September 20, 2020

CP Online Health

Eat Well, Life Well

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