Knowledge translation (KT) was introduced by the Canadian Institutes of Health Research in 2000 to convey the importance (timely and ethical use) of ensuring that the knowledge gained from research is used by practitioners to improve the health outcomes of members of society (Bowen & Graham, 2013). Knowledge translation is a term that is widely recognized to describe the creation of research-based knowledge and its movement to inform practice within a particular setting (Sudsawad, 2007). Knowledge translation, the movement of a new idea from a research setting, peer-reviewed journal, systematic review or continuing education course to day-to-day practice, is a social process of change that occurs over time (Rogers, 1983, 2003b). This social process of change is responsive to elements in the practice environment, the individual practitioner, the research evidence, and the implementation strategies used for change (Rogers, 2003b). Knowledge translation is more than just knowing; KT involves putting that knowledge into action. Practitioners' progression from gathering new information, forming an opinion, and utilizing new knowledge in practice may be examined through frameworks of KT.
The purpose of this article was to provide a theoretical approach that informs the translation of knowledge into practice. Knowledge translation, the movement of new knowledge into practice encompasses (1) becoming aware of new knowledge and interventions, (2) modifying one's beliefs, and (3) adopting new interventions to improve the quality of care and outcomes for all members of society (Bowen & Graham, 2013; Campbell & Halbert, 2002; Davis et al., 2003; National Center for the Dissemination of Disability Research, 2005). The conceptual framework described in this article utilized the Diffusions of Innovations Theory (DOI) and the Ottawa Model of Research Use (OMRU) concurrently to examine factors that influence the process of KT (Logan & Graham, 1998; Rogers, 1983, 2003b). The DOI describes discrete steps along the path from original awareness of new knowledge to changes in clinical behavior. The OMRU provides a lens to examine factors at each step that may promote or hinder practice change. Used concurrently, the DOI and the OMRU offer insight into key elements, potential facilitators, and barriers that mediate KT. The framework is applicable to the interprofessional workforce in early intervention (EI), as well as clinicians across practice settings.
FRAMEWORKS FOR KT
Occupational therapists, physical therapists (PTs), speech and language pathologists, and special educators represent members of the interprofessional workforce providing services to infants, young children, and families in EI. Early intervention providers are expected to integrate discipline-specific knowledge with the global knowledge of EI when developing and implementing service plans (Catalino, Chiarello, Long, & Weaver, 2015). The dynamic body of knowledge that informs practice in EI provides the foundation for examining KT in the interprofessional workforce (Campbell & Sawyer, 2009; Cramer et al., 2011; Kleim & Jones, 2008; Landry, Taylor, Guttentag, & Smith, 2008).
Frameworks of KT, such as the DOI and the OMRU, enable identification of factors within the individual practitioner, the innovation or knowledge, and the practice environment that mediate the process of integrating new knowledge into practice (Hudon, Gervais, & Hunt, 2015; Kitson et al., 2008). Rogers' DOI explains that the uptake of new knowledge and its utilization in practice are a social process that occurs overtime within the members of an organization, professional group, or system of care (Beal, Rogers, & Bohlent, 1957; Estabrooks, Thompson, Lovely, & Hofmeyer, 2006; Rogers, 2003b). The social system according to Rogers (2003a) represents the individuals, informal groups, organizations, and relationships that practitioners develop with colleagues and families in EI (Rogers, 2003a). Rogers posits that individuals move along a continuum of five stages that he refers to as the innovation–decision process (Rogers, 2003b). The movement from initial awareness of new knowledge to forming an opinion, decision making, implementation, and sustained use is a process that is mediated by variables that may exist within the micro (practitioner) and macro (practice environment) levels of practice (Davis, 2006; Sudsawad, 2007).
The OMRU provides insight into the influences that impact movement through the process of KT. The OMRU identifies six core elements that are dynamic and interactive throughout the uptake of new knowledge; (1) potential adopters, users of the information, (2) innovation, research-informed knowledge, (3) practice environment, (4) transfer strategies, (5) adoption or rejection, and (6) outcomes. The OMRU considers interactions among these elements instrumental in the translation of knowledge. The constraints and supports that exist within any of the core elements can impact practitioners' stepwise process of translating new knowledge into practice. For example, a support in the practice environment may be opportunities for team meetings, and availability of a mentor, whereas a constraint may be lack of access to peer-reviewed journals.
The OMRU brings into focus the importance of looking at the individual within the organizational, regulatory, and social aspects of their practice environment, and the DOI highlights the stages individuals transition through when adopting new practices. When applied concurrently, the OMRU and the DOI provide a framework that focuses on variables influencing the progression, stagnation, or, in some instances, the iterative process of adopting research-informed knowledge for use in EI practice. The information that is gathered from the utilization of KT frameworks can be used to develop recommendations for change and tailor KT initiatives to meet EI providers' needs (Cunningham, Rosenbaum, & Hidecker, 2016; Hudon et al., 2015; Levac, Clegg, Camden, Rivard, & Missiuna, 2015).
PROCESS OF KT
When EI providers are motivated to deliver services and care that align with the best available research, they may set into motion the steps associated with KT (Rappolt & Tassone, 2002). Engagement in the process of KT enables practitioners to utilize emerging evidence and modify their interventions accordingly (Damiano & Leonard, 2015). For the EI workforce, the research-informed knowledge may be discipline specific or global EI practices. According to Rogers, awareness of the first stage in KT is initiated when EI providers become alerted to the availability of new information (Rogers, 2003b). There are active and passive methods that introduce practitioners to new knowledge. When practitioners are dissatisfied with the effectiveness of a current intervention, they may actively begin the awareness–knowledge stage by constructing clinical questions and searching the literature. Although passive attendance at meetings can increase awareness of new knowledge, this is often less effective in changing clinical behaviors than active, self-initiated methods (Palisano, Campbell, & Harris, 2012). In addition to awareness and knowledge of a new practice, a shift in attitude and opinion may be necessary to prompt changes in practice behaviors. The decision to adopt the new innovation is related to an individuals' perception of their needs and usefulness of the innovation (Rogers, 2003c). Individuals' rationale for use, attitudes, and beliefs contributes to movement along the continuum of change (Luckenbill Brett, 1987).
The forming of opinions and attitudes toward the new practice occurs during the persuasion stage of KT. During the persuasion stage, individuals develop perceptions of the innovation based on the information they have gathered. Individuals consider the advantages that the innovation has relative to current practices. Other factors taken into consideration are complexity of the innovation and compatibility with current way of thinking. Social referencing has a powerful influence during the persuasion stage (Rogers, 2003b). When practitioners hold onto deeply held beliefs about current practices, it may impede their openness for change; however, the opinions and knowledge of colleagues can guide the adoption of new knowledge (Damiano & Leonard, 2015; Logan & Graham, 1998). The attitude that the individual develops may impede or facilitate movement into the decision stage.
The decision stage is the point in the process in which the practitioner decides to use or reject the innovation in practice. A component of the decision stage may be a trial period, during which the individual will consider the advantages of the innovation over current practice. A trial period may also entail implementing the new practice with only one child or family that the provider feels would benefit from a new approach.
Practitioners start applying the innovation in practice during the implementation phase, which involves overt behavior changes (Rogers, 2003b). The possibility of unintended consequences resulting from the implementation of an innovation may present the need for additional knowledge. The availability of resources, such as access to experienced colleagues and funding for future training, will facilitate the transition and continued use of a newly learned practice (King & Chiarello, 2014). As the newness of the innovation diminishes, it becomes integrated into everyday practice and the individual moves into the confirmation stage. During the confirmation stage, the newly integrated knowledge is shared with colleagues and families. The confirmation stage is identified by the practitioners' continued use of the innovation, acknowledgment of benefits, and placement in their toolbox for use with appropriate children and families. However, the continued use of the innovation is dependent upon its usefulness to support an individual child or family. Assessment and monitoring of changes in the child's behaviors will provide information on the effectiveness of the intervention and implications for ongoing use. When the interventions are no longer making positive changes in the lives of children and families, the process of KT may begin again (Bruder & Dunst, 2005).
Identification of the facilitators and barriers that exist along the stepwise process of change, the innovation–decision process, is an important component for shifting a practitioner's philosophies and clinical behaviors. The OMRU brings into focus the importance of identifying facilitators and barriers that may exist within the key elements of the individual, new knowledge and practice environment.
Individuals are the actors, the adopters, and users of the information in the process of KT (Logan & Graham, 1998). The decisions, actions, and personal characteristics of practitioners contribute to the provision of research-informed interventions for children and families receiving EI services. For example, Rogers (2003c) classifies individuals by their readiness for change and adoption of a new way of practicing. Innovators are the first to adopt new ideas, whereas members of the late majority are cautious of new ideas. The adoption and implementation of a new philosophy or treatment encompass factors not only within the individual but also within the knowledge.
The innovation, or new knowledge, may have been recently introduced to the field, or the individual may not have been aware of its existence. Considerations in applying the innovation include compatibility for practice within a child's home, usefulness for parents, time required to become competent in applying the new knowledge, and availability of ongoing support. New knowledge can be categorized as what, how, and why knowledge (Rogers, 2003b). Early intervention providers are expected to be aware of interventions that are demonstrating effective outcomes for young children, the mandates and philosophy of the Individuals with Disabilities Education Act (IDEA) Part C (2004), and the Recommended Practices of the Division for Early Childhood of Council for Exceptional Children (2014). The how knowledge will guide the behaviors and actions of EI providers as they intervene with young children and families. Finally, the why knowledge informs practitioners of theoretical foundations, empirical research, and scientific evidence that support practices. The 3 categories of knowledge represent a holistic approach to exploring KT among EI providers. As practitioners blend the what, how, and why knowledge of EI into clinical behaviors, they are narrowing the gap between knowledge and practice.
The practice environment refers to the physical, psychosocial, regulatory, and organizational structure that is the context of the work environment. The practice environment in EI is shaped by IDEA (2004) and directs a service delivery model that is family-centered and provided in the child's natural environment. The natural environment encompasses the physical location, activities, and materials, as well as the family dynamics, interactions, collaborations, and relationships that exist within the child's environment (Chiarello, 2012). The location of EI services may be the child's home, day care setting, or community park, each with unique resources and members. Best practice guides clinicians to incorporate the family's toys, materials, and resources, while identifying everyday activities for learning and practicing of new skills throughout the day (Fleming, Sawyer, & Campbell, 2011; O'Reagan Kleinert & Effgen, 2013).
FACILITATORS AND BARRIERS
Facilitators and barriers for the individual practitioner
Practitioners who are comfortable with the high degree of uncertainty that accompanies change may be considered innovators (Rogers, 2003c). The innovator takes the lead in engaging in literature searches, critical appraisal of research articles, and creating opportunities to engage in professional development activities (Schreiber, Stern, Marchetti, & Provident, 2009). A practitioners' comfort with social media allows them to access online list serves and professional groups. For example, PTs can broaden their perspective through accessing the pediatric list serve of the Academy of Pediatric Physical Therapy (http://pediatricapta.org/index.cfm). Affiliations with professional organizations have been reported to facilitate the uptake of new knowledge into practice. In a 2015 study, Deville, McEwen, Arnold, Jones, and Zhao (2015) reported that PTs who are members of professional organizations are often the first to adopt new interventions/assessments. Furthermore, participation in communities of practice may reduce uncertainty and facilitate the transfer of a new intervention into practice (Barnett, Vasileiou, Djemil, Brooks, & Young, 2011; Deville et al., 2015; Rogers, 2003c).
Movement along the innovation–decision process is slow for practitioners who hold onto deeply held beliefs and practice in an environment that is lacking in role models and a social network of support (Rogers, 2003c). Practitioners who are content with the status quo may be considered traditionalists and the last ones in the group to trial a new intervention (Rogers, 2003c). Similarly, practitioners who are limited in their ability to engage in self-reflection might be unaware of a need to adopt new clinical behaviors (Schreiber & Stern, 2005; Wainwright, Shepard, Harman, & Stephens, 2010). Practitioners' lack of skill and comfort searching and evaluating research evidence has been reported as a barrier for PTs in pediatric practice (Jette et al., 2003; Schreiber & Dole, 2012; Schreiber, Stern, Marchetti, Provident, & Turocy, 2008). In addition, PTs and occupational therapists may be strongly vested in a certain practice due to the time they dedicated to developing expert skills, resulting in slow adoption of new interventions despite evidence-informed research (Damiano, 2007; Van Sant, 2008). For example, when implementing activity-focused interventions, PTs and occupational therapists identify elements within the practice environment, task, or child that may interfere with the learning of new motor skills (Valvano, 2004; Valvano & Rapport, 2006). Therapists who are content with a direct hands-on, therapist-driven approach to intervention may experience internal conflict when asked to align themselves with a collaborative and parent-directed education model of EI (Childress, 2004).
Facilitators and barriers of the new knowledge
The availability of research evidence and best practices in useable formats facilitates the transfer of research-informed knowledge into practice. Clinical practice guidelines may reduce the uncertainty and complexity that PTs often associate with a new intervention (Kaplan, Coulter, & Fetters, 2013; Van Sant, 2013). Recent literature cites the usefulness of interactive activities and multidimensional methods of increasing the application of evidence-informed knowledge into practice (Schreiber & Dole, 2012). Participants in a study utilizing the Internet as a platform for e-learning cited the usefulness of videos and case scenarios to support application of newly gained evidence into practice (Camden, Rivard, Pollock, & Missiuna, 2015). In a systematic review, Menon, Korner-Bitensky, Kastner, McKibbon, and Straus (2009) concluded that active, multicomponent strategies (i.e., opinion leaders, interactive educational sessions, and outreach visits) are preferred formats for enhancing knowledge and practice behaviors.
In addition to having access to interactive professional development activities, the practitioner will consider individual attributes of the intervention as well. Early intervention providers may consider the overall benefits of the new intervention in terms of economics, usefulness, social factors, and convenience (Grol, Bosch, Hulscher, Eccles, & Wensing, 2007). When the innovation demonstrates changes in outcomes that are visible to the child, family members, and practitioner, there is increased rate of adoption. As a practitioner implements a new practice that is associated with positive changes in the child's outcomes, the value of that new practice may be increased for the family and the practitioner (Dunst, 2015).
Determining the relevance of a new treatment approach for a specific child is a challenging task considering the complexity of social, medical, behavioral, and developmental issues with which young children present (Schreiber & Stern, 2005). Adoption of innovations may also be deterred when new knowledge is perceived as complex, requiring additional time to learn (Rogers, 2003c). Early intervention practitioners can utilize the Knowledge Translation Action Plan from the American Occupational Therapy Association (2016) to map out individual steps to translate newly learned knowledge into practice. If the innovation necessitates an uncomfortable shift in practice or a change in strongly held beliefs, the practitioner may be slow to adopt the new practice (Logan & Graham, 1998). The shift in practice from a traditional model that is driven solely by recommendations and direct service provision by the professional to the best practice model of collaboration with families in EI may be challenging for some clinicians (Childress, 2004).
Facilitators and barriers of the practice environment
Practice environments that support a culture of learning and stimulate cross-disciplinary communication play an important role in the translation of knowledge into practice that is consistent with the evolution of policy and research (Rogers, 2003a). The federal legislation of IDEA Part C (2004) considers sharing of information, knowledge, and interaction among team members core to the provision of services for children and families (O'Reagan Kleinert & Effgen, 2013). The sharing of knowledge and expertise among team members supports the development of holistic plans for intervention, as well as supporting professional learning and development for practitioners. Practice environments may serve as conduits for the exchange of knowledge from experienced to novice clinicians thereby helping to shape beliefs and put new knowledge into action (Damiano & Leonard, 2015; Logan & Graham, 1998; Lomas, 1993). Team assessments, cotreatments, and interdisciplinary teaming are channels of communication for exchange of knowledge among team members; however, they are not consistently utilized (O'Reagan Kleinert & Effgen, 2013). Similarly, creating work environments, or surrounding oneself with individuals with varying perspectives, promotes the exchange of new knowledge (Zwarenstein & Reeves, 2006). As Rogers (2003a) explains without differing views, there would be no exchange of new knowledge. Practice environments that foster mind-sets that are inquisitive and accepting of new ideas will further encourage practitioner engagement in KT (Backus & Jones, 2013; Barnett et al., 2011). In addition, EI provider agencies that support innovators and have in place opportunities for review of progress notes, feedback, and journal clubs exemplify strategies to enhance KT for the practitioner (Straus, Tetroe, & Graham, 2009).
Practice environments with inadequate infrastructure to support knowledge exchange may present barriers for KT. Limited access to university databases, often experienced in community-based settings such as EI, may hinder providers' awareness of practice requirements aligning with the philosophies and mandates of IDEA Part C (2004) (Barnard & Wiles, 2001; Rogers, 2003c; Schreiber & Stern, 2005). Community PTs often have limited opportunity to interact with colleagues (fellow therapists and those from other disciplines) and exchange information, potentially compromising awareness of new research evidence (Catalino et al., 2015). For example, when formal channels of communication, such as team meetings and cotreatments, are limited by state EI regulations, motivated providers may create their own social networks for communication (Rogers, 2003c).
Practice within the EI community setting challenges providers to utilize resources available within the child's home, day care setting, or backyard. Therapists who are more comfortable bringing toys and equipment to use during treatment sessions may need to identify available resources within the child's environment to support learning of new motor skills. Childress (2004) discussed the challenge that special educators experience when adopting practices of parent collaboration and utilization of materials and toys in the home to optimize a child's learning and development.
Adoption of new practices by EI providers may be impacted by financial and time constraints associated with participation in professional development activities. Financial burdens placed on members of the EI workforce that are fee-for-service may restrict access to conferences due to travel and lost workdays. Limited opportunities to attend conferences hinder not only acquisition of new information but also opportunities to interact with colleagues and experts and expand social networks. The isolation that PTs' report may hinder stimulation of questions, self-reflection, and development of inquisitive minds for EI practice (Koole et al., 2011). The community-based setting of EI not only enables providers to collaborate and work closely with parents, family members, and caregivers but also limits interdisciplinary learning opportunities among colleagues.
Providers in EI are responsible for partnering with parents to implement a plan of care that reflects child and family-identified goals and values, while utilizing practices that represent the best available research evidence (Hickman, McCoy, Long, & Raub, 2011). In addition, IDEA (2004; §601.E) seeks to ensure that practitioners are implementing scientifically based practices to the maximum extent possible (http://idea.ed.gov/part-c/downloads/IDEA-Statute.pdf). Maintaining currency with knowledge that informs EI practice contributes to the growth and development of infants and toddlers at a crucial time in development.
Frameworks of KT provide a theory-driven approach to study the experiences and needs of EI practitioners as they integrate the demands of everyday clinical practice, with those of remaining up-to-date with current evidence (Curran, Grimshaw, Hayden, & Campbell, 2011). Early intervention providers' engagement in KT supports implementation of the most effective interventions not only in their own daily practice but also in the strategies utilized by families, caregivers, and the EI team.
The concurrent application of the DOI and the OMRU provided a description of the constraints and supports specific to the utilization of research-informed knowledge and best practices in EI. The interactive process of KT is shaped by the actions and decisions of practitioners, provider agencies, professional organizations, researchers, employers, children, and families (Graham et al., 2006). Furthermore, the process takes place within a practice environment defined by organizational structure and culture and financial and resource constraints (Greenhalgh, Robert, McFarlane, Bate, & Kyriakidou, 2004). The interaction among the multiple stakeholders, practice environment, and knowledge creates the landscape for the movement of new information, an innovation into practice. As the field of EI supports the professional development of the interdisciplinary workforce through the lens of KT, the outcomes for children and families may be enhanced.
Implementation of KT initiatives to support change in EI practice by the interprofessional workforce encompasses a variety of strategies, as well as the support of multiple stakeholders. When applied concurrently, the DOI and the OMRU demonstrate that change in practice behaviors results from much more than awareness of new knowledge and treatment approaches (Francis & Perlin, 2006). Utilization of KT strategies that address identified knowledge-to-practice gaps, while meeting the needs of service providers working in EI, represents a dynamic and responsive approach for the translation of knowledge into practice. Recommendations for change at the levels of the individual, agency/employer, and state/local governments are introduced later.
RECOMMENDATIONS FOR CHANGE
Although the following recommendations are organized into three different levels of change, they are interrelated and represent a unified approach for KT. The steps, resources, and evidence associated with each level of change are presented in Table 1. As multiple stakeholders begin to explore opportunities for change, they can initiate a combined movement toward narrowing the knowledge-to-practice gap. Collaboration among the interprofessional workforce, EI provider agencies and employers, and state and local governments will generate varying perspectives and stimulate innovative ideas for advancing practices of EI providers.
Early intervention providers' participation in narrowing the knowledge-to-practice gap begins with self-assessment. Awareness of one's current level of knowledge and skills prepares individuals to accept a new way of thinking and shift practice behaviors (Schreiber & Dole, 2012). Physical therapists, for example, can assess their individual areas of strengths and weaknesses by accessing the Updated Competencies for Physical Therapists Working in Early Intervention (Chiarello & Effgen, 2006). In addition, EI providers can assess their ability to lead, build relationships, and be innovative thinkers. Innovative thinkers are open to new ideas, often take the lead, and become champions of change (Rogers, 2003c). Identifying oneself as an innovative provider is an important step not only at the individual level but also for the larger community of practitioners (Barnett et al., 2011).
An innovative practitioner, a champion of change, can discuss with administrators the value of developing a community of practice. Communities of practice provide opportunities for the interprofessional team to engage in sharing of cross-disciplinary knowledge, identify a knowledge-to-practice gap, and develop further strategies for change (Reed & Hocking, 2013). Organizations can assess their capacity to acquire research and promote its use among practitioners (Canadian Foundation for Healthcare Improvement, 2014). Agency administrators who are committed to supporting the implementation of evidence-informed research into practice can identify and support innovators within their organization.
Implementation at the systems level of change would require collaboration, innovation, and commitment among practitioners, agency administrators, state and local governments, educators, researchers, and members of professional organizations. The Knowledge Translation Planning Template is a KT tool that can be used to identify the goals of the project, timeline for change, and collaborating partners (Barwick, 2008, 2013). The application of pre- and posttests is one method that can be used to determine the effectiveness of KT strategies in sustaining change in practice behaviors (Cunningham et al., 2016).
The utilization of the DOI and the OMRU as a conceptual framework to examine the process of integrating research-informed knowledge into practice represents a paradigm shift in the approach to professional development. Changes in practice behaviors, an anticipated outcome of professional development, may not happen instantaneously. The actions and decisions taken by practitioners include searching for evidence, seeking opinions of colleagues, observing experts, and implementing the practice with one child at a time. The DOI and the OMRU introduce elements within the service provider, the practice environment, and new knowledge that mediate practice behavior changes. Organizing professional development activities through the lens of KT suggests developing multifaceted and interactive KT strategies that reflect the needs of local users of new knowledge. A KT initiative will require collaboration among EI providers, agencies and employers, potential funders, state and local governments, and professional organizations. Furthermore, it will demonstrate a commitment to narrowing the knowledge-to-practice gap and the advancement of the field of EI.
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