Re-Framing the knowledge to action challenge through NIHR knowledge mobilisation research fellows. Comment on “CIHR Health System Impact Fellows: Reflections on ‘Driving Change’ Within the Health System"

The ambition of the Canadian Institutes for Health Research (CIHR) Health Service Impact (HIS) Fellowship initiative to modernise the health system is impressive. Embedded researchers who work between academia and non-academic settings offer an opportunity to reframe the problem of evidence uptake as a product of a gap between those who produce knowledge and those who use it. As such, there has been an increasing interest in the potential of people in embedded research roles to work with stakeholders in the co-production of knowledge to address service challenges. In this commentary, we draw on research and experiential evidence of an embedded researcher initiative, which has similar intentions to the HIS Fellowships programme: the National Institute for Health Research (NIHR) Knowledge Mobilisation Research Fellowship (KMRF) scheme. We outline the similarities and differences between the two schemes, and then consider the work, characteristics and skills, and organisational arrangements evident in operationalising these types of roles

From Linear to Complicated to Complex Comment on "Using Complexity and Network Concepts to Inform Healthcare Knowledge Translation"

Attention to collaborative approaches to encouraging evidence use in healthcare practice are gaining traction. The inherent complexities in collaborative and networked approaches to knowledge translation (KT) have been embraced by Kitson and colleagues in their complexity network model. In this commentary, the potential of complexity as presented by Kitson et al within their model is considered. The utility of such a model will be contingent upon how easy users find it to understand and apply to their challenge, and doing so in a way that is useful to not only help with explanation, but also with prediction

Optimising the conceptualisation of context; comment on "Stakeholder Perspectives of Attributes and Features of Context Relevant to Knowledge Translation in Health Settings: A Multi-Country Analysis"

Context matters. Therefore, efforts to develop greater conceptual clarity are important for science and practice. In this commentary, we outline some key issues that were prompted by Squire’s et al.’s contribution. Specifically, we reinforce context as an interactive concept and therefore something that is hard to ‘pin down’, the problematic nature of conceptualising context in implementation and de-implementation, and a requirement for the development of culturally sensitive understandings. Finally, we suggest it is vital that continued investment into providing a more comprehensive list of determinants needs to be accompanied by an equal effort in developing practical methods and tools to support use and application

It’s more complicated than that Comment on “Translating evidence into healthcare policy and practice: single versus multi-faceted implementation strategies – is there a simple answer to a complex question?”

In this commentary the findings from a systematic review that concluded there is no compelling evidence to suggest that implementing complicated, multi-faceted interventions is more effective than simple, single component interventions to changing healthcare professional’s behaviour are considered through the lens of Harvey and Kitson’s editorial. Whilst an appealing conclusion, it is one that hides a myriad of complexities. These include issues concerning how best to tailor interventions and how best to evaluate such efforts. These are complex issues that do not have simple solutions

From knowing to doing—from the academy to practice Comment on “The many meanings of evidence: implications for the translational science agenda in healthcare”

In this commentary, the idea of closing the gap between knowing and doing through closing the gap between academics and practitioners is explored. The two communities approach to knowledge production and use, has predominated within healthcare, resulting in a separation between the worlds of research and practice, and, therefore, between its producers and users. Meaningful collaborations between the producers and users of research could in theory, create the conditions for more situated knowledge production and use, and result in a potential reduction in the evidence-practice divide within a health service context

From Linear to Complicated to Complex Comment on “Using Complexity and Network Concepts to Inform Healthcare Knowledge Translation”

Abstract Attention to collaborative approaches to encouraging evidence use in healthcare practice are gaining traction. The inherent complexities in collaborative and networked approaches to knowledge translation (KT) have been embraced by Kitson and colleagues in their complexity network model. In this commentary, the potential of complexity as presented by Kitson et al within their model is considered. The utility of such a model will be contingent upon how easy users find it to understand and apply to their challenge, and doing so in a way that is useful to not only help with explanation, but also with prediction

A realistic evaluation : the case of protocol-based care

Background 'Protocol based care' was envisioned by policy makers as a mechanism for delivering on the service improvement agenda in England. Realistic evaluation is an increasingly popular approach, but few published examples exist, particularly in implementation research. To fill this gap, within this paper we describe the application of a realistic evaluation approach to the study of protocol-based care, whilst sharing findings of relevance about standardising care through the use of protocols, guidelines, and pathways. Methods Situated between positivism and relativism, realistic evaluation is concerned with the identification of underlying causal mechanisms, how they work, and under what conditions. Fundamentally it focuses attention on finding out what works, for whom, how, and in what circumstances. Results In this research, we were interested in understanding the relationships between the type and nature of particular approaches to protocol-based care (mechanisms), within different clinical settings (context), and what impacts this resulted in (outcomes). An evidence review using the principles of realist synthesis resulted in a number of propositions, i.e., context, mechanism, and outcome threads (CMOs). These propositions were then 'tested' through multiple case studies, using multiple methods including non-participant observation, interviews, and document analysis through an iterative analysis process. The initial propositions (conjectured CMOs) only partially corresponded to the findings that emerged during analysis. From the iterative analysis process of scrutinising mechanisms, context, and outcomes we were able to draw out some theoretically generalisable features about what works, for whom, how, and what circumstances in relation to the use of standardised care approaches (refined CMOs). Conclusions As one of the first studies to apply realistic evaluation in implementation research, it was a good fit, particularly given the growing emphasis on understanding how context influences evidence-based practice. The strengths and limitations of the approach are considered, including how to operationalise it and some of the challenges. This approach provided a useful interpretive framework with which to make sense of the multiple factors that were simultaneously at play and being observed through various data sources, and for developing explanatory theory about using standardised care approaches in practice

An Untapped Resource: Patient and Public Involvement in Implementation Comment on “Knowledge Mobilization in Healthcare Organizations: A View From the Resource-Based View of the Firm”

This commentary considers the potential role of patient and public involvement in implementation. Developing an analytical thread from the resource-based view of the Firm, we argue that this involvement may create unique resources that have the capacity to enhance the impact of implementation activity for healthcare organisations

Resource based view of the firm as a theoretical lens on the organisational consequences of quality improvement

Evaluating the investment that healthcare organisations make in quality improvement requires knowledge of impact at multiple levels, including patient care, workforce and other organisational resources. The degree to which these resources help organisations to survive and thrive in the challenging contexts in which healthcare is designed and delivered is unknown. Investigating this question from the perspective of the Resource Based View (RBV) of the Firm may provide insights, although is not without challenge

A case study evaluation of implementation of a care pathway to support normal birth in one English birth centre: anticipated benefits and unintended consequences

Background: The policy drive for the UK National Health Service (NHS) has focused on the need for high quality services informed by evidence of best practice. The introduction of care pathways and protocols to standardise care and support implementation of evidence into practice has taken place across the NHS with limited evaluation of their impact. A multi-site case study evaluation was undertaken to assess the impact of use of care pathways and protocols on clinicians, service users and service delivery. One of the five sites was a midwifery-led Birth Centre, where an adapted version of the All Wales Clinical Pathway for Normal Birth had been implemented. Methods: The overarching framework was realistic evaluation. A case study design enabled the capture of data on use of the pathway in the clinical setting, use of multiple methods of data collection and opportunity to study and understand the experiences of clinicians and service users whose care was informed by the pathway. Women attending the Birth Centre were recruited at their 36 week antenatal visit. Episodes of care during labour were observed, following which the woman and the midwife who cared for her were interviewed about use of the pathway. Interviews were also held with other key stakeholders from the study site. Qualitative data were content analysed. Results: Observations were undertaken of four women during labour. Eighteen interviews were conducted with clinicians and women, including the women whose care was observed and the midwives who cared for them, senior midwifery managers and obstetricians. The implementation of the pathway resulted in a number of anticipated benefits, including increased midwifery confidence in skills to support normal birth and promotion of team working. There were also unintended consequences, including concerns about a lack of documentation of labour care and negative impact on working relationships with obstetric and other midwifery colleagues. Women were unaware their care was informed by a care pathway. Conclusion: Care pathways are complex interventions which generate a number of consequences for practice. Those considering introduction of pathways need to ensure all relevant stakeholders are engaged with this and develop robust evaluation strategies to accompany implementation