From knowing to doing: A framework for understanding the evidence-into-practice agenda

ed and augmented from Eckblom, 2001 Box 2: Types of knowledge Explicit vs tacit knowledge There is a substantial literature in psychology about the nature of memory and how this produces different types of knowledge. It is now common to distinguish between ‘declarative’ and ‘procedural’ memory/ knowledge (Squire, 1987; Singley and Anderson, 1989). • Declarative knowledge is explicit knowledge, knowledge that you can state. • Procedural knowledge is tacit knowledge; you know how to do something but cannot readily articulate this knowledge. A second classification (e.g. Department of Information Studies, 2000) defines organisational knowledge as all the ‘software’ of an organisation, including: • Formal codified knowledge, such as structured data, programmes and written procedures • Informal knowledge, such as that embedded in many systems and procedures, which shapes how an organisation functions, communicates and analyses situations • Tacit knowledge arising from the capabilities of people, particularly the skills that they have developed over time • Cultural knowledge relating to customs, values and relationships with clients and other stakeholders. Box 3: Integrating knowledge in evidence-based practice Evidence-based medicine is about ‘integrating individual clinical expertise with the best available external clinical evidence from systematic research...’ (Sackett et al , 1996: 71) Evidence-based practice ‘is more than a matter of simply accessing, critically appraising, and implementing research findings. It also involves integrating such knowledge with professional judgement and experience.’ (Davies 1999: 166-167) Box 4: Four main types of research utilisation. 1. Instrumental use. Research feeds directly into decision-making for policy and practice. 2. Conceptual use. Even if practioners are blocked from using findings, research can change their understanding of a situation, provide new ways of thinking and offe r insights into the strengths and weaknesses of particular courses of action. New conceptual understandings can then sometimes be used in instrumental ways. 3. Mobilisation of support. Here, research becomes an instrument of persuasion. Findings or simply the act of research can be used as a political tool and to legitimate particular courses of action or inaction. 4. Wider influence. Research can have an influence beyond the institutions and events being studied. Evidence may be synthesised. It might come into currency through networks of practioners and researchers, and alter policy paradigms or belief communities. This kind of influence is both rare and hard to achieve, but research adds to the accumulation of knowledge which ultimately contributes to large-scale shifts in thinking, and sometimes action. Adapted from Weiss (1998). Box 5: Replication of research findings. e.g. The Effective Practice Initiative. Studies have found that the effectiveness of probation programmes based on ‘what works’ principles declines when programme delivery diverges from that prescribed in their manuals. For accreditation, the delivery of programmes is internally audited and direct observation or video sampling ensures proper replication (Furniss and Nutley, 2000). e.g. The Kirkholt burglary prevention initiative. A number of replications of the highly successful Kirkholt burglary prevention project were mounted as part of the Safer Cities programme but failed to deliver such good results. Tilley (1993) argues that strict replication is impossible, and proposes a ‘scientific realist’ approach which focuses on how causal mechanisms trigger desired outcomes within particular contexts. Box 6: The replication/innovation continuum The need for knowledge to evolve: a crime prevention ‘arms race’. Ekblom (2001) describes an ‘arms race’ between offenders and those involved in crime prevention which demands the evolution of ‘what works’ knowledge. As technological and social change create new opportunities for offending, crime preventers race to acquire, share and apply new knowledge. ‘Tinkering’: using research in education. Hargreaves (1998) argues that knowledge needs to evolve within the real world context in which it is applied. Teachers must ‘tinker’ with research findings to adapt them to practice in the classroom. Where it is properly supported, systematised and shared, ‘tinkering’ can lead to innovation. Box 7: Four key elements to be considered in research utilisation 1. The source of information whether individual, agency or organisation • Perceived competence • Credibility of experience and motive • Sensitivity to user concerns • Orientation toward dissemination and knowledge use 2. The content or message • Credibility of research and development methodology • Credibility and comprehensiveness of outcomes • Utility and relevance for users • Capacity to be described in terms understandable to users • Cost effectiveness • Competing knowledge or products 3. The dissemination medium the ways in which knowledge is described, packaged and transmitted • Physical capacity to reach intended users • Timeliness of access • Accessibility and ease of use, user friendliness • Flexibility, reliability and credibility • Clarity and attractiveness of the information ‘package’ 4. The user • Perceived relevance to own needs • User's readiness to change • Format and level of information needed • Level of contextual information needed • Capacity to use information or product (resources, skills and support) Adapted from NCDDR (1996) Box 8: Research use as ‘knowledge transformation’ ‘Knowledge transformation’ draws on old knowledge in a particular problem context to engage in learning towards a solution. There are four necessary conditions: 1. a knowledge base 2. a problem definition related to that knowledge base 3. transformation/learning strategies involving various modes of representing ‘old’ knowledge as well as the acquisition of ‘new’ knowledge 4. appropriate motivation. Adapted from DesForges (2000). Box 9: A multi-dimensional model of research implementation Kitson et al. (1998) have developed a multi-dimensional framework for research utilisation which emerged from the equation SI = f(E, C, F) in which successful implementation (SI) is a function (f) of the relation between: E evidence: • the research findings • clinical experience • patient preferences; C context: • an understanding of the prevailing culture • the nature of human relationships as summarised through leadership roles • the organisation's approach to the routine monitoring of systems and services; and F facilitation: • personal characteristics of facilitators • the facilitator's role and position within the organisation • the skills, knowledge and style of the facilitator. Each must be considered simultaneously, and Kitson et al. (1998) give each equal weight. Implementation is most likely to be successful when all three are rated highly. By involving practitioners in discussions about the local position on each of these dimensions, tailored action plans for implementation can be developed. Box 10: ‘Research in practice’: post-structuralist approaches to research implementation Wood et al. (1998) found that health professionals do not simply apply abstract scientific research but collaborate in discussions and engage in work practices which actively interpret its local validity and value. There is no such thing as ‘the’ body of evidence: evidence is a contested domain and is in a constant state of ‘becoming’. Research is rarely self-evident to the practitioner but varies according to the context in which it is received. Within particular contexts, research is related to ‘situated knowledges’, structured local ways of thinking and acting. This ‘contextualisation’ halts the process of ‘becoming’ and makes evidence more amenable to control. Implementation involves reconnecting research with practice, taking account of locally situated practices that inform and are informed by research. This approach encourages a focus on local ideas, practices and attitudes, and suggests that the key is to engage the interest and involvement of practitioners in change programmes. Box 11: Some conceptual frameworks that can inform RU/ EBP implementation Diffusion of innovations Studies of the diffusion of innovations have sought to develop models of how innovations spread through a population and identify the main predictors of adoption rates (Wolfe, 1994). The rate of adoption has been characterised in terms of the ‘S-shaped curve’ and the pattern of diffusion has been identified as ranging from highly centralised to highly decentralised (Rogers, 1995). A number of factors have been found to influence the extent to which an innovation is adopted, including: adopter characteristics; the social networks to which adopters belong; innovation attributes; environmental characteristics; and the characteristics of those who are promoting an innovation (see Nutley and Davies, 2000, p 38, Figure 3). Recent studies have questioned the apparent orderliness of the diffusion process and instead characterise it as a nonlinear dynamic system (Van de Ven, 1999). Institutional theory Institutional theory emphasises that no organisation can be properly understood apart from its wider social and political environment. These environments create the institutions (regulative, normative and cognitive) that constrain and support the operation of individual organisations (Scott, 1995). Institutional theory highlights the way in which existing routines (logics of appropriate action) are highly resilient to the introduction of new ideas (March and Olsen, 1989). Where new practices are adopted they may be partly symbolic and only ‘loosely coupled’ to mainstream organisational activity (Meyer and Rowan, 1977). With respect to innovation uptake, institutional theorists have identified that adoption decisions can relate more to the institutional pressures, associated with certain fads and fashions, than to rational choices about the best course of action (Abrahamson, 1996; Walshe and Rundall, 2001). As innovations gain acceptance organisations adopt them in order to seek legitimacy (DiMaggio and Powell, 1983; O’Neill et al 1998; Westphal et al, 1997). This pattern of behaviour is heightened during times of high uncertainty, when organisations are more likely to imitate other organisations, especially those deemed to be norm setters (DiMaggio and Powell, 1983). Managing change in organisations There is a wealth of literature concerned with understanding and managing change at individual, group and organisational levels. At the individual level this has focused on the reasons for resistance to change (Bedeian, 1980) and on how to ‘get people on board’ (Carnall, 1990; Schein, 1985). At the next level up, the focus is on the development of group norms and how these help or hinder change (Huczynski and Buchanan, 1985). At the organisational level one of the main concerns is how to achieve enduring change; that is, change that goes beyond structural redesign to impact on ‘the way things are done around here’ organisational culture (Williams et al 1989; Wilson, 1992). Stage models and recipes for change abound (Collins, 1998) and the roles and requirements of change agency are also addressed (Buchanan and Boddy, 1992). There are concerns that the literature has tend to adopt a rather unitary view of organisations and that not sufficient attention has been paid to the conflicting interests found within organisations (Collins, 1998; Buchanan and Badham, 1999). Knowledge management Knowledge management is concerned with developing robust systems for storing and communicating knowledge. To date there appear to be two prominent approaches to the management of knowledge: a codification strategy and a personalisation approach (Wiig, 1997; Hansen et al, 1999). Codification strategies tend to be computer-centred; knowledge is carefully codified and stored in databases. In a personalisation approach it is recognised that knowledge is closely tied to the person who develops it, and hence what is developed are enhanced opportunities for sharing knowledge through direct person-to-person contact. The role of information and communication technology within this is to help people communicate knowledge, not to store it. Individual learning Social psychology has long been concerned with understanding the process by which individuals learn. Behaviourialists have studied the effects of different stimuli in conditioning learning, while cognitive psychologists have sought to understand the learning processes that occurs within the ‘black box’ between the stimulus and the response (Dubrin, 1990). Models of the process of learning include Kolb’s learning cycle (Kolb et al 1988), with its emphasis on promoting better understanding of different individual learning styles (Honey and Mumford, 1992). Organisational psychologists have enhanced our understanding of the factors that help or hinder individual learning within organisations (Mumford, 1988). Recent concerns have focused on how to promote lifelong learning and the role of self-directed and problem-based professional education regimes in achieving this (Schmidt, 2000; Collin, 2001). Organisational learning Organisational learning is concerned with the way organisations build and organise knowledge and routines, and use the broad skills of their workforce to improve organisational performance (Dodgson, 1993). The literature in this area has highlighted a number of factors that facilitate or impede ongoing learning. These include: the importance of appropriate organisational structures, processes and cultures (Tushman and Nadler, 1996; Dodgson, 1993; Starkey, 1996); the characteristics of individuals who bring new information into the organisation (Michael, 1973; Allen, 1977); and the role of research and development departments (Mowery, 1981; Dodgson, 1993). Analyses of the learning routines deployed by organisations have distinguished between adaptive and generative learning (Senge, 1990). Adaptive learning routines can be thought of as those mechanisms that help organisations to follow pre-set pathways. Generative learning, in contrast, involves forging new paths. Both sorts of learning are said to be essential for organisational fitness, but by far the most common are those associated with adaptive learning (Argyris and Schon, 1998). Box 12: Insights from organisational learning Many of the existing strategies for implementing EBP (which centre on issuing practice guidelines, backed up by audit and inspection regimes) would seem to reinforce the predisposition towards adaptive learning. If evidence-based practice is centrally defined and imposed, organisations are likely to get stuck in an adaptive learning loop and this raises questions about how new knowledge will be generated. The generation of new knowledge often relies on local invention and experimentation (Hargreaves, 1998), but this may be stifled by centralised control of both what counts as evidence and what practices are condoned. The concept of organisational learning therefore suggests that an approach to EBP implementation that casts the practitioner as problem solver (as in evidence-based medicine – see Box 3 above) may be better suited to the development of learning organisations than the top down implementation of detailed guidelines and protocols. Box 13: Examples of interventions aimed at achieving practice change Professional interventions • Distribution of educational materials • Educational meetings • Local consensus processes • Educational outreach visits • Local opinion leaders • Patient-mediated interventions • Audit and feedback Financial interventions • Provider interventions • Patient interventions Organisation interventions • Revision of professional roles • Multidisciplinary teams • Formal integration of services • Skill mix changes • Communication and case discussion Patient-oriented interventions • Mail order pharmacies • Mechanisms for dealing with patient suggestions and complaints • Consumer participation in governance of health care organisations Structural interventions • Changes to setting/site of service delivery • Changes in medical records systems • Presence and organisation of quality monitoring • Staff organisation Regulatory interventions • Changes in medical liability • Management of patient complaints • Peer review Adapted from Davies et al., (2000) Box 14: Considering the context: broad-based approaches to implementing EBP Two forms of organisational technique for implementing EBP have been deployed in the health care field: 1. Quality Improvement (QI) methods 2. Breakthrough collaboratives. Good quality evaluations of either are rare but key success factors centre on thorough planning of interventions practioner leadership a supportive cultural context effective monitoring systems. (Halladay and Bero, 2000). Halladay and Bero (2000) suggest that clinical governance within the UK NHS represents a systemic conceptualisation of the uptake of evidence and subsequent change in clinical practice. This makes system managers as much as clinicians responsible for the use of evidence, and relies on evidence from routine monitoring as well as research. Box 15: Strategies for implementing evidence-based practice Type of intervention Distinguishing features Complexity of intervention Professionally based interventions Single interventions typically available for use within a professionalised health care organisation. They are disaggregated from their context for the purpose of study and assessment. LOW Organisational interventions Multifaceted interventions, relying on the adoption of explicit change management techniques; focused within the boundary of the health care organisation, but with a reliance on interorganisation reference and/or collaboration. Increasing complexity Systemic re-orientation The attempt to alter the fabric and structure of the system in which health care is provided. It involves the re-conception of the task as one taking place within a holistic system of care inclusive of health care organisations, universities, professional bodies, patient groups, payers and regulators. HIGH From Halladay and Bero (2000). Box 16: Two dimensions of evidence-based practice Type of evidence A distinction has been made between two models of how evidence is generated and used to influence practice – the research implementation model and the outcomes feedback model (Kendrick, 2001). In the implementation model, research based evidence (particularly in relation to what works) is used to shape practice. In contrast, the outcomes feedback model relies on monitoring routine observational data and feeding this back to practitioners. Evidence is not fed into the system as a priori knowledge but is derived from monitoring the process and outcome of care as it happens. Variations in outcomes trigger explanatory investigations, with the aim of identifying the best form of remedial action. Focus of attentionThe focus of attention range from the individual to the broader organisation/system (seeBox 15). Much of the early work in evidence-based medicine took as its focus thepractice of individual clinicians. Thus the implementation of evidence based practicewas in large measure interpreted as changing the way in which individuals madedecisions in relation to treating individual patients (Sackett et al 1996). 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