Overview

Knowledge exchange (also known as knowledge transfer) involves using research findings to inform clinical practice. The reason knowledge exchange is needed is a substantial amount of time and money is invested by health and social services across the world in generating research knowledge but this knowledge is not always transferred into practice which means the benefits for patients are lost. Knowledge exchange is achieved through collaboration, interaction and using a problem-solving process; all skills occupational therapists use on a daily basis. The key message is that in knowledge exchange interactive rather than passive approaches are needed to achieve change. This process should be facilitated by a knowledge broker.

The principles of change management can be used to support this process (Bryar and Bannigan 2003). The literature on knowledge exchange in occupational therapy is limited but there are examples of it happening.

We live in a knowledge society in which sharing information and collaboration are key survival skills (Knexa 2005). Knowledge transfer is a broad-based approach to sharing information that is reliant on collaboration and so is a growing area of interest. This interest is not confined to the health and social care sector; the literature on knowledge transfer crosses many different disciplines from management to education to nursing (Thompson et al 2006). Universities, for example, are increasingly focusing their attention on knowledge transfer because they recognise its economic and social potential (e.g. Universities Scotland 2006, West Yorkshire Knowledge Exchange 2006). The value of knowledge transfer to those working in health and social care is the improved health and well-being of society (Askew et al 2002, Nuyens and Lansang 2006). There has been some consideration of knowledge transfer in occupational therapy (e.g. Soderback and Frost 1995, Johnson 2005, Loisel et al 2005, MacDermid et al 2006) but the paucity of literature in relation to occupational therapy suggests the concept will be new to many. Although knowledge transfer may be a new concept for many occupational therapists it has a long history (Nuyens and Lansang 2006). It has existed in other guises (for example research utilisation) for a long time (see Caplan and Rich 1975, Weiss 1979 or Brett 1986 for early work on the concept). Whilst knowledge transfer has its roots in research utilisation it is a broader concept that, when used in fields other than health and social care, involves using a wide range of different sources of information, not just research findings.

This chapter will explain what knowledge transfer is, explore why it is relevant to occupational therapists, examine what difference it makes for occupational therapists and their clients in practice, and outline the practical issues that need to be considered in order to determine what occupational therapists can do to facilitate knowledge exchange. Please note that this chapter is an introduction to this topic. There is a lot of literature available, much of which exists outside of occupational therapy, so use the resources suggested (below) to further familiarise yourself with the topic. Whilst it is important to be familiar with the literature, so that we can learn from the experiences of others, you should also not be afraid to just have a go!

What is knowledge transfer?

In health and social care knowledge transfer in the form of research utilisation predates interest in evidence-based practice (see Chapter 14). Research utilisation, i.e. using research findings in practice to improve patient care, is one aspect of evidence-based practice (Bannigan 2004, 2007). That one whole section of a book about skills for practice has focused on evidence-based practice confirms that evidence-based practice is now an accepted part of health and social care practice (Canadian Health Services Research Foundation 2004). The emphasis on evidence-based practice ensures that knowledge transfer in health and social care focuses on ‘research-based knowledge’ as opposed to other sources of information (Canadian Health Services Research Foundation 2004). Evidence-based practice is about clinical decision making in which the decisions made by occupational therapists are made on the basis of patients’ values, clinical expertise, a consideration of resources and the best available research evidence (Dawes et al 2005). It is because evidence-based decisions rely on the use of best available research evidence that, in order to be an evidence-based practitioner, an occupational therapist needs to be able to use research findings in their everyday practice (Eakin et al 1997, Ilott and White 2001, COT 2005). The use of research findings to inform practice is an example of ‘knowledge transfer’, although it would be more accurate to call it research knowledge transfer.

Generally, ‘Knowledge transfer is about exchanging good ideas, research results, experiences and skills between universities, other research organisations, business, government, the public sector and the wider community to enable innovative new products, services and policies to be developed’ (ESRC 2005a). This means knowledge transfer is a broad concept and in its broadest sense can involve the use of good ideas, experiences, skills and research results. However, when the use of the term knowledge transfer is used in health and social care it refers to the use of research findings, i.e. ‘to have knowledge of facts (represented by research results) and to use these facts in their practices, policies and products’ (Lomas 2007: 129). The knowledge used in knowledge transfer in health and social care should be research based because we cannot rely on anecdote or experience. After all, ‘…because patients so often get better on their own, no matter what we do, clinical experience is a poor judge of what does and does not work’ (Doust and Del Mar 2004: 474). Although it is emphasised that we use research-based knowledge, occupational therapists as ‘health professionals do not apply abstract disembodied scientific research rigidly to the situation around them. Instead they collaborate in discussion, relate the evidence to the context, and engage in work practices that actively interpret and (re)construct its local validity and usefulness’ (Dopson and Fitzgerald 2005a: 103). The sorts of activities used in knowledge transfer, include:

The World Health Organization (2004) defines knowledge transfer as translating knowledge into action to improve health, by bridging the gap between what is known and what is actually done. This means knowledge transfer

The Canadian Health Services Research Foundation is a leading organisation in the field of knowledge transfer in health care (International Development Research Centre 2007) and it no longer refers to knowledge transfer but now uses the term ‘knowledge exchange’. It defines knowledge exchange as collaborative problem-solving between researchers and clinical decision makers (such as occupational therapists) that happens through linkage and exchange (Canadian Health Services Research Foundation 2007a). Effective knowledge exchange involves interaction between the people making the clinical decisions on the ground and researchers who are creating knowledge. It results in mutual learning, for both the occupational therapist and the researcher, through the process of planning, producing, disseminating and applying existing or new research in decision-making (Canadian Health Services Research Foundation 2007a). The shift to using the term knowledge exchange is still relatively recent so knowledge transfer is still the most widely used term. It has also been noted that the following terms, knowledge utilisation, knowledge dissemination, knowledge brokering, knowledge transfer and knowledge exchange, are used interchangeably in the literature (International Development Research Centre 2007). The key features of knowledge exchange are that it

This means it requires the use of the key skills that occupational therapists use in their everyday clinical work.

Knowledge exchange involves collaboration

Knowledge exchange is an area of practice where there is a need for practitioners, researchers, educators and managers to work together. Evidence-based practice involves complex clinical decision-making because it does not just focus on research knowledge but patient characteristics, situations and differences (Jones and Santaguida 2005). This means for knowledge exchange to happen researchers need to work with occupational therapists (Johnson 2005); they cannot work in isolation or just publish their research findings assuming that changes in occupational therapy practice will follow. The need for clinicians and researchers to work together was highlighted in the findings from the Nursing Environments: Knowledge To Action (NEKTA) study. It found that ‘In general, the closer participants were to the delivery of care, the less likely they were to have any knowledge of the [research] reports’ (Leiter 2006: 1). The recognition of a need for collaboration between clinicians and researchers arises from a shift in understanding about research and clinical decision making. That is, neither activity is a single event or product and there is a need to acknowledge not only the complexity involved in each activity but that this is increased when research is expected to influence clinical decision making (Bannigan 2004, 2007, Lomas 2007). Hence one way to create more research-informed clinical decisions is to focus on better linkage and exchange between the processes that create the facts (research) and the ones that incorporate the values (clinical decision making) (Lomas 2007). Linkage is achieved through the use of collaboration, i.e. practitioners and researchers working together, which means that it is necessary to take into account the context in which people work (Chunharas 2006, Nuyens and Lansang 2006).

Knowledge exchange is dependent on interaction

Whereas linkage is achieved through collaboration, exchange is achieved through interaction. Lomas (2007) has described ‘…human interaction as the engine that drives research into practice’ (p. 130). The ESRC (2005b) confirmed Lomas’s (2007) analysis in their observation that ‘At its simplest, knowledge transfer is about starting a conversation’ (p. 1). This observation also explains why in Lomas’s (1993) schemata of diffusion, dissemination and implementation (see Box 15.1 for explanation of terms) that diffusion and dissemination are unlikely to result in research use. Communication is a two-way process and both diffusion and dissemination involve only one-way communication, i.e. from researcher to occupational therapist, and so do not necessarily encourage the development of a dialogue. Knowledge exchange, like implementation, is contingent on a dialogue being created between researchers and research users, such as occupational therapists (ESRC 2005b). The importance of interpersonal networks was identified in an ethnographic study by Gabbay and le May (2004) and in a systematic review by Greenhalgh et al (2004). For those trying to facilitate the dialogue needed to achieve knowledge exchange will need to think about how the people involved in change may respond. This is because change is difficult for most people (Bryar and Bannigan 2003). Rogers (2003) identified five types of response to innovations, i.e.

In the light of this analysis any occupational therapists involved in knowledge exchange should try to develop links with early adopters in the first instance.

In interacting with others to facilitate knowledge exchange, as well as thinking about the people involved, it is also important to focus on how the ‘actionable messages’ from research findings are communicated (Organising Committee 2001, Askew et al 2002). It has been noted that ‘In many instances it is possible that the expertise of communicating with [clinical] decision makers is not available within research organisations and therefore researchers may need to use others’ (Askew et al 2002: i). The reality is ‘The research world favours grant acquisition and academic publication over knowledge synthesis and engagement with the health service’ (Lomas 2007: 129). In research grants there may be some support for dissemination plans but this is not always the case. It is often assumed the researcher will disseminate findings because there are a number of career incentives to encourage them to do so. For example, in the UK, the College of Occupational Therapists (2005) code of ethics and professional conduct states ‘Occupational therapy personnel undertaking any form of research activity have an obligation to share their findings in order to inform or change practice, e.g. through publication or presentation’ (p. 17). Usually the dissemination will just be the passive process of presenting and publishing papers. Yet at the very least multiple audience-specific messages are needed (Lavis et al 2003) to achieve knowledge exchange but this can be time-consuming work and so begs the question whose job is it to do this?

As knowledge exchange involves a two-way process of communication it means that all people in the collaboration need to be open to learning from others as well as sharing their ideas and experiences (ESRC 2005a). This is a significant shift in perspective from the idea of knowledge transfer which implies that knowledge transfers from one group to another and that all parties do not necessarily benefit and learn from each other. It also means knowledge exchange brings groups together who would not normally work together, which results in a better understanding of each other’s work (Canadian Health Services Research Foundation 2006, Lomas 2007).

Until recently knowledge exchange has not been anyone’s job (Bannigan 2004). In many ways knowledge exchange has fallen between a rock and hard place; researchers have not been funded to do it (Universities Scotland 2006) and equally there have been disincentives for practitioners to engage in this type of activity due to a lack of reward. This means there has been no incentive for occupational therapists to take responsibility for knowledge exchange. Where practitioners have tried to get involved in knowledge exchange the infrastructure was often not in place and their colleagues were not always receptive to these initiatives. Lately universities have set up Research and Enterprise offices and employed people to support this activity, such as Knowledge Transfer Officers. This is because ‘There is increasing recognition that this aspect of higher education is enormously important and universities are being encouraged to do even more of this kind of activity’ (Universities Scotland 2006). Whilst knowledge exchange has become increasingly important to universities why should occupational therapists get involved? Is knowledge exchange relevant to the work of occupational therapists?

What is the relevance of knowledge exchange to occupational therapists?

There seems to be a broad agreement about the fact that research evidence rarely has a direct impact on clinical decision making (e.g. Thompson et al 2005). The need for knowledge exchange emerged in response to the gap between the publication of research findings and its use by various stakeholders (Schryer-Roy 2005). It has already been observed that a substantial amount of time and money is invested by health and social services across the world in generating research knowledge but, if this knowledge is not transferred into practice, the benefits for patients do not ensue. In blunt terms it means the investment is a waste of money, which is unacceptable in publicly funded services. As such all professionals working in health and social care, including occupational therapists, have to ask some very serious questions as to why we are continuing to produce these reports if in fact they are not being utilised by policy and clinical decision makers (Juzwishin 2001). This implies that an active process is needed if research findings are to be applied to practice because the mere existence of knowledge is insufficient. In physiotherapy Jones and Santaguida (2005) examined current physiotherapy research programmes and found that a considerable number of them were orientated towards benefiting patients. Despite this they also questioned how much impact these programmes of research have on the broader community. They posed the following questions:

In the light of this analysis they observed ‘…that physiotherapists must go beyond a circumscribed focus on physiotherapy treatment or publishing research in peer reviewed journals, and must become more attentive to the many factors which drive the policy process’ (Jones and Santaguida 2005: 15). They also suggested that physiotherapists will only be able to do this “…if they are familiar with the following:

While physiotherapy was the focus of Jones and Santaguida’s (2005) work it is unlikely that the situation will be any different for occupational therapists who also want to improve the patient experience of and outcomes of their interventions. This means knowledge exchange is as pressing an issue for occupational therapists as it is for physiotherapists.

What difference does knowledge exchange make to occupational therapists and their clients in practice?

Although knowledge exchange as a concept has had limited attention in occupational therapy it does happen (see Vignettes 15.1-15.3). These examples reflect the work of some tenacious researchers in occupational therapy rather than the existence of any formal knowledge exchange processes. In these vignettes it is clear how research-based knowledge can improve patient experience and/or outcomes of occupational therapy interventions.

The practical issues involved in facilitating knowledge exchange in occupational therapy

To continue to overcome the gaps between publication of research findings and practice practitioners generally need to familiarise themselves with the literature on facilitating knowledge exchange. The difficulty of bringing about change should not be underestimated (Bryar and Bannigan 2003, Dopson et al 2005). The bottom line is there is no guaranteed method of knowledge exchange because of the range of factors that impact on it (Jones and Santaguida 2005). There is wide agreement that passive processes are ineffective and this message has been a consistent over time (Caplan and Rich 1975, Lomas 1991, NHS CRD 1999). The most precise knowledge we have is that interactive engagement (i.e. interpersonal contact) is effective in achieving knowledge exchange (Lavis et al 2003, Thompson et al 2006). The lessons from previous research or evaluations, such as the NEKTA study (Leiter 2006), provide useful insights into the likely challenges. For example the barriers experienced in the NEKTA study were:

The likelihood of success was increased by:

Therefore practitioners should avoid didactic methods and use the findings from studies, such as the NEKTA study (Leiter 2006), to identify and eliminate barriers and repeat the techniques that contributed to successful knowledge exchange. However, it is important that no one study is assumed to be definitive. The change management literature can also be used to support this process (Bryar and Bannigan 2003) because it is likely to involve changes in behaviour and/or systems. It is important to note that, ‘Evidence based healthcare is likely to be imperfectly implemented through uniform approaches within such highly complex and variable settings characteristic of healthcare’ (Dopson and Fitzgerald 2005b: 3).

Rogers (2003) proposed a five-stage model for the diffusion of innovations (see Box 15.2) that may be useful for shaping thinking about knowledge exchange in occupational therapy. Again it is important to recognise the model for what it is, i.e. a theoretical model, and not fall into the trap of assuming it is an authoritative method or that it is a rationalistic process (Fitzgerald and Dopson 2005). Even if the model is used to shape thinking there are no precise procedures for each stage. For example in relation to stage one, knowledge (Box 15.2), ‘the research literature does not explain how to select the target audience(s) for a message, only that once a target audience is identified, the specific knowledge-transfer strategy should be fine-tuned to the types of decisions clinical decision makers face and the decision making environments in which they live or work’ (Lavis et al 2003: 225). A range of sources should be drawn upon (for example Ebener et al 2006, Nuyens and Lansang 2006, Tugwell et al 2006) because there is no one best way to proceed (Fitzgerald and Dopson 2005).

A new role, the knowledge broker, has emerged out of the need for knowledge exchange (Lomas 2007). It has already been highlighted that ‘The traditional outputs of research projects, such as final reports and peer reviewed papers, are often inaccessible to the key decision makers, either due to constraints in accessing them or the language in which they are written’ (Askew et al 2002: i). In the light of this Askew et al (2002) suggested the need for mediators between information providers and clinical decision makers. Knowledge brokers link ‘…researchers and decision makers, facilitating their interaction so that they are able to better understand each other’s goals and professional cultures, influence each other’s work, forge new partnerships, and promote the use of research-based evidence in decision-making’ (Canadian Health Services Research Foundation 2007a). Knowledge brokering activities include:

As with research utilisation knowledge brokering is not a new concept (Lomas 2007) but it has not been widely used in a health and social care context until recently. This means there is a scarcity of literature about the role of knowledge broker per se. There are other roles that can be identified in the literature, i.e. opinion leader, facilitator, champion, linking agent and change agent, that provide some indication of what is involved in the role of knowledge broker (Thompson et al 2006).

Ultimately knowledge brokering in health and social care is about increasing the evidence-based decision-making, management and delivery of services in an organisation (Canadian Health Services Research Foundation 2007b). Knowledge brokering can be individually or structurally focused but either way knowledge exchange is achieved through the use of interaction which means it requires a knowledge broker to have a wide range of interpersonal skills (Lomas 2007). ‘Knowledge brokering uses a portfolio of resources to make health services research and decision making more accessible to each other’ (Lomas 2007: 131). The attributes and skills needed are:

In some countries there are knowledge-brokering services (see Box 15.3). Lomas (2007) is keen to point out that knowledge brokering is not a panacea. While knowledge brokers have a role to play essentially all stakeholders have an obligation to facilitate knowledge exchange and strategies should be developed to accomplish this (Nuyens and Lansang 2006).

Whilst a knowledge broker can be an external facilitator or even be contracted from a specific knowledge-brokering service (Box 15.3) the majority of knowledge brokers that practitioners will come across will be individual occupational therapists who adopt this role as, for example, an opinion leader or facilitators (see Box 15.4), with their organisation or geographical area. Sometimes people will work together, e.g. facilitators and opinion leaders, to increase the effectiveness of a change project (Thompson et al 2006). Ideally knowledge exchange relies on researchers and clinical occupational therapists working together. Although some occupational therapy researchers have been identified who have engaged in knowledge exchange (see Vignettes 15.1-15.3) Stryer et al (2000) found that researchers have not perceived knowledge exchange as part of their role. Whilst knowledge exchange should be fundamental to research work (ESRC 2005a) it is time consuming (Lavis et al 2003). In the light of this researchers should consider working with knowledge brokers, this may be an external agency or a clinician who has adopted the role (Box 15.4). There is also a need for researchers to lobby for the inclusion of knowledge exchange in the research process so that funding for this work is secured; the use of knowledge brokers has cost implications (Bannigan 2004, Nuyens and Lansang 2006).

Summary

Knowledge exchange is an important process for improving patient care that requires more attention from occupational therapists. It necessitates recognition that knowledge exchange is as much a social process as a technical process. There is a general trend towards increased interactions between researchers and users, and knowledge exchange strategies increasingly incorporate active processes, interaction and a consideration of context. Every opportunity for knowledge exchange should be approached on its merits. Lessons learnt from previous research and evaluations, as well as other resources, can inform this work. The only certainty is that interactive rather than passive approaches are effective in facilitating knowledge exchange. However the words of Johann Wolfgang von Goethe aptly summates the challenge of knowledge exchange for occupational therapists, ‘Knowing is not enough, we must apply; willing is not enough, we must act’.