Knowledge translation: Future steps for the MACP?
Recently I have had the honour to take on the position of knowledge translation officer as part of the MACP executive committee. I was given permission to shape this role in any which way I chose.
So, I thought long and hard in respect to what knowledge translation is and what it might become. I also considered the key priorities of the MACP and its important role in the development of musculoskeletal practice in the UK across professional boundaries. Its key strategic goals include engaging with and positively influencing advanced practice and MSK standards.
This has given me space to consider what is knowledge translation in a world of evidence-based practice where access to knowledge is so immediate, diverse and complex.
So, what is knowledge translation?
Knowledge translation seeks to narrow the perceived gap between knowledge and practice. It has been described as a dynamic and iterative process that include synthesis, dissemination, exchange and ethically sound application of knowledge to improve the health of stakeholders as well as strengthen the healthcare system (from the Canadian Institutes of Health Research).
The National Institute for Health and Care Research describe knowledge translation as a part of knowledge mobilisation:
“Getting the right information to the right people in the right format at the right time, so as to influence decision-making. Knowledge Mobilisation includes dissemination, knowledge transfer and knowledge translation.” (National Institute for Clinical Research)
Knowledge and ways of knowing:
Knowledge is a complex concept. It can be described in many ways. It could be described as factual knowledge whereby trustworthy sources, perhaps reflective of scientific methods ensure a fact of the matter. Knowledge can be tacit and difficult to locate. It can be an implicit form of knowing. An example of this might be the feeling of apprehension when confronted by a situation that is inherently concerning such as witnessing a patient describe features of cauda equina syndrome. Knowledge can also be described from a position of practical wisdom to do the right action at the right time in the right situation for the right person. Seen in this way knowledge is inherently value laden as well as socially, politically and culturally entangled.
Evidence-based practice and knowledge translation:
In many ways there are parallels in thinking about knowledge translation in very much the same way as we might consider how we use evidence in practice. A traditional view of evidence-based practice asserts that certain forms of evidence are better than others. This is epitomised by the evidence-based hierarchy where systematic reviews of randomised control trials reside at the top of the hierarchy and lower forms of evidence are those that have less internal validity and sit at the bottom of the hierarchy such as expert opinion. The reason for this is due to risk of bias. However, as Kerry (2017) describes, this immediately becomes problematic because the expert clinician needs to use their judgement and therefore opinion in order to apply the best of the available evidence and contextualise it for the individual presenting case that sits in front of them in practice.
In the field of knowledge translation there has been a historic perspective, similar to that of the traditional view of evidence based medicine, believing that if only knowledge could be transmitted in a linear way, exact, clear and concise fashion that it will be received as such, and be understood in exactly the same way as it was expressed. However, there may be significant contextual differences between the circumstances under which the knowledge was acquired, transmitted and received with the spaces in-between being entirely different. Interpretation is always required no matter how objective the knowledge transmission may appear to be. This reliance on linear, techno-rational notion of translation (from research generation to selection to creation and dissemination of clinical practice guidelines) may have in fact created a second translation gap (Rycroft-Malone et al, 2013).
Gaby and le May (2016) articulately convey the challenge that clinicians face in responding to the pressure that builds with incessant guidelines on evidence-based patient pathways. They say:
"The struggle is not just about practice, but also professional autonomy and identity. Yet both sides of the argument recognise that best practice must be grounded in best evidence and that guidelines have their place. So, what exactly is that place and how do we get from the linear rationalism of guidelines to the complex wisdom of good practice?"
They also reflect upon the complex contexts and environments that clinicians occupy when making these clinical decisions. They counted many domains not just clinical but also management, public health, professional self-management and research. This is also reflected in advanced and consultant practice with the domains of clinical, research, education/training, leadership and consultancy, where decision making must be negotiated, contextualised and navigated. Gaby and le May suggest that practitioners often instantaneously respond to this challenge by using their ‘mindlines’ which are guidelines in the head, in which evidence from a wide range of sources has been melded with tacit knowledge to experience and continual learning. This has become internalised as a clinician’s personal guide to practice varies depending on their context. They go on to say that clinicians acquire their mindlines over a lifetime, informed by their training, their own and each other’s experience, their interactions with colleagues and patients, by their reading, understanding of local circumstances and systems, their experience of handling the many conflicting demands and a host of other influences. Seen in this way mindlines are much more flexible, malleable and complex than guidelines could ever be and therefore much better to adapt within the many roles and functions that clinicians need to traverse. They refer to this form of knowledge as "knowledge-in practice-in-context" which accommodates the necessarily ‘fuzzy logic’ that is a part of everyday professional life.
One can quite imagine how a clinical journey from the simple pattern recognition of early training to the development of an unconscious tapestry of complex decision-making processes go beyond the mere technical expertise that was once so expertly and confidently expressed in a weekend course.
As clinicians gather their bricolage from different kinds of knowledge, experience, values and behaviours, their mindlines will also evolve. However, when clinicians encounter the mindlines of other respected colleagues and their perspectives do not necessarily align their mindlines morph.
Seen in this way knowledge is not translated but transformed. It centres around a social process of evolution, of genesis, of endurance, and extinction.
Knowledge Transformation: A Way Forward?
The process of knowledge transformation does not eradicate traditional forms of knowledge translation but include it within a social, shared and dynamic space (Salter and Kothari, 2016). This, for me, demands a greater emphasis on developing communities of practice who share professional interests, passions and problem-solving through a mutually supportive and informal environment. This development of collective mindlines may allow much-needed room for individual and shared growth. However, there is the risk of ill-considered mindlines being shared, and if they were uncritically accepted would undermine good practice. This demands a certain type of skill, as Gaby and LeMay go on to say:
“Examples of those skills, which need to be further explored, tested, and developed, include knowing whom best to trust for useful and reliable advice about specific topics; being able to question that advice (that is, critical appraisal skills not just for research articles, but also for information from, for example, colleagues, online guidelines, the media, patients, commissioners); being comfortable about being challenged; sharing and questioning each other’s shortcuts for finding up-to-date information; avoiding groupthink; and agreeing collective norms and targets for improving care, and hence accepting mutual responsibility for achieving and reviewing them. Above all, the common thread appeared to be creating the space and the comfortable climate for respectful critical dialogue even during the everyday chatting and story-swapping we all enjoy”
I propose that seeing knowledge translation more as knowledge transformation that supports evidence-based practice, clinical guidelines, reflective practice, and social and collective theories of practice through communities of practice is a worthwhile step to take. These collaborative learning environments could be supported through the curation of multiple knowledge sources that include not just clinical research but blogs, podcasts, video’s through shared spaces such as webinars, reading groups, coffee shops, pubs, bars and restaurants.
Knowledge Trans(lation)formation Officer, MACP Executive Committee.
Kerry R. Expanding our perspectives on research in musculoskeletal science and practice. Musculoskelet Sci Pract. 2017 Dec; 32:114-119. doi: 10.1016/j.msksp.2017.10.004.
Rycroft-Malone J, Wilkinson J, Burton CR, Harvey G, McCormack B, Graham I, et al. Collaborative action around implementation in Collaborations for Leadership in Applied Health Research and Care: towards a programme theory. J Health Serv Res Policy. 2013;18(3 Suppl):13–26.
Gabbay J, le May A. Mindlines: making sense of evidence in practice. Br J Gen Pract. 2016;66(649):402-403. doi:10.3399/bjgp16X686221
Salter, K.L., Kothari, A. Knowledge ‘Translation’ as social learning: negotiating the uptake of research-based knowledge in practice. BMC Med Educ 16, 76 (2016). https://doi.org/10.1186/s12909-016-0585-5
Canadian Institutes of Health Research https://cihr-irsc.gc.ca/e/29418.html accessed 28/4/2022: 15:44
National Institute for Health and Care Research https://www.nihr.ac.uk/about-us/glossary.htm?letter=K&postcategory=-1 accessed 28/4/2022 15:47