders to engage; identifying agents of change; designing the KT strategy; implementing the intervention or change approach; and evaluating the outcomes (Figure 2). Examples are provided for each stage of the process to support those involved in KT efforts in developing and executing an effective KT strategy.
Theme 5: Relevance of KT to Health Care Providers In identification of a theme that addresses the relevance of KT to health care providers, 3 subthemes were specified: 1) KT as applied by health care providers in their clinical activities;8,60 2) KT activities that seek to influence the behaviour of health care providers3,9,10,31,51,52,57,58; and 3) KT activities in which health care providers contribute to research, policy, and advocacy.8 As a central component of clinical care is the sharing of knowledge between clinicians and patients, much of clinical practice can be construed to be KT.8 Effective health care provision demands that clinicians use sound means of communicating with patients and their families or caregivers.61 Health care providers must target and tailor key messages and be receptive to knowledge from patients, family members, and caregivers that could influence care and improve outcomes.8 As health care providers are credible and valued sources of knowledge to patients, family members, and caregivers, a health care provider’s capability to assist patients in applying the increasingly sophisticated tools and resources for self-management can optimize patient outcomes.45 Health care providers can play an important role in supporting their patients’ efforts to pull and use valuable knowledge relevant to their own health care needs. The second subtheme recognizes that health care providers are the targets of many of the KT efforts within health care.3,52,59 The wide range of modalities used to achieve KT, with variable success, includes conferences, workshops, Telehealth, dissemination of practice guidelines and highquality review sources (such as Cochrane systematic reviews), academic detailing, and financial incentives. A good understanding of KT, including attention to skills in pulling knowledge from high-quality sources can ensure that health practitioners optimize the use of best evidence and improve the quality of care provided to clients. Findings about the effectiveness of various KT approaches can also inform the training and continuing education of health professionals.6,9 For example, courses, workshops, and seminars have been shown to be more effective at transmitting knowledge and promoting changes in clinical practice when they use multiple interventions, 2-way communications, and locally respected health personnel as educators.10,38 www.TheCJP.ca
The third subtheme addresses circumstances in which KT becomes useful to health care providers who wish to have an influence on research, policy, decision making, and advocacy. The unique and valuable knowledge that is gained through delivering clinical care in real-world settings has the potential to advance research and policy and to bring about beneficial change.24 Although the concept of evidence-based practice is well known, critiques in recent years suggest there is also a need for practicebased evidence, that is, evidence with greater applicability and generalizability to real-world experience that draws on the tacit knowledge and expertise of health care providers and patients.50,52,54,59,62–68
Discussion
In our review of general literature on KT, we identified a series of prominent themes and, here, we address issues that hold specific implications for mental health care providers. As it has been noted that gaps between science and practice are great in the field of mental health,2,27,69 KT strategies may hold particular value. More so than in other areas of health care, mental health is an area in which detrimental and stigmatizing misinformation is widespread and resistant to modification, both among the general public65 and health care providers.66,67 Moreover, the diverse ethnocultural composition of modern societies bring a multiplicity of cultural and historical beliefs and practices regarding mental health and illness.70 Consequently, effective approaches to KT may be particularly important to facilitate exchange and uptake of high quality knowledge related to mental health. Regarding the effectiveness of KT efforts to foster innovation and improvement in mental health programs, various authors have emphasized the importance of organizational culture and attitudes of health care providers.2,9,69 Within the cultures in which mental health care providers operate, particular value is often placed on tacit knowledge, that is, knowledge that is developed from direct experience and action, highly pragmatic and situation-specific, and often understood and applied subconsciously and thus difficult to articulate or codify.68 Tacit knowledge is often distinguished from explicit knowledge, which follows logic, can be codified, written down, and effectively communicated to others.68 In comparison to many other areas of health care in which explicit scientific knowledge is favoured, tacit knowledge may be of particular importance in the field of mental health. Goering et al50 have described how the successful application of psychotherapies depends prominently on the qualitative and tacit knowledge that is exchanged between clinician and patient.
Conclusions
Developments in both the conceptual understanding and effective practice of KT may be of value to health care providers working in mental health and the definition of KT is broad enough to be relevant to their day-to-day practice. Awareness of effective approaches to KT may help health The Canadian Journal of Psychiatry, Vol 59, No 3, March 2014 W 167
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care providers to optimize their treatment approaches and become adept at locating, using, disseminating, and implementing valuable new knowledge while supporting their patients’ efforts to do so as well. Frameworks, tools, and resources have been developed that may be useful to health care providers in applying effective KT practices.
Acknowledgements
Financial support for conducting this review was provided to Emily Jenkins through a CIHR Canadian Graduate Scholarship Doctoral Award and a Fellowship through Knowledge Translation Canada. Dr Fischer acknowledges research and salary support from a CIHR–Public Health Agency of Canada Applied Public Health Chair.
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