VINNVRD Discussions

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A knowledge translation research program some
snapshots
Carole A. Estabrooks Professor Canada Research
Chair in Knowledge Translation Faculty of
Nursing University of Alberta
VINNVÅRD Discussions Stockholm August 14, 2007
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A Changing Research Agenda

• Funding agencies are no longer content to support
  research that solely aims to advance scientific
  knowledge
• Directives are now in place to promote research
  transfer to policy and decision-makers
• What are the implications of this?
• for researchers
• for users?

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Mode I Knowledge production

• Traditional Science
• Located in the academy
• Curiosity driven
• Objective
• Organized according to discipline

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Mode II Knowledge Production

• In a mode II society
• Diversification of knowledge sites production
• Practical application
• Social processes
• Organized according to task, not discipline

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Mode II society

• Broader set of criteria to measure quality
• Fulfill social, economic, political interests
• Knowledge must have a practical outcome
• Knowledge is contextual

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Mode II like funding, research and activities are
increasingly attractive and evident however.

• they are not cost neutral or without
  implications

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Correlation is significant at the 0.01 level
(2-tailed). Correlation is significant at the
0.05 level (2-tailed).
Correlations
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Knowledge use in context

• Contextual factors influence the uptake of new
  knowledge
• Knowledge is transformed to suit the local
  context
• Challenges the idea that knowledge can be simply
  imported directly into clinical practice

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University of Alberta
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Key Groups in Canada
Laval
University of
Montreal
University of Alberta
McMaster University
University of Ottawa
University of Toronto
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Knowledge Utilization Studies Program (KUSP)
www.ualberta.ca/kusp
Funded primarily by Canadian Institutes of
Health Research (CIHR) To a lesser extent
by Alberta Heritage Foundation for Medical
Research (AHFMR) Social Sciences and Humanities
Council (SSHRC)
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Diffusion of Innovation

• Elements
• The Innovation
• Communication Channels
• Time
• Social System

• Stages
• Awareness
• Persuasion
• Decision
• Implementation
• Adoption

1931 - 2004

• Influencing factors
• Attributes of the innovation
• Individual
• Organizational

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PARiHS Framework for Research Implementation
Evidence-based practice
Leadership

Context


Facilitation
Evaluation
Evidence

Kitson, et al., 1998, QSHC Rycroft-Malone et al,
2002 (J Adv Nurs)
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Locating research implementation in nursing
services delivery

• The largest health provider group in Canada
  (CIHI, 2003)
• gt18 of all health care workers in Canada
• 2 of all workers in the Canadian labour force
• The impact on outcomes
• 30-Day Mortality (Estabrooks et al., 2005)
• work by Aiken, Needleman, Blegen and others

terminology commonly used in nursing is research
utilization (registered) professional nurses
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Why what we know may not apply to the delivery
of nursing services

• Nursing services often delivered in a different
  context
• Rooted in a different relationship to the
  organization
• Different effects exerted by organizational and
  local culture
• Requires some similar but also some different
  knowledge forms
• Located lower in organizational hierarchy

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Interventions aimed at increasing research use
in nursing A systematic review
Thompson, Estabrooks, Wallin, Scott-Findlay,
Moore (Implementation Science 2007, 215)

• 3 RCTs and 1 CBA
• Results
• Methodological quality of studies generally low
• Single interventions
• Most common intervention was education
• Research use measured using surveys (three
  studies) and compliance with clinical practice
  guidelines (one study)
• Researcher led educational meetings ineffective
  in 2/4 studies
• Educational meetings led by local opinion leader
  and the formation of multidisciplinary committees
  both effective at increasing research use

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Little is known about how to increase research
use in nursing, and the evidence to support or
refute specific interventions is inconclusive.
To advance the field, we recommend that
investigators (1) use theoretically informed
interventions to increase research use, (2)
measure research use longitudinally using
theoretically informed and psychometrically sound
measures of research use, as well as, measuring
patient outcomes relevant to the intervention,
and (3) use more robust and methodologically
sound study designs to evaluate interventions.
If investigators aim to establish a link
between using research and improved patient
outcomes they must first identify those
interventions that are effective at increasing
research use.
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1997 to 2007

• Research utilization in nursing An examination
  of formal structure and influencing factors
  (1997)
• Determinants of research utilization Pain
  management in adults and children (1999 2003)
  NHRDP/CIHR, AHFMR
• Two bibliometric studies
• Developing a valid and reliable measure of
  research utilization

Phase I

• Translating research in acute care hospitals
  (AKUTE)
• Translating research in pediatric care (pain
  management)
• Translating research in elder care

Phase II
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1997 to 2007

• Research utilization in nursing An examination
  of formal structure and influencing factors
  (1997)
• Determinants of research utilization Pain
  management in adults and children (1999 2003)
  NHRDP/CIHR, AHFMR
• Two bibliometric studies
• Developing a valid and reliable measure of
  research utilization

Phase I

• Translating research in acute care hospitals
  (AKUTE)
• Translating research in pediatric care (pain
  management)
• Translating research in elder care

Phase II
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Understanding the influence of context on
knowledge translation
three programs
Facility Based Elder Care (LTC)
Pediatric Acute Care
Adult Acute Care
Utilization of research in hospitals (AKUTE)
Translating research in elder care (TREC)
CIHR Team grant (TROPIC)

• TREC program
• 3 prairie prov., LTC
• Context surveillance
• Enhanced AF
• KT and resident outcomes
• Pilot studies

• Context assessment
• Context to KT
• Multi-level structural eqn. modeling
• KT and clinical outcomes

• Pilot (in progress) in AB teaching hosp.
• Five groups of health professionals
• Instrument testing
• Next stage - western provinces (outcomes,
  multi-level modeling)

6M (SEK 36M)
4.7M (SEK 28M)
150K (SEK900K)
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Pediatrics
Objective To determine the influence of
organizational context on KT, and KT on patient
outcomes (pain intensity)
Pediatric Acute Care

• Three projects
• EPIC (dBase)
• Assessing context (Edmomton led)
• A facilitation intervention

CIHR Team grant (Bonnie Stevens, PI)

• Context assessment
• Context to KT
• Multi-level structural eqn. modeling
• KT and clinical outcomes

N8 pediatric hospitals N24 patient care
units N800 nurses 4 additional groups
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Adult/acute care (AKUTE)

• Objectives
• to determine the feasibility of a larger scale
  study in Western Canada
• To develop validate the Alberta Context (ACT)
  tool
• To identify predictors of research utilization
• To assess five provider group differences and
  similarities

(Mostly) Adult Acute Care
Utilization of research in hospitals
(AKUTE) (Estabrooks Norton, PIs)

• Pilot (in progress) in AB teaching hosp.
• Five groups of health professionals
• Instrument testing
• Next stage pilot tracer outcomes component
• Then four western provinces (outcomes
  multi-level modeling)

N4 teaching hospitals N453 (5 professional
groups)
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Elder care (TREC)
Phase II (2007-2011) of a multi-year (2002 to
2022) research program
Facility Based Elder Care (LTC)
Purpose To address the impact of context on
knowledge translation (KT) and subsequent impact
of KT on health outcomes (and secondarily
provider and system outcomes)
Translating research in elder care
(TREC) (Estabrooks, PI)

• Multi-method
• Multi-level
• Longitudinal (5 years)
• 3 major inter-related projects
• Longitudinal profiling
• Context case studies
• AF intervention
• Series of 3 pilot studies of interventions to
  increase research use

e.g., better pain management, falls and falls
injury reduction, better management of difficult
behaviours
N 3 Provinces N 6 regions N 30 facilities N
60 120 units N 1000s individuals (5
professional groups health care aides)
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• Aims
• To build KT theory on the role of context in
  influencing knowledge use in long term care (LTC)
  settings and among non-professional care givers
• To pilot innovative KT interventions
• To contribute to enhanced use of knowledge,
  quality improvement, and better resident outcomes
  in LTC

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The three main projects

• Longitudinal profiling
• 3 to 4 waves with ACT (assessing context and KT)
• MDS/interRAI (outcomes)
• Case studies in each province
• 1 comprehensive per province
• 2-3 focused per province
• Rapid cycle audit feedback intervention
• 12 facilities
• 6 quarterly cycles in 18 mo.

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Three pilot projects

• Leadership development
• Care managers
• Supportive supervision
• Registered nurses
• Strategic storytelling
• Health aides

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Additional pilot projects (tentative)

• Physiological stress and the ACT
• Kathy Hegadoren, et al.
• Good days work
• Trish Reay, et al
• Quality of moment
• Anne Marie Boström

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Translating Research in Elder Care

• Current status
• Hiring staff centrally and in each province
• Forming decision making, governance, operating
  structures
• Establish International Scientific Advisory
  Committee
• Pilot testing ACT in LTC
• Pilot testing re MDS/RAI data
• Pilot testing AF intervention
• Three planned intervention pilots launch fall
  2007
• Project 1 data collection begins April 2008
• Project 2 data collection begins Jan. 2008

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Constructs in the Alberta Context Tool (ACT)

• Context as per PARIHS
• Leadership
• Culture
• Evaluation
• Context
• System resources
• Information transfer mechanisms (ITMs)
• Context
• Social capital
• Organizational slack
• Research Utilization (4 items, with definitions
  examples)
• Instrumental, conceptual, persuasive (symbolic),
  overall/general
• Demographic profile

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• Additional concepts in ACT
• Facilitation (constant)
• Added depending on setting and study objectives
• SF-8
• Burnout (MBI-GS) (9 items) Maslach Leiter
• Work violence Index (WVI) Estabrooks Duncan
• Conditions of work effectiveness (CWEQ-II)
  Laschinger
• Environmental complexity scale (ECS)
  OBrien-Pallas

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Pilot testing the ACT

• Pilot study out of the field in 4 teaching
  hospital study (AKUTE), currently being analyzed
  early results very promising (used online
  paper)
• Pilot study data collection currently ongoing in
  pediatric units (online completion 20 min.)
• Feasibility testing completed in LTC (with health
  care aides)
• LTC pilot study begins Sept 2007 (paper and
  pencil format)

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www.ualberta.ca/kusp