Knowledge Translation

 

1. Unit Introduction

This unit will:

1. Examine knowledge translation from a transdisciplinary perspective
2. Highlight three key factors in knowledge translation – evidence, context, and facilitation – and how they relate to the complexity of addiction research
3. Illustrate these concepts using examples of knowledge translation from system change initiatives in British Columbia’s mental health and substance use services

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2. What is Knowledge Translation?

Knowledge translation involves applying research on substance use and addiction to practice and policy. Knowledge translation has changed dramatically over the past two decades.

• Traditionally, academic approaches to knowledge translation might have involved writing a paper for a peer-reviewed journal or presenting research findings at a conference or seminar for a particular audience such as addiction researchers or physicians or drug users.
• Other approaches to knowledge translation have included systematic reviews (such as the Cochrane Collaboration) or summaries for a general audience such as a pamphlet or magazine article.
• Technology has enabled knowledge translation activities to expand considerably. The internet and other digital technology have allowed researchers to share, teach, and implement their research in collaboration with individuals and organizations through social media (such as Facebook, Twitter, Instagram), online blogs and newsletters, data visualization tools and infographics, photography, apps, online learning tools, and virtual communities and networks.

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2.1 Knowledge Translation and Transdisciplinarity

Knowledge translation is always challenging.

• It has to consider both content and process.
• It has to engage with a range of audiences and modes of learning and sharing.
• It has to think about how to be effective in affecting a range of outcomes, whether in research, treatment, policy or a program area.

Transdisciplinarity adds to these challenges.

• Not only have knowledge translation activities changed over the past two decades, so has our understanding about knowledge translation itself.
• The research literature on knowledge translation has documented multiple shifts in knowledge translation’s scope: from a one way process of bringing evidence into practice and policy, to multidirectional processes, involving multi-holders of multi forms of knowledge.
• The research content we have to share is more developed as it reflects multiple disciplinary inputs. At the same time, as we think about various knowledge translation activities, we need to balance addressing and tailoring our work to multiple audiences who have different perspectives and still representing transdisciplinarity in our overall message.

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3. Evidence, Context, and Facilitation

There are many different frameworks for conceptualizing knowledge translation. These frameworks can be a useful and practical tool for researchers in framing their work and possible knowledge translation activities.
The PARiHS (Promoting Action on Research Implementation in Health Services) framework suggest that knowledge translation is a function of three factors:

1. the nature of the evidence to be shared and applied
2. the qualities of the context of implementation
3. the approach to facilitation of the involvement of knowledge users.

Effective knowledge translation of transdisciplinary content in addiction requires balancing all of these factors.

1. We have to consider multiple forms of evidence.
2. We have to meaningfully factor in multiple contexts for application to practice and policy.
3. We have to be skilled in engaging multiple sectors and facilitating knowledge sharing and learning through a variety of formats and processes.

Image via National Library of Medicine, open access, http://openi.nlm.nih.gov/imgs/512/66/3068117/3068117_1748-5908-6-20-1.png

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3.1 Evidence, transdisciplinarity and knowledge translation

• Different disciplines value different forms of evidence.
• A major challenge in creating a form of knowledge translation that is truly transdisciplinary is to not only include multiple forms of research from multiple disciplines but also to combine research evidence with other sources of evidence.
• Rycroft-Malone and colleagues (2004) have proposed 4 types of evidence which include: research, knowledge from clinical practice, personal knowledge and experience of patients, and data from the local context
• Considering the nature of what counts as evidence is important for all knowledge translation. It’s especially important in fields like addiction where how an issue is problematized and prioritized can be highly polarized.

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3.2 Evidence

“Our problem is that we still tend to see evidence as a product, a commodity, a thing that can be put into a system. Indeed evidence is a complex construction of facts, propositions, experiences, biographies and histories and ultimately an exercise of judgement bounded by time and context.” (Kitson, 2008)

• Traditionally it has been assumed that research evidence from the quantitative tradition has been the form of evidence that has qualified as evidence. The randomized control trial has been pre-eminently valued, with a concomitant undervaluing and neglect of other forms of evidence.
• The importance of identifying tacit practice knowledge, and considering clinical and policy wisdom as evidence is now being discussed. Pang (2007, p.247) has described how important it is in global application of evidence to rely not only on RCTs but also on observational studies, qualitative research and even “experience”, “know-how”, consensus and “local knowledge”.
• To generate solutions in the modern context, knowledge is required from many fields, and work is needed at the boundaries of many disciplines (Nowotny 2006, Carlile 2004).
• Nutley and colleagues (2007) discuss not only the direct use of research to make decisions (instrumental use of research) but indirect or conceptual use of research that reshapes thinking around policy and practice problems or plays “a more ‘consciousness-raising role’” (p. 2). In conceptual research use, the focus is not only to convey research findings, but instead to promote the assimilation of research ideas, theories and concepts into discourse and debates. This conceptual use of research, in a paradigm-challenging approach is highly relevant to the task of bringing sex-and gender-based analysis and action to substance use policy and practice.

Figure: Evidence should include multiple forms of knowledge from different sources

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3.3 Example: Evidence and the Movement towards Trauma-Informed Practice Trauma-Informed Practice Guidelines

This guide was developed in consultation with researchers, practitioners and health system planners across British Columbia working in mental health and substance use services. It is grounded in evidence from research, policy, and clinical practice, with the goal of advancing the integration of trauma-informed practice at all levels: in individual practice, in organizations, and across systems.

It draws upon multiple forms of knowledge and evidence:

• An academic literature review of the growing body of evidence on the nature and impact of trauma
• Reports and manuals developed by mental health and addiction practitioners from housing, child services, and related health care services describing their work implementing trauma-informed practice (this are a limited number of studies on this in the academic literature)
• In focus groups and interviews, BC practitioners, researchers, and system planners described the work they were already doing to address the needs of clients with trauma concerns. In particular they provided local data and context for the diverse experiences of trauma affecting Aboriginal people, men and boys, girls and women, gay, lesbian, bisexual and transgendered people, veterans, refugees, and people with injuries and disabilities.

All of this information was distilled into four principles that became the foundation for implementing policy and practice change related to trauma-informed practice within the context of mental health and addiction services.

The four principles are:

1. Trauma awareness
2. Safety and trustworthiness
3. Choice, collaboration, and Connection
4. Strengths based and skill building

The guide can be downloaded from http://bccewh.bc.ca/wp-content/uploads/2012/05/2013_TIP-Guide.pdf

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4. Context, transdisciplinarity and knowledge translation

The context for knowledge translation in addiction can be particularly challenging as there are a range of co-existing views on substance use and addiction. Addiction can be seen as a disease, as a mental health disorder, as a brain disorder and as a public health issue simultaneously. This can affect the openness of individuals, organizations and systems to the use of different types of evidence, to incorporating new perspectives and types of analysis (such as sex and gender based analysis), and the ability to change in response to new knowledge.

The public health view of addiction, recently put forth by some governments, might be the view with the most potential for transdisciplinary knowledge building. In the public health view, attention is brought to how determinants of health such as gender, violence, income, genetics, social support and health services all combine to affect the health and substance use of individuals and communities.

Transdisciplinarity can address these problems of context in a range of ways.

• We can create opportunities related to traversing disciplinary boundaries and paradigms and identify the challenges in doing so.
• We can consider the needs of individual practitioners and professional groups as recipients and implementers of knowledge and the barriers to implementation with these audiences. Factors such as knowledge user time, professional affiliation, agency interests and ideological environment.
• While individuals in different paradigms of addiction may talk past each other, transdisciplinary involvement can lead to the development of a new common language.

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4.1 Example: Two-eyed Seeing as a Model for Transdisciplinary Knowledge Building

One promising area for transdisciplinary knowledge translation in addiction is in the area of indigenous health and well-being. The “Two-Eyed Seeing” lens developed by Mi’kmaq Elders Murdena and Albert Marshall is one way to conceptualize how to integrate and connect the best of Indigenous and Western knowledge systems. Two-eyed Seeing encourages us to learn to see from one eye with the strengths of Indigenous knowledges and ways of knowing, and learn to see from the other eye with the strengths of Western knowledges and ways of knowing … and that we learn to use both these eyes together, for the benefit of all.
For definition, learning activities and other resources on two-eyed seeing (including a handout on “TRANSDISCIPLINARY RESEARCH THEORY AND BEST PRACTICES – Integrative Science and Two-Eyed Seeing”) see: http://www.integrativescience.ca/Activities/

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4.2 Example: Two-eyed Seeing and the Movement towards Trauma-Informed Practice

Indigenous Cultural Competency Training and Trauma-Informed Practice in British Columbia’s Mental Health and Substance Use Services

In British Columbia, the Provincial Health Services Authority has developed an on-line Indigenous Cultural Competency Training Program for people working with the health authorities in British Columbia. The training promotes a culturally competent view of historical trauma that can assist service providers in building self-awareness and skills in this area.

• The movement towards trauma-informed practice within mental health and substance use services is building upon this work and creating ethical space for the linking of Indigenous and western knowledge paradigms.
• Trauma-informed practice includes a recognition of trauma caused by colonization & racism, historical trauma (Indian Residential Schools, Indian Hospitals, 60’s scoop), and intergenerational trauma.
• As such, the trauma-informed practice initiative is able to build upon existing work related to increasing cultural safety. It provides an opportunity to hold challenging conversations about colonization, oppression, intergenerational trauma, and racism. Because the language of trauma-informed practice (e.g., principles of collaboration, safety, trustworthiness) is aligned with indigenous values and beliefs, there is growing support within Aboriginal communities for trauma-informed practice.
• See: www.culturalcompetency.ca

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4.3 Example: Two-Eyed Seeing, Trauma-informed Practice and Motivational Interviewing

Motivational interviewing is an evidence-based communication style shown to improve engagement, retention, and treatment outcomes and very common within the addiction field.

• Connects with indigenous approaches to addiction
• Connects with trauma-informed practice
• Across many program areas within the BC mental health and substance use system, practitioners have made use of motivational interviewing approaches.
• The research evidence for motivational interviewing is strong. Many individuals working from a ‘trauma-informed practice’ perspective have adapted motivational interviewing as it fills an evidence gap in the field while also aligning with many principles of trauma-informed practice such as collaboration, and respect for autonomy and empowerment.
• Motivational interviewing also aligns with many indigenous approaches to addiction. And, because motivational interviewing has widespread support and is familiar to many non-indigenous practitioners in the addiction field, it can provide a ‘port-of-entry’ or common language for transdisciplinary approaches to addiction.
• See: Native American Motivational Interviewing: Weaving Native American and Western Practices

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5. Facilitation, transdisciplinarity and knowledge translation

Facilitation is required to engage fully with evidence and to the understanding of context in knowledge translation.

• Facilitation means finding processes that engage knowledge users in learning about, synthesizing and applying the evidence to their specific context in a way that is linked to system wide efforts.
• Knowledge users have diverse agendas, time frames, cultures, and sources of knowledge they consider legitimate. Transdisciplinary researchers have to facilitate intersectoral or interdisciplinary processes, promote multi-sectoral participation, prevent oversimplication, and support a ‘whole systems’ view.
• This process can be conceptualized in a number of ways:
  • “The research-to-practice pipeline” captures many of the barriers and facilitators adopting new knowledge. Newer models provide more nuanced views of the processes of dialogue, synthesis, co-construction of knowledge, co-learning, reflection, integration, and collaboration.
• What these processes look like can vary enormously.
  • They may be integrated into the research process as in the case of feminist participatory action research methodologies with their focus on inclusion, participation, action, change and reflexivity. They might capitalize on informal learning such as ‘water cooler chats’ in treatment organizations or organizational ‘champions’ who share resources and new information through posters, pamphlets, and regular staff meetings. They might involve formal networks such as communities of practice that meet regularly in-person or virtually

The research-to-practice pipeline (Glasziou and Haynes, 2005)

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5.1 Example: Discussion Guides as a mechanism for facilitation

• Discussion guides can be a tool for facilitating practice change amongst mental health and substance use professionals.
• This discussion guide on principles of trauma-informed practice was developed in response to a request from program managers who were using regular staff meetings as a space for reflection on what aspects of trauma-informed practice were going well in their program and areas for change.

 

 

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5.2 Example: Virtual communities as locations that support facilitation

• Bringing people from different disciplines and/or sectors together in short term virtual communities can support discussion and co-synthesis of evidence, and catalyse action to change practice and policy.
• Communities of practice are “groups of people who share a concern, a set of problems, or a passion about a topic, and who deepen their knowledge and expertise in this area by interacting on an ongoing basis.” (Wenger, McDermott, and Snyder 2002)
• Communities of practice, face-to-face or virtual, bring people from different disciplines and/or sectors together to support discussion and co-synthesis of evidence, and catalyse action to change practice and policy.
• Such facilitated processes can support sex- and gender- based analysis
• “Gendering the National Framework” was a virtual community of practice that brought a sex/gender and diversity-based analysis to the National Framework for Action to Reduce the Harms Associated with Alcohol and Other Drugs and Substances in Canada. Through a facilitated process, participants (many of whom were service providers in the addiction field) were able to examine resistance to applying sex-, gender-, and diversity-based analysis in their particular field; to examine mainstreaming gender-based responses; and to offer descriptions of gender-specific programming in their settings.
• see: Poole, Nancy. 2011. “Boundary Spanning: Knowledge Translation as Feminist Action Research in Virtual Communities of Practice.” In Designing and Conducting Gender, Sex, and Health Research edited by John Oliffe and Lorraine Greaves, 215-226. Los Angeles: SAGE Publications.

 

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5.3 Example: Organizational checklists/assessment as a mechanism for facilitation

• Implementing trauma-informed practice requires a shift in organizational culture for many organizations and programs.
• The culture of an organization reflects what is considered important and unimportant, how it understands the people it serves, and how it puts these understandings into daily practice.
• BC Mental Health and Substance Use Services Checklist
  1. Administration
  2. Hiring Practices
  3. Training for Staff
  4. Support and Supervision of Staff
  5. Assessment and Intake
  6. Policies and Procedures
  7. Monitoring and Evaluation
  8. Overall Policy and Program Mandate
• This Organizational Checklist was developed and revised through consultation with people working in the mental health and substance use field throughout British Columbia. It is a tool that organizations can use as a guideline for the implementation of trauma-informed practice.
• The checklist can be completed by program administrators, program evaluators, and staff to evaluate or direct the implementation of trauma-informed principles, as well as to identify areas for improving services offered by the organization or program. The checklist addresses both service-level and administrative or system-level changes.
• Importantly, the checklist had the endorsement of leadership at all levels of the British Columbia mental health and substance use system of care.

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6. Knowledge Translation and System Change: Getting Started

• There area a number of existing knowledge translation planning tools for researchers. Ideally, knowledge translation is incorporated into the overall research plan and factors such as the needs of the knowledge users or who the knowledge users might be for a particular area of research are considered.
• Transdisciplinary researchers can benefit from examining the breadth of knowledge translation approaches across disciplines and which ones are the most successful in encouraging uptake of new knowledge. It is likely that transdisciplinary researchers will have to use multiple approaches to knowledge translation or pilot innovative or creative approaches to knowledge translation.

National Collaborating Centre for Methods and Tools (2012). Knowledge translation planning tool. Hamilton, ON: McMaster University. (Updated 20 November, 2013). Retrieved from http://www.nccmt.ca/registry/view/eng/131.html. Melanie Barwick, Suzanne Ross, Paula Goering, Nora Jacobson, Dale Butterill

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6.1. Discussion Questions: Getting Started

Evidence:

• What is the evidence we have to share?
• How does it fit in with previously known evidence?

Context:

• We are inserting our research into a context that is not neutral. What contextual factors do you need to be aware of? Describe the context into which you will be adding your research.

Facilitation:

• Involvement of knowledge users is key. How do we facilitate it? What tools will help?

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7. Unit Summary

• Addiction research is complex. Our knowledge translation approaches must reflect the nature of our research.
• Three factors to consider:
  1. Evidence – must recognize how the evidence we want to share fits into a larger transdisciplinary frame
  2. Context – must allocate extensive effort to understanding the context in which we are inserting our piece – it can be messy, political, often gender-blind and crowded
  3. Facilitation – must facilitate understanding, adaptation and use of our evidence, not just drop it in the context

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8. Unit References

Bammer, Gabriele. 2005. Integration and implementation sciences: Building a new specialization.Ecology & Society no. 10 (2):78-103.

Carlile, P. R. (2004). Transferring, translating, and transforming: An integrative framework for managing knowledge across boundaries. Organization Science, 15(5), 555-568.

Contandriopoulos, Damien. 2011. On the nature and strategies of organized interests in health care policy making. Administration & Society 43 (1):45-65.

Dopson, Sue, and Louise Fitzgerald. 2005. Knowledge to Action? Evidence-Based Health Care in Context. New York Oxford University Press.

Glasziou, Paul and Haynes, Brian. 2005. The paths from research to improved health outcomes. Evidence Based Medicine.” no. 10:4-7.

Harvey, G., A. Loftus-Hills, J Rycroft-Malone, A. Titchen, Alison L. Kitson, and B. McCormack. 2002. “Getting evidence into practice: the role and function of facilitation.” Journal of Advanced Nursing no. 37 (6):577 – 588.

Helfrich, C. D., Damschroder, L. J., Hagedorn, H. J., Daggett, G. S., Sahay, A., Ritchie, M., . . . Stetler, C. B. (2010). A critical synthesis of literature on the promoting action on research implementation in health services (PARIHS) framework. Implementation Science, 5(82), 20.

Jacobson, N., Butterill, D., & Goering, P. (2003). Development of a framework for knowledge translation: understanding user context. Journal of Health Services Research & Policy, 8(2), 94-99.

Kitson, Alison L. 2008. The uncertainty and incongruity of evidence-based healthcare International Journal of Evidence-Based Healthcare no. 6 (1):1-2.

———. 2009a. Knowledge translation and guidelines: A transfer, translation or transformation process?International Journal of Evidence-Based Healthcare no. 7 (2):124-139.

———. 2009b. The need for systems change: Reflections on knowledge translation and organizational change. Journal of Advanced Nursing no. 65 (1):217-228.

Kitson, Alison L., J. Harvey, and B. McCormack. 1998. Enabling the implementation of evidence-based practice: A conceptual framework. Quality in Health Care no. 7:149 – 158.

Legare, France. 2009. Assessing barriers and facilitators to knowledge use. In Knowledge Translation in Health Care: Moving from Evidence to Practice edited by Sharon E. Straus, Jacqueline Tetroe and Ian D. Graham, 83-93. Chichester, UK: Blackwell-Wiley

Nowotny, H., Scott, P., & Gibbons, M. (2001). Re-Thinking Science: Knowledge and the Public in an Age of Uncertainty. London: Polity Press.

Nutley, S. M., Walter, I., & Davies, H. T. O. (2007). Using Evidence: How Research can Inform Public Services. Bristol, UK: The Policy Press.

Pang, T. (2007). Evidence to action in the developing world: What evidence is needed? Bulletin of The World Health Organization, 85(4), 247.

Poole, N. 2011. Boundary Spanning: Knowledge Translation as Feminist Action Research in Virtual Communities of Practice. In Designing and Conducting Gender, Sex, and Health Research edited by John Oliffe and Lorraine Greaves, 215-226. Los Angeles: SAGE Publications.

Poole, N and Greaves, L. 2015. “Enlarging Knowledge Translation to Reflect Transdisciplinarity.” In Transforming Addiction: Gender, Trauma and Transdisciplinarity, edited by L. Greaves, N. Poole & E.Boyle, 203-215. New York: Routledge.

Miller, W.R. and S. Rollnick. 2002. Motivational Interviewing: Preparing People for Change 2ed. New York, NY: The Guilford Press

Rycroft-Malone, J, Gill Harvey, Kate Seers, Alison L. Kitson, Brendan McCormack, and Angie Titchen. 2004. An exploration of the factors that influence the implementation of evidence into practice. Journal of Clinical Nursing no. 13 (8):913-924.

Urquhart, C., & Jasiura, F. 2012. Collaborative Change Conversations: Integrating Trauma-Informed Care and Motivational Interviewing with Women.In N. Poole & L. Greaves (Eds.), Becoming Trauma Informed, 59-70. Toronto, ON: Centre for Addiction and Mental Health.

Thompson, David S., Kathy O’Leary, Eva Jensen, Shannon Scott-Findlay, Linda O’Brien-Pallas, and Carole A. Estabrooks. 2008. The relationship between busyness and research utilization: It is about time. Journal of Clinical Nursing no. 17 (4):539-548.

Wenger, Etienne, Richard McDermott, and William C. Snyder. 2002. Cultivating Communities of Practice: A Guide to Managing Knowledge. Boston, MA: Harvard Business School.