What is knowledge and when should it be implemented

bs_bs_banner Journal of Evaluation in Clinical Practice ISSN 1365-2753 What is knowledge and when should it be implemented? Laura O’Grady PhD* Scientific Associate, Knowledge Translation Research Network, Ontario Institute for Cancer Research, Toronto, ON, Canada and Assistant Professor, Department of Family and Community Medicine, Dalla Lana School of Public Health, Faculty of Medicine, University of Toronto, Toronto, ON, Canada Keywords experiential, implementation, knowledge, methods, research, tacit, translation Correspondence Prof Laura O’Grady Department of Family and Community Medicine Dalla Lana School of Public Health Faculty of Medicine University of Toronto 263 McCaul Street, Room 323 Toronto, ON Canada M5T 1W7 E-mail: [email protected] Abstract A primary purpose of research is to generate new knowledge. Scientific advances have progressively identified optimal ways to achieve this purpose. Included in this evolution are the notions of evidence-based medicine, decision aids, shared decision making, measurement and evaluation as well as implementation. The importance of including qualitative and quantitative methods in our research is now understood. We have debated the meaning of evidence and how to implement it. However, we have yet to consider how to include in our study findings other types of information such as tacit and experiential knowledge. This key consideration needs to take place before we translate new findings or ‘knowledge’ into clinical practice. This article critiques assumptions regarding the nature of knowledge and suggests a framework for implementing research findings into practice. * Affiliations when article was written. Accepted for publication: 20 July 2012 doi:10.1111/j.1365-2753.2012.01899.x Since 1997, the Journal of Evaluation in Clinical Practice has published annual thematic editions and individual papers [1] aimed at reviewing, debating and challenging issues around the concept of evidence-based medicine. In this article, I intend to stimulate a similar discussion with a focus on implementation research and its applied forms including knowledge translation (KT). Implementation research is defined as, ‘. . . the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices into routine practice, and, hence, to improve the quality and effectiveness of health services’ [2]. In 1992, the National Health Service in the United Kingdom identified the dissemination and utilization of research findings into clinical practice as a priority [3]. In 2000, the Canadian Institutes of Health Research (CIHR) [4] introduced the concept of KT. Research funded by CIHR now requires two KT components: to engage audiences as research is being conducted, known as ‘integrated’ KT, and to disseminate study findings to appropriate audiences, known as the ‘end of grant’ KT. It is important to acknowledge KT in this critique as other organizations, including the World Health Organization, have adopted the requirements established by CIHR [5]. Similar to implementation science, effective KT is intended to inform research scientists, support health providers, advise policy analysts and educate the general public. The underlying principle of KT has existed for many years in different forms including implementation science, knowledge management, dissemination and quality improvement. Many articles have been written about KT, including theoretical frameworks and applications [6]. It is understood that clinical guidelines and decision aids should be translated from the evidence of published research studies. However, what constitutes evidence is an issue in of itself [7]. KT should also include patient perspectives [8]. The underlying principles of KT have been defined [9] but, like evidence, they need further unpacking and clarification. Knowledge is an elusive construct whose definition continues to be debated by many, from philosophers to educators to information science specialists. It has often erroneously been considered to be interchangeable with information. Information is the movement of messages, whereas knowledge is created collaboratively by this process, context dependent and constructed by the users. A fundamental element in knowledge development is the distinction between tacit (which is understood, known but not necessarily declared) and explicit (which is reified, deliberately stated and shared) knowledge. Both forms are required for knowledge to be © 2012 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice 18 (2012) 951–953 951 What is knowledge? created. Innovation is not likely possible without an understanding of problems and ways to resolve them. The interplay between these two concepts is facilitated by externalization (collaborating with others) and internalization (reflection within) [10]. It has also been suggested that knowledge consists of data, which form the property of object, and information is a sub-component of data. Data can be temporal, thematic and spatial. According to Boiset [11], the interpretation of data and information is required to form knowledge. It is with this foundation that we will form a means by which knowledge, as we have defined it, can be operationalized to facilitate successful translation. Researchers can produce knowledge informed by quantitative and qualitative data. In accordance with Boisot’s [11] view, I suggest that mixed methods studies begin to provide us with information [12] although that can be challenging because they draw on different disciplines. To create ‘knowledge’, more is required. In addition to combining data and information we also need to consider tacit knowledge, which is often implicitly known and understood, but not necessarily declared. Many of us may not have insight into how we work. We may ‘do without thinking’. It may require introspection, which may deliberately include questions about steps taken and decisions made. This type of material is not commonly articulated by doctors or clinician scientists through conference presentations or journal articles. In addition, stakeholders have their own tacit knowledge when it comes to the application of research findings. For some, teaching can provide insights as we are required to make conscious and explicitly state the tacit. Patients also have much knowledge to contribute through their experiences of living with illness. However, they may not be explicitly aware of this or of its value as it may be considered more intuitive in nature [13]. This form of anecdotal or experiential information is often not included in research studies [8]. Figure 1 provides a framework, which illustrates how research is currently skewed towards quantitative data and the tacit knowledge of health providers and clinical researchers, who are primary contributors to ‘knowledge’. In its current form, our main source of knowledge used in clinical practice resides in the lower left quadrant of the figure. The source of this knowledge is research conducted by research clinicians and to a certain extent tacit knowledge from practitioners. Randomized controlled trials had now been cont extualized with qualitative findings to produce. Figure 1 Current model of biomedical ‘knowledge’. 952 L. O’Grady A research grant may support the discovery of new data or findings, but is that really knowledge? Only through some form of a systematic review can we begin to find ways to implement what we have learnt. I suggest that knowledge is wisdom derived from the combination of research, which includes data derived from quantitative research and findings produced from qualitative research, and experience. It involves knowing when, how and in what ways to apply pre-existing tacit and experiential knowledge to the distillation of data and findings into information. In what ways can we improve our current research methods to create a space for knowledge worthy of translation into action? The following real world example attempts to illustrate this concept. In 1996, a class of medications called protease inhibitors, which blocked the replication of HIV was released. With these, new treatments dose timing and strict adherence were critical to ensure effectiveness. Although reduced viral loads were widely reported, not everyone experienced similar outcomes. Doctors learned from their social science colleagues that some patients were having difficulty adhering to the strict regimes these new medications required [14]. The data from the randomized controlled trials had now been contextualized with qualitative findings to produce information. It may have been translated, but was it knowledge? And was this information widely known? Anecdotally, it was reported that some patients used electronic devices as reminders to take their medication. In this case, the stakeholder, patients had developed experiential knowledge. Many may have adopted this strategy without sharing it with anyone. Patients lack a forum to do so, at least in terms of publishing in peer-reviewed medical journals. Therefore, this ‘knowledge’ may have escaped the literature despite supporting adherence. However, this information may not be credible as patients’ reflections may be inaccurate or based on personal beliefs [15]. In addition, there are a variety of issues with how information is solicited from patients within the clinical scenario. Likely occurring within research studies as well, these issues include incidents of misinterpretation, inaccurate assessments, biased or limited recollection, cultural partiality, and limited means of communication [15]. Human beings and the tools we devise to measure and interpret our behaviour are fraught with the potential for bias and error. One way to move towards wisdom may be through reification of these various sources in a format that is accessible to all the interested parties so it can be read and reflected upon. The electronic health record (EHR) could provide such a solution. These records contain data in the form of medications administered, adverse reactions and laboratory results as well as information in the form of various notes related to patient care. If patients were provided access to the EHR and could share their experiences, then we may begin to uncover details that could have been otherwise overlooked. In addition, if clinicians were encouraged to include tacit knowledge as accrued through practice, a repository of rich source material could be amassed. In turn, this could be reviewed by clinician scientists, which may lead to further inquiry, inform research and/or practice. In the practice of KT or implementation, we assume that the output of each funded study creates ‘knowledge’ that is valuable, reliable, has practical implications and can be readily implemented. It is only through the combination of data and findings that we create information. This information, combined with tacit and experiential knowledge, brings us closer to understanding © 2012 Blackwell Publishing Ltd L. O’Grady Figure 2 Proposed model of medical knowledge. what will best translate into improved health care. Figure 2 illustrates a scenario weighting each component equally. It may be an unlikely objective to implement this model given the time and skills required and other constraints as discussed. However, efforts must be made to move towards this goal including recording relevant clinical material in a common resource such as an EHR. So what is knowledge and when should it be implemented? This should happen only when we will achieve wisdom by including data, findings, experiential and tacit understandings in medicine. Funding This study was conducted with the support of the Ontario Institute for Cancer Research through funding provided by the Government of Ontario, Canada. References 1. Buetow, S., Upshur, R., Miles, A. & Loughlin, M. (2006) Taking stock of evidence-based medicine: opportunities for its continuing evolution. Journal of Evaluation in Clinical Practice, 12 (4), 399–404. 2. Eccles, M. P. & Mittman, B. S. (2006) Welcome to implementation science. Implementation Science, 1 (1). Available at: http://www. implementationscience.com/content/1/1/1/ (last accessed 10 August 2012). © 2012 Blackwell Publishing Ltd What is knowledge? 3. Department of Health (1992) The New NHS: Modern, Dependable. London: Department of Health. 4. Canadian Institutes of Health Research (CIHR) (2000) The CIHR Act. Available at: http://laws-lois.justice.gc.ca/eng/acts/C-18.1/index.html (last accessed 4 May 2012). 5. World Health Organization (2005) Knowledge translation in global health. Available at: http://www.who.int/bulletin/volumes/83/10/ editorial21005html/en/index.html (last accessed 4 May 2012). 6. McKibbon, K. A., Lokker, C., Wilczynski, N., Ciliska, D., Dobbins, M., Davis, D., Haynes, R. B. & Straus, S. (2010) A cross-sectional study of the number and frequency of terms used to refer to knowledge translation in a body of health literature in 2006: a Tower of Babel? Implementation Science, 5 (1), 16 Available at: http://www. implementationscience.com/content/5/1/16/ (last accessed 10 August 2012). 7. Dobrow, M. J., Goel, V. & Upshur, R. E. (2004) Evidence-based health policy: context and utilisation. Social Science and Medicine, 58 (1), 207–217. 8. Robinson, L., Netwton, J. & Dawson, P. (2012) Professionals and the public: power or partnership in health research? Journal of Evaluation in Clinical Practice, 18, 276–282. 9. Straus, S. E., Tetroe, J. & Graham, I. (2009) Defining knowledge translation. CMAJ, 181 (3–4), 165–168. 10. Nonaka, I. (1994) A dynamic theory of organizational knowledge creation. Organization Science, 5 (1), 14–37. 11. Boisot, M. (1998) The Information Perspective. Knowledge Assets: Securing Competitive Advantage in the Information Economy. New York: Oxford University Press. 12. Teddlie, C. & Tashakkori, A. (2009) Foundations of Mixed Methods Research: Integrating Quantitative and Qualitative Approaches in the Social and Behavioral Sciences. Thousand Oaks, CA: Sage Publications. 13. Buetow, S. A. & Mintoft, B. (2011) When should patient intuition be taken seriously? Journal of General Internal Medicine, 26 (4), 433– 436. 14. Remien, R. H., Hirky, A. E., Johnson, M. O., Weinhardt, L. S., Whittier, D. & Le, G. M. (2003) Adherence to medication treatment: a qualitative study of facilitators and barriers among a diverse sample of HIV+ men and women in four US cities. AIDS and Behavior, 7 (1), 61–72. 15. Redelmeier, D. A., Schull, M. J., Hux, J. E., Tu, J. V. & Ferris, L. E. (2001) Problems for clinical judgement: 1. Eliciting an insightful history of present illness. CMAJ, 164 (5), 647–651. 953