knowledge translation

Knowledge translation: beyond the peer reviewed papers


Oh the risks and pitfalls of trying to get research into clinical practice! There’s an often-cited figure estimating it takes around 17 years for a new practice to enter routine clinical care (Dilling, Swensen, Hoover, Dankbar, Donahoe-Anshus, Murad & Mueller, 2013) – that’s a long time!

There are many reasons for this delay:

  • Inertia – change is hard!
  • Systems – often support the status quo, may not fund new or innovative practice
  • Peer pressure – to keep on doing the same as everyone else
  • Questioning whether the benefits are truly there
  • Busy clinical practice making it difficult to think differently
  • Contradictory reports in research
  • Lack of confidence to make a change (original training maybe didn’t include the skills now needed)
  • Expectations, perhaps from the people we hope to help
  • Holding on to beliefs that feel good/provide short-term effects but may not provide long-term ones

Blogs, like this one, are one way to bridge the research to practice gap. Social media has become a powerful influence, at least in explicit attitudes even if not necessarily daily clinical practice. There are risks, however, in using social media for ongoing learning though I will say that there are also risks in attending conferences, workshops, reading books, reading journals and the like!

The main risk, in my humble opinion (see what I did there?!), is that authors write what they know, and everything that’s put out “there” is filtered through the author’s opinion. Now that’s not novel, it happens in peer-reviewed research as well. The difference in peer-reviewing is that at least two other people, often more, also have read and critiqued the article. This doesn’t mean unbiased papers though, but perhaps a better quality of bias!

Knowledge translation is a real thing. It’s the process of disseminating information from research into clinical practice. This process isn’t straightforward, because all research is biased and no research (pretty much) will fit directly into the nuances of your particular practice context. Although few quantitative research studies openly declare their philosophy of science, it’s assumed that their findings are devoid of values and context: a dangerous assumption given that our clinical worlds are full of competing values and our contexts are hugely variable.

To translate something from research into practice takes some skill. Firstly to distill the research findings into usable bits and pieces, while understanding the contexts and assumptions built into those results. Then to have awareness of the context in which the research might be implementing. Finally, to have creativity to work out which parts of the research will fit well into this clinical context

To do knowledge translation means recognising different philosophical traditions – knowing that all research holds assumptions, and these aren’t declared in many cases (because it’s assumed everyone knows them!). Qualitative researchers, by and large, are more likely to openly state their philosophical stance, making it far easier to understand the assumptions they’ve made in conducting their research. Once assumptions are known, it’s easier to establish which parts of the research will hold in a different context.

When I look at the list of reasons people don’t implement new information, what strikes me is how human they are. They’re about how WE as humans respond to change. They’re about systems and links between actions and what happens next (contingencies). They’re about our social nature, and that we’re motivated by needing to belong, to feel competent and for things to make sense. Introducing new ideas means someone has to be the first one to try it – this means that person is “different”, they don’t belong. Any new thing needs to be learned: that means a time when it’s likely people using it will feel less than competent. And new things often mean letting go of old beliefs and habits, so for a time at least, things don’t make sense as they used to.

One way social media has worked to translate knowledge into practice is by making it OK to belong to a “tribe”. When there are enough people saying similar things, it’s easier to feel like this new idea is acceptable – and by implementing it, we still belong.
Social media might also break the complex ideas developed in research into smaller, bite-sized chunks, so making it much easier to put into practice without feeling incompetent.

But social media doesn’t work as well at helping us let go of old beliefs and habits. What seems to happen is a lot of “he said” and “she said” and argumentation that only serves to reinforce each person’s current stance. It’s relatively uncommon for these kinds of discussions to move beyond posturing, and frankly, I think this is destructive. It’s one of the reasons I don’t engage in critiquing posts where I think the person’s incorrect. My strategy is to post positive information because the more often positive information is made available, the more likely it will be seen. But given recent readership stats on this blog, perhaps it’s not such a good strategy! Gone are the heady days of 1200 hits on a post in a single day!

Nevertheless I post to help disseminate information that is otherwise locked up in journals behind paywalls, to write the long-form because one of the first steps in knowledge translation is to read the research then summarise it. I also do it for myself (mainly I do it for myself) – because when I write, I’m sorting out what I think. Writing to learn is recognised as a useful strategy for deep learning and understanding (Stewart, Myers & Culley, 2010).

Occupational therapy could be considered the “knowledge translation” profession – much of our work involves taking skills developed in the comparatively controlled world of the clinic out into daily life. Occupational therapists are also practical problem solvers, given the philosophical basis for the profession is likely pragmatism (Ikiugu & Schulze, 2006). It’s probably where occupational therapists who are enthused about research and its application could do the most good. The philosophy of science I think most suits occupational therapy is functional contextualism – how workable are solutions given the values and context of the person?

Research deserves to be used. It’s usually why people begin to do research – they’re curious about a situation or a problem, then want to work out why. Implementing that research may not fit so well but this is where we need to be to make a change in our world.

Dilling, J. A., Swensen, S. J., Hoover, M. R., Dankbar, G. C., Donahoe-Anshus, A. L., Murad, M. H., & Mueller, J. T. (2013). Accelerating the use of best practices: the Mayo Clinic Model of Diffusion. Joint Commission journal on quality and patient safety, 39(4), 167–176. https://doi.org/10.1016/s1553-7250(13)39023-0

Ikiugu, M. N., & Schultz, S. (2006). An argument for pragmatism as a foundational philosophy of occupational therapy. Canadian Journal of Occupational Therapy, 73(2), 86-97.

Stewart, T. L., Myers, A. C., & Culley, M. R. (2010). Enhanced learning and retention through “writing to learn” in the psychology classroom. Teaching of Psychology, 37(1), 46-49.

Wensing, M., Grol, R. Knowledge translation in health: how implementation science could contribute more. BMC Med 17, 88 (2019). https://doi.org/10.1186/s12916-019-1322-9

The know-do gap: does social media help change things?


This post is prompted by a Facebook post from Connor Gleadhill asking “in what way is SoMe contributing to knowledge translation (KT)? I’m interested in the experience of those tagged and if anyone is aware if it has been rigorously tested. As far as I’m aware it hasn’t. Is it simply a confirmation bias arena? We are humans after all, and we curate our experience on SoMe.”

Oh such a great question and one reason I still hang out on social media!

I’ve been blogging since 2007, two years before the famous Body in Mind (who have just announced they won’t post any more content). Over that time I’ve risen to the top of the blogs, then plummeted down to my current level. Yet I still have a passion for doing this (usually) weekly post.

One reason I post is in answer to Connor Gleadhill’s question: one method for translating knowledge from journals into clinical practice is through online content. Content that’s accessible (not behind a paywall). Content that offers an opinion. Content that (hopefully) translates a-contextual information into a context more familiar to clinicians.

Is there evidence that knowledge translation occurs in this space or is it all a vast echo chamber where we listen to ourselves and pretend that everyone who is anyone agrees?

Well, in the pursuit of understanding this phenomenon, I’ve been researching the research looking at the effectiveness of one form of social media: the community of practice. A community of practice is a concept developed by Wenger yet one that has (probably) existed since humans took up tools and started learning from each other. It’s a place where “groups of people … share a concern or a passion for something they do and learn how to do it better as they interact regularly.” Senior or recognised “expert” members of the group provide experiential knowledge to guide junior or “apprentice” members as they learn how to … the “how to” depends on the group. In my case, it’s a group devoted to learning how to apply a multifactorial model of pain into diverse areas of clinical practice.

The group I’m part of is unusual in that it has emerged organically, not having been established artificially for the purpose of studying it. I’ve written a paper on the findings from a study of this group, to be submitted shortly. So when I talk about “effectiveness” I have to refer to artificial studies where communities of practice have been examined. One integrative review by Rolls, Hansen, Jackson and Elliott (2016) found 77 studies consisting of 44 qualitative papers, 20 mixed methods studies, and 8 literature reviews. The range of social media used was wide and included Listservs (remember them?), Twitter, “general social media” (not sure what that really means!), discussion forums, Web 2.0, virtual communities of practice, wiki, and Facebook. The clinicians involved included medical practitioners, multidisciplinary specialty group, health care professional “in general”, midwifes, nurses, and allied health professionals. The study found that:

…social media use is mediated by an individual’s positive attitude toward and accessibility of the media, which is reinforced by credible peers. The most common reason to establish a virtual community was to create a forum where relevant specialty knowledge could be shared and professional issues discussed (n=17). Most members demonstrated low posting behaviors but more frequent reading or accessing behaviors. The most common Web-based activity was request for and supply of specialty-specific clinical information. This knowledge sharing is facilitated by a Web-based culture of collectivism, reciprocity, and a respectful noncompetitive environment. Findings suggest that health care professionals view virtual communities as valuable knowledge portals for sourcing clinically relevant and quality information that enables them to make more informed practice decisions.

Rolls, Kaye, Hansen, Margaret, Jackson, Debra, & Elliott, Doug. (2016). How Health Care Professionals Use Social Media to Create Virtual Communities: An Integrative Review. Journal of Medical Internet Research, 18(6), e166. doi: 10.2196/jmir.5312

Heidi Allen and colleagues (2013), from Body in Mind, found that by releasing papers on social media, there was an increase in dissemination of those papers. Chan and colleagues (2018) also identified that there was much “scholarly engagement” through online interactions. There are detailed analyses of the social construction of knowledge online (Gunawardena, Flor, Gomez & Sanchez, 2016), studies of how acceptable social media knowledge translation is amongst health researchers and clinicians (Tunnecliff, Illic, Morgan, Keating, Gaida, Clearihan et al 2015), and examination of patient’s use of social media (Antheunis, Tates & Nieboer, 2013).

Social media can “democratise” information. Because social media is readily accessible across so many forms and devices, and because there is greater opportunity to interact with authors, and the numbers of people seeking health info, social media allows more information flow than journal articles or conferences. There’s always a risk in that: loud voices, those with marketing smarts, those with a punchy delivery and especially those with a controversial message will attract more attention than, for example, my long form writing on complex topics.

Reader beware must also be the motto. Info dumping a load of references tangential to the actual topic, along with little, if any, critical analysis of that material, can lead to what appears to be authoritative content, but may perpetuate unhelpful and outdated ideas.

I continue blogging because it helps me sort my ideas out. I find it helps me “construct” and assemble what I know into something I can then apply. It helps me sift through the overwhelming wealth of research pouring out of Universities and research groups everywhere around the world. As I look at the over 1100 posts I’ve written, I can see the issues I’ve pondered, and the stance I take on issues such as communication, respect, thinking before adopting a new treatment, clinical reasoning, collaboration. Many of these are attitudes towards people who live with pain.

The things I most appreciate about social media are that I have a network of people with whom I can nerd out. People who do “get it”. People who may not agree with me but who are willing to entertain alternative views. People who push me to learn about areas I wouldn’t normally. People who live with pain who inspire me. People for whom I have great compassion because of their personal stories. I have a sense of community. A real assemblage of people I can turn to when I have questions.

In answer to the question “Does social media contribute to knowledge translation?” I would say it is as effective as the readers and contributors make it, possibly more effective than attending a conference (the best part is always the social isn’t it?!), certainly more useful for generating clinical discussion than a publication locked up in a journal, and as long as conversations remain respectful and discuss ideas and not personalities, it’s an effective way for clinicians to construct knowledge for their practice setting. I’m still going to blog even if my average reader numbers in the last week were a measly 100 people.

Allen, Heidi G, Stanton, Tasha R, Di Pietro, Flavia, & Moseley, G Lorimer. (2013). Social media release increases dissemination of original articles in the clinical pain sciences. PloS one, 8(7), e68914.

Antheunis, Marjolijn L., Tates, Kiek, & Nieboer, Theodoor E. (2013). Patients’ and health professionals’ use of social media in health care: Motives, barriers and expectations. Patient Education and Counseling, 92(3), 426-431.

Chan, Teresa, Trueger, N Seth, Roland, Damian, & Thoma, Brent. (2018). Evidence-based medicine in the era of social media: Scholarly engagement through participation and online interaction. Canadian Journal of Emergency Medicine, 20(1), 3-8.

Gunawardena, Charlotte N, Flor, Nick V, Gómez, David, & Sánchez, Damien. (2016). Analyzing social construction of knowledge online by employing interaction analysis, learning analytics, and social network analysis. Quarterly Review of Distance Education, 17(3), 35.

Tunnecliff, Jacqueline, Ilic, Dragan, Morgan, Prue, Keating, Jennifer, Gaida, James E, Clearihan, Lynette, . . . Mohanty, Patitapaban. (2015). The acceptability among health researchers and clinicians of social media to translate research evidence to clinical practice: mixed-methods survey and interview study. Journal of medical Internet research, 17(5).

Knowledge translation: A home for occupational therapy?


Modern occupational therapy is involved with helping people participate in daily life in the real world. Indeed, occupational therapy has always been about “doing” – see here for a brief history of occupational therapy – but it has been difficult, in a strongly reductionist and biomedical context, to articulate the unique and particular contribution occupational therapy makes within healthcare.

In a conversation last week with Dr Mary Butler from Otago Polytechnic, we were discussing our areas of research. I mentioned that knowledge translation, or helping clinicians use research that is often locked up in peer-reviewed journals, is my passion. Something clicked and we both recognised that the process of translating from one “artificial” setting to the real world is where both of us feel completely at home. As our conversation rambled (we know how to talk!), we described the way we go about contributing to research and clinical practice: looking from the evidence-based material or research in daily life, to where this knowledge needs to be applied. Our passion is understanding the where/how/why/what that gets in the way of bringing evidence to the lived experience, whether that be researching how an older person with poor vision might avoid falls (change the lightbulbs for brighter ones – it can help!), or working out a clinical reasoning model to help therapists think broadly about pain and factors influencing disability.

Knowledge translation is an area of research and practice that bridges the gap between journal articles and implementation. It involves identifying needs in the real world (read: practice area), identifying or developing research to solve those problems, making the solutions (research) accessible, then adopting and modifying that information as it’s implemented so that it does what it needs to do.

For occupational therapists, this is work as usual. We work with the person to identify their needs: what does this person want and need to do in daily life? We then scour our knowledge bases, often assessing the person’s capabilities, understanding the context and environment, research the constraints on the person’s participation and establish the obstacles that prevent this person from participating in what they want and need to do. We then tailor the solutions to fit the unique demands of the person, the task (or occupation) and the contexts, and help the person implement the solution so they can participate.

And this is why it’s so difficult to answer that seemingly simple question: What can you offer people? Why should I refer to you? What do you do? Because my answer will almost always be “it depends …!”

Working in pain management as I do, I draw on pain research across basic science, biology, biomechanics, physiology, sociology, anthropology, psychology in many different fields. I also need to know about pharmacology, kinesiology, strength and fitness research, and yes I even have to read about surgery, physiotherapy, nursing, post-operative recovery. Because the people I work with have relationships with others, I need to understand relationship dynamics, employer/employee relations, collegial relations at work, friendships, mateships and both introversion and extraversion. I could go on – but the point is not just how many fields I need to be conversant with, it’s that the way I use this knowledge is unique to occupational therapy. Let me elaborate.

All those fields of knowledge are relevant to my work, but the area that is utterly unique to occupational therapy is understanding the interaction between this person and his/her many different participation contexts. This means that I might be working on graded exposure to the fear of bending forward. A physiotherapist may have been working on this in a gym or fitness context – but this environment is controlled, there is a therapist hovering near, the loads and positions and floor surface and lighting and number of people around and noise level is all controlled and fairly consistent. As an occupational therapist, my job is to help this person generalise the fear reduction experienced in the gym to every day life. That means loading things into the boot of the car, or over the back seat of the car, or the laundry basket, or picking up the clothes off the floordrobe in the teens bedroom, or picking up the dog pooh from the back yard, or bending to weed the garden, or bending to put the shoes and socks on, or clean the bottom of the bath or shower. I have to help the person identify where they need to bend over, and grade the demands to a level that the person can only just manage – so he or she can push towards increasing confidence in any situation.

Translating from one context to another doesn’t always happen by itself. I’m sure there are many times we’ve seen someone walking beautifully, using the painful foot with a completely correct heel-toe pattern in the clinic – then perhaps unexpectedly meeting the person in the shopping mall on a wet day when the floor is slippery only to find he or she is leaning on the shopping trolley, limping and hardly putting any weight on the foot at all.

Knowing about a strategy doesn’t mean it’s used in the real context in which it’s needed. A mindfulness meditation carried out in clinic, where it’s quiet and there are no distractions, and no children saying “what’s for dinner!” and no partner coming home after a busy day wanting to decompress by talking… is a very different experience carried out at home! And this complexity is the practice space for occupational therapists. It looks like “doing meditation” and “oh but we’ve done that in one session” – but it’s a complex balancing of priorities, establishing boundaries, caring sufficiently for oneself over others, being willing to bring the mind back repeatedly as salient thoughts and sounds intrude.

I think that many clinicians assume that what is done in treatment has carryover into daily life. I would argue that this gap between knowing and doing, discussed so much in knowledge translation about research and clinical practice, is precisely what is missing in much of our pain rehabilitation. We may not even recognise that the person hasn’t integrated the skills we’ve been focusing on: why? Because we don’t enter the person’s everyday life.

Some of the things occupational therapists focus on so much include meaning and values, the social context, the physical environment, the cognitive and sensory environment – and at times, we can forget that we draw on foundation science in our treatment approach, so we hand out long-handled reachers for picking the clothes up from the floordrobe, forgetting that it’s possible for people to learn how to bend over without fear… and that’s a conversation for occupational therapists to have. I hope that by starting to recognise our “knowledge translation” space, we might gain more confidence to read research well outside “occupational” areas, and begin to consider how we can apply what other disciplines study to the everyday lives of the people we help.