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research-article2015

QHRXXX10.1177/1049732315580300Qualitative Health ResearchHarvey et al.

Article

Exploring the Hidden Barriers in Knowledge Translation: A Case Study Within an Academic Community

Qualitative Health Research 1­–12 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1049732315580300 qhr.sagepub.com

Gill Harvey1, Rhianon J. Marshall1, Zoe Jordan1, and Alison L. Kitson1

Abstract Debates about knowledge translation (KT) typically focus on the research–practice gap, which appears to be premised on the assumption that academics are a homogeneous collective, sharing a common view. We argue that a number of hidden barriers need to be addressed related to the understanding, interpretation, ability, and commitment to translate knowledge within academic communities. We explore this by presenting a qualitative case study in a health sciences faculty. Applying organizational and management theory, we discuss different types of boundaries and the resultant barriers generated, ranging from diversity in understanding and perceptions of KT to varying motivations and incentives to engage in translational activity. We illustrate how we are using the empirical findings to inform the development of a KT strategy that targets the identified barriers. Investing in this internal KT-focused activity is an important step to maximize the potential of future collaborations between producers and users of research in health care. Keywords evidence-based practice; knowledge transfer; knowledge utilization; semi-structured interviews; qualitative analysis; translation

Against a background of growing interest and concern about how to address the perceived gaps between research evidence and decision making at a practice and policy level in health care, a range of strategies have been pursued. As a major producer of research evidence, academic institutions are increasingly required to think about how to maximize the impact of their research endeavors, as apparent through the numerous debates on knowledge translation (KT) in academic and policy literature. A myriad of different terms are in use to describe the process of connecting the worlds of knowledge production and knowledge use—translational science, knowledge transfer, translation, utilization, and mobilization, to name just a few (McKibbon et al., 2010). The choice of terminology is interesting in that it might reflect the ways in which the process of moving from knowledge production to knowledge use is conceptualized, for example, as a linear “pipeline” model or as a more interactive and iterative process (Davies, Nutley, & Walter, 2008). In this article, we explore issues relating to understanding and perceptions of KT within an academic community. While we recognize and examine issues relating to language and terminology, to ensure consistency throughout the article we will use the term knowledge translation (KT), as defined by the Canadian Institutes of Health Research

(Straus, Tetroe, & Graham, 2009): “A dynamic and iterative process that includes the synthesis, dissemination, exchange and ethically sound application of knowledge to improve health, provide more effective health services and products, and strengthen the health care system” (p. 165). One translational strategy that appears to be growing in popularity is the deliberate creation of partnerships between higher education and the health system community (including service providers, policy makers, and industry), as evidenced by initiatives in countries such as Canada, the United Kingdom, the United States of America, and Australia (Table 1). As research funding bodies and national governments have begun to explore how they can quantify a return on their health research investment in terms of health and economic impact, initiatives are increasingly targeted at creating academic– health partnerships and collaborations directed toward finding solutions for real-life patient, practice, and health 1

University of Adelaide, Adelaide, South Australia, Australia

Corresponding Author: Alison Kitson, University of Adelaide School of Nursing, North Terrace, South Australia 5005, Australia. Email: [email protected]

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Table 1.  Examples of National Research Funders’ Initiatives on KT. Country

National Initiatives

Further Information

Canada

•• The Canadian Institutes for Health Research (CIHR) provides research funding for KT awards in areas such as knowledge synthesis, knowledge to action, science-policy fellowships, and “Partnership for Health System Improvement” grants. •• KT Canada is a network of experts involved in promoting and researching KT. One initiative, supported by a Strategic Training Initiative in Health Research (STIHR) grant, is directed toward enhancing capacity in KT and KT research, through providing training on KT from basic principles for researchers and knowledge users through to post-graduate and advanced (postdoctoral) training in the science of KT. •• The National Institutes of Health (NIH) National Centre for Advancing Translational Sciences (NCATS) has a Clinical and Translational Science Awards (CTSA) program to support multidisciplinary research and build research partnerships to accelerate translation of research into clinical treatments and improved health outcomes.

http://www.cihr-irsc.gc.ca/e/27293.html http://ktclearinghouse.ca/ktcanada http://www.cfp.ca/content/58/6/623. full?etoc http://www.implementationscience.com/ content/6/1/127

•• The National Institute for Health Research (NIHR) has established a number of initiatives to promote academic– health service partnerships to focus on translation, including Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) and Academic Health Science Networks (AHSNs). •• Translational research centers have been set up in fields such as patient safety and rare diseases, and funding is provided for Knowledge Mobilization Fellowships. •• The National Health and Medical Research Council (NHMRC) provides funding for partnership and individual “Translating Research Into Practice” (TRIP) researcher fellowships directed toward KT. •• A research translation faculty has been established and the creation of Advanced Health Research and Translation Centers is currently underway.

http://www.nihr.ac.uk/about/ collaborations-for-leadership-in-appliedhealth-research-and-care.htm http://www.england.nhs.uk/ourwork/partrel/ahsn/ http://www.nihr.ac.uk/about/patient-safetytranslational-research-centres.htm http://www.nihr.ac.uk/funding/knowledgemobilisation-research-fellowships.htm http://www.nhmrc.gov.au/research/ research-translation-0 http://www.nhmrc.gov.au/research/ research-translation/research-translationfaculty http://www.nhmrc.gov.au/research/ nhmrc-advanced-health-research-andtranslation-centres

United States of America

England

Australia

http://www.ncats.nih.gov/ http://www.ncats.nih.gov/research/cts/ctsa/ ctsa.html http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC3168860/

Note. KT = knowledge translation.

system–level challenges. In turn, this places an increasing expectation on researchers to be knowledgeable, skilled, and engaged in the processes and practice of KT. The rationale for developing the science of KT and creating more formal academic–health system partnerships is that by bringing the producers and users of research closer together, it should help to increase their mutual understanding, promote collaboration, and build capacity for applied research within the health service (Rycroft-Malone et al., 2013). Ultimately, the aim is to build translation into research, rather than it being seen as an “end-stage” activity within the research process. This implies a move away from the more traditional models of KT where researchers (often academics in higher education establishments) produce research that they then “push” out to intended users via dissemination methods

such as journal publications, research reports, and evidence syntheses. Rather, the intention is to establish more equal relationships between the users and producers of research and to ensure that research addresses the important questions from a patient, practice, and policy perspective (Nutley, Walter, & Davies, 2007). Hence, the approach is one that moves away from the “researcherpush” model and recognizes the importance of “researchuser-pull” in the translational process, with research producers and research users working alongside each other in a more collaborative relationship (Van De Ven & Johnson, 2006). This is reflected in the previously described definition of KT (Straus et al., 2009). Evaluations of KT initiatives shed light on the enablers and barriers that exist when attempting to mobilize knowledge between academic institutions and research

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Harvey et al. users in health care. These include factors relating to the research evidence itself and how well it fits with existing service priorities and provision; the experience of clinicians and patient expectations; the influencing effect of the organizational and clinical context in which care is delivered, including policy, politics, and power relationships; and the strategies that are used to facilitate and promote KT (Dopson & Fitzgerald, 2005; Kitson, Harvey, & McCormack, 1998; Kitson et al., 2008; Rycroft-Malone et al., 2004). In the KT field, to date, much of the research and policy focus has been centered on the research–practice gap and identifying ways to overcome barriers such as those noted above. The implicit assumption seems to be that academic institutions—as a key source of research evidence—have a shared motivation to transfer the knowledge that they produce. However, a particular finding of interest from emerging empirical accounts of academic– health service collaborations is the internal boundaries that exist within academic institutions and the impact that these can have in terms of creating barriers to knowledge creation and sharing (Currie, El Enany, & Lockett, 2014; Kislov, 2013). Often these trace back to epistemological differences in relation to how knowledge is defined, with a resulting impact on how KT is then conceived. For example, how knowledge is interpreted will depend on whether a biomedical or social science perspective is prominent. In medical science, knowledge is typically viewed as something that is explicit and formal; thus, research findings are privileged and specifically research findings that result from robust, controlled experimental studies. By contrast, social scientists tend to have a wider view of knowledge as something that is socially situated, encompassing both formal and tacit dimensions and subject to influence by social norms, structures, and power relationships (Harvey, 2013). Different interpretations of knowledge will in turn influence perceptions of what KT means and what it involves. Fundamentally, different interpretations of KT as a knowledge transfer problem or a knowledge production problem are possible (Greenhalgh & Wieringa, 2011; Van De Ven & Johnson, 2006). Differing perspectives on knowledge and KT are a very real possibility within an academic faculty such as Health Sciences, which typically has a wide range of disciplines represented, from bench scientists through to applied health researchers and social scientists. At a collective level, such a faculty group can be seen to be in a prime position to translate its research outputs to benefit health and society. However, it also raises interesting and important questions in terms of whether and to what extent a faculty group shares a common view of KT and how it relates to their particular field of study. In turn, this could have significant implications for establishing research partnerships to promote KT within the wider

health service community. It is against this general backdrop that the study we describe in this article took place. Within our university, the Faculty of Health Sciences (FHS) decided to develop a translational science (the term that was adopted within the university) strategy in recognition of the importance of KT and a commitment to ensure that the research being undertaken achieved maximum impact on health care decision making at a patient, practice, policy, and population level. As a first step in this process, we searched the literature to establish what was already known or what work had previously been undertaken to explore KT within an academic environment. Surprisingly, we could not find any published reports or accounts of translating knowledge between and within academic communities in a faculty setting such as that we work in. The most relevant insights were within the organizational theory literature, particularly in studies of knowledge transfer and translation within the commercial sector, examining the concept of boundaries, and how they act as barriers that limit or inhibit internal knowledge transfer. For example, Szulanski (1996) studied the impediments to the transfer of best practice in eight manufacturing and service industries and concluded that knowledge was internally “sticky” because barriers existed that impeded the flow of knowledge. These barriers related to properties of the knowledge to be translated, the individuals targeted with the new knowledge, and the context within which they were working. To address these barriers and enhance KT, Szulanski concluded that organizations needed to invest in strategies to develop learning capacity, foster relationships, and systematically understand and communicate practice (Szulanski, 1996). Carlile (2002) studied boundaries and the processes of intra-organizational KT through an ethnographic study in four different companies. His research highlighted the different types of boundaries that existed depending on the ease with which a common understanding could be reached about the knowledge to be transferred. Three types of boundaries were identified, described as syntactic, semantic, and pragmatic boundaries. Syntactic boundaries existed where the individuals and teams involved in giving or receiving new knowledge experienced some differences in the language and terminology they used but were able to reach a solution by finding a common syntax. A more complex boundary—a semantic boundary— arose when there were different interpretations of the knowledge; hence, there was a requirement to establish and agree a common meaning. The most complex boundary was termed a pragmatic boundary,1 which was likely to exist where the new knowledge introduced a greater degree of novelty. Here, more than a difference in language or meaning was encountered; knowledge was seen to be “at stake”; in other words, adopting the new

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knowledge involved processes of contestation and often negotiation in terms of power, roles, and relationships. From this boundary theory, Carlile (2004) proposed different strategies to address the barriers resulting from syntactic, semantic, and pragmatic boundaries. At a syntactic boundary, knowledge transfer strategies were seen to be sufficient, built around an agreed language and set of messages. At a semantic boundary, the emphasis needed to shift to a translational strategy to achieve a sense of collective meaning, whereas at a pragmatic boundary, a more transformational approach was required to address the complex issues around the knowledge differences between different groups, for example, in relation to power, vested interests, and politics. What these findings suggest is that the types of barriers that are recognized at the research–practice interface are equally likely to exist within an organization. To explore this further—and in the absence of research specifically set within an academic environment—we undertook a qualitative study among our colleagues to explore their understanding and views of KT. We believed this was an important step to develop a clear indication of what the KT strategy needed to address and what actions would be required to create faculty ownership and engagement in implementing the strategy.

Method Study Design The research reported here represents the first phase of a larger piece of work to develop and implement a KT strategy across a university faculty. This initial study adopted a single site qualitative case study methodology to elicit the views and opinions of faculty staff about KT. The study commenced in October 2012, with the following aims: i. to explore and map staffs’ understanding and interpretation of the concept of KT; ii. to examine the breadth and depth of current research and learning and teaching KT-related activity; iii. to describe perceived enablers and barriers to KT; and iv. to define what KT “successes” would look like within the FHS.

Participants We adopted a purposive sampling strategy, targeting representatives from all schools within the faculty. These schools represent a diverse range of disciplines, including but not limited to medicine, nursing, dentistry, population

health, psychology, and medical sciences. The faculty is one of five faculties within a research-intensive university and has close links to the nearby acute teaching hospital and other locally based research organizations. Within each school, we sampled individuals who had a leadership role, as either a head of school or as a chair of one of the two decision-making bodies within the school and faculty, namely, the Research Committee or the Learning and Teaching Committee. Thirty individuals were invited to participate in the study, and 29 agreed to be interviewed. However, personal circumstances and the timescale for data collection meant that two participants were subsequently unavailable, resulting in a final sample of 27 (Table 2).

The Semi-Structured Interviews Interviews were conducted over an 8-week period between November and December 2012 by two members of the research team, in accordance with the University Human Research Ethics guidelines. Verbal consent to participate was gained at the commencement of each interview. A series of primer questions was forwarded to respondents prior to the interview, based on a preliminary review of the literature and the authors’ own experience in KT. The interview followed a broad outline around a number of core topics (Table 3). These included questions to elicit participants’ understanding of KT; their views on whether and how KT was embedded in their school’s current activities (learning and teaching and/or research); their views on the challenges, facilitators, and enablers of the process and, finally, their views on how successful KT activity could be articulated. Twenty-four interviews were conducted, lasting for an average of 30 minutes (range = 15–53 minutes). Two interviews were conducted with more than one interviewee present; one interview had three participants present and another had two participants. Twenty-two interviews were conducted face-to-face; the remaining two were telephone interviews. All of the interviews were digitally recorded and transcribed verbatim by one of the research team.

Data Analysis Data analysis was undertaken inductively using what could be described as a conventional content analysis approach (Hsieh & Shannon, 2005). A member of the research team who had not been involved in conducting the interviews led the process of data analysis. After reading each of the interview transcripts to establish familiarity with the data, the transcripts were then re-read, and free-text codes were assigned (Miles & Huberman, 1994). As analysis progressed, codes were collated into categories and themes,

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Harvey et al. Table 2.  Characteristics of Interview Respondents (N = 27). Descriptor Gender Role

Position

Category

n

Male Female Head of school Research Committee member Learning and Teaching Committee member Professor Associate professor Lecturer/research fellow

14 13 8 12 7 18 3 6

Table 3.  Areas of Questioning Within the Semi-Structured Interview. Topic Area Definitions of KT and translational science Translational activities— General Translation from research to health care   Translation in learning and teaching   Facilitators and barriers  

Example Questions •• What do you understand by the term Translational Science? •• When do you think about KT within a research project? •• What translational activities related to practice and/or policy are you and your colleagues currently engaged in? •• Can you give some examples of ways that research from your school has been disseminated to the clinical and/ or policy setting? •• How do you measure the success of the translational process? •• What mechanisms do you use to ensure that the most up-to-date evidence is used in undergraduate/ post-graduate teaching? •• How do you teach your students about translational science? •• What obstacles do you think there are to having a more explicit KT strategy within your school? •• What would help to overcome these obstacles?

Note. KT = knowledge translation.

without the use of analytic software. During the process of analysis, emergent codes, categories, and themes were discussed and refined with other members of the research team until agreement was reached (Guba & Lincoln, 1989). There was sufficient consistency in the categories and themes identified to suggest that data saturation had been achieved with the interview sample. No direct member checking of the transcripts or coding took place. However, a series of stakeholder events were held, where the study findings were presented; these provided an opportunity to check the representativeness and trustworthiness of the findings.

In reporting the findings, we present direct quotes from participants. These have been anonymized by using codes that indicate the school where the participant was based (Numbers 1–8) and the role they represented (Head of School—HOS; Learning and Teaching—L&T; Research—R). Where two or more participants represented the same role in the same school, they are distinguished by the use of lowercase letters (e.g., 2:Ra or 2:Rb).

Findings We identified six themes within the interview data, each with a number of distinctive categories. These are summarized in Table 4 and discussed in more detail below. Generally, the findings reflect a broad range of perceptions, different starting points, and potentially conflicting views about the imperatives, benefits, barriers, and consequences of addressing KT.

Prior Understanding of KT A clear distinction was apparent between participants who had a clear, explicit understanding of KT and those whose understanding was either unclear or more implicit. This was reflected in their familiarity with the language and terminology around KT. Some participants could describe the concept clearly, whereas for others, the language was unfamiliar and did not hold any particular meaning. Within these categories, further distinctions could be observed. For example, among those participants who had an explicit understanding of KT, some described it as a cyclical process, whereas others referred to it as a pipeline. Yeah, so we see it as kind of a pipeline, where we have to invest in all areas, because if we have leakages in the pipe, you can’t get what we discover to the other end if you have holes in the pipe all the way. (3:R) We would take a view of it as something that focuses upon moving from out of knowledge creation in to synthesizing and then translating for whatever the entity or audience is . . . beginning with what is it you need to know about it? So you’ve really got practice-based research rather than research-based practice . . . I actually do think that this relay thing is pretty stupid. Um, simply because it absolves the bench scientists of ever thinking about what is the end user going to do. (8:HOS)

For some participants, the term was closely linked to commercialization of new products or discoveries, “ . . . you know I’m a simple guy, to me it’s bang for buck. Ultimately, you want the best outcomes you can afford that are going to benefit the community” (6:L&T). This

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Table 4.  Summary of Key Themes and Categories Identified From Data Analysis. Theme Prior understanding of KT How KT currently happens? Ease of undertaking KT

What needs to happen to achieve KT?

Indicators of success

Unintended consequences of focusing on KT

Categories •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• •• ••

Level of familiarity with the concept Explicit vs. implicit Positive vs. negative perceptions Explicit vs. implicit Developing skills and knowledge Core vs. add-on activity Impact of wider strategy and policy Competing pressures and drivers Restrictions of funding Skills, knowledge, and confidence Ability and willingness to collaborate and network Timescales Connecting, engaging, and communicating Moving from silos Making KT more explicit Getting opinion leaders onside Recognizing existing knowledge and expertise Everyone’s job vs. a role for some Staff-related measures (awareness and understanding, inter-disciplinary working) Impact at a patient and community level Focusing on real-world problems Research income and kudos Embedding KT Negative impact on discovery research Loss of serendipitous findings Raising public expectations (timescales and funding limitations)

Note. KT = knowledge translation.

was in contrast to the view that KT was fundamentally concerned with community engagement and integrating new knowledge in the real-world to realize benefits. I think it is seen as fairly narrow by [some] people . . . it has been seen as coming up with something that you can commercialize, way too narrow in my belief. In practice this hardly ever happens right and lots of people come up with things but they are houses of cards, they are emperors with no clothes. (3:R)

An observation was also made by a small number of participants that KT was an activity with its own knowledge base which should be recognized and applied in any discussions about the concept. We don’t think that people have taken the view that KT is an activity that requires its own pedagogical knowledge, if you,

yeah, the narrow view assumes that we write information to tell people what they should be doing . . . and they’ve not seen translation as giving rise to original knowledge . . . [8:Ra]

Among those with a less explicit knowledge or understanding of KT, some participants commented that KT was not a part of their current discourse, because they used other terms such as applied research or scientist practitioners; others described KT as an integral part of everything they did and not something that could be separated out. We don’t ever use that term, we don’t use that language . . . the commitment . . . is there but it is not explicit, it’s implicit. . . . I think there would be varying degrees of acceptance and I think that would relate largely to the difference between different staff members and where their research lies and I guess um, some of the issue might be that this is just language for something we have already done and many people are annoyed by that. (4:L&T)

This latter quote highlights a further distinction within the theme of prior understanding of KT, specifically in relation to positive and negative perceptions about the concept. The majority of respondents spoke positively about KT in terms of addressing real-world problems and having an impact at a community level: “[it] is a way of breaking out of the naïve rationalist straight jacket that’s been put around research, and actually trying to get it more participatory, more emancipatory” (8:Rb). However, there were also some participants who reported feeling that KT was a trend that was “imposed” on them, leading to a sense of being constrained by the requirements of policy makers and funding agencies. . . . it is imposed more from the government and the granting agencies, rather than from us. But the very fact that there are now larger organizations dedicated to the significance of the project and defending it on that societal and health level is making people think about it at an earlier stage. But again, I feel constrained because you end up having to make “this will lead to blaghty blah” statements. Even so, I feel uncomfortable; it is not something we have done a lot of. It’s a recent trend. (4:R)

How KT Currently Happens As with the theme on prior understanding of KT, there was a clear distinction between participants who were engaged in activities with a specific KT focus and those who described it as something that was more implicit or assumed. This related to both research and learning and teaching activities. For example, where the focus was an

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Harvey et al. explicit one, post-graduate teaching programs included developing students’ skills in finding the right research questions, consumer engagement, literature searching, and undertaking systematic reviews. In contrast, other participants described a process of “osmosis” (6:HOS) by which skills and knowledge in KT were transferred from experienced to more junior researchers.

were less likely to publish their work or would be unable to get articles in the most highly rated journals.

. . . neither do I recognize it as being recognized and taught as such. On the other hand, I think at a practical day to day level it is strongly implied within the whole program. I think there is an underlying ethos in the medical program that this is what it’s about. (6:L&T)

Really improving people’s health care is unglamorous . . . Most of the [KT] publications, they tend to be relatively low impact factor . . . Whereas basic science is usually global and hence has high impact factors, putting it into practice is contextual, therefore it can’t be as big an audience. But there is also the issue of it being seen as unglamorous . . . (7:HOS)

. . . we’ve relied on cultural osmosis as much as structured programs and that sort of thing . . . I think I just assumed that it sort of takes place, naturally, by dint of academics who are responsible for courses and programs, . . . and the sort of subject areas we’re in, well of course we’re evidence-based. We have our research leaders give their boutique lectures and so on, it’s all about research and evidence base. (6:HOS)

Some participants commented on the way in which current academic structures and incentives impacted on the level of attention that was given to KT, both at a strategic and individual researcher level. Although the university was encouraging faculty members to secure the most highly regarded and competitive research grants, there was a feeling that this side-lined a focus on KT. [the university has] emphasized CAT1 [Category 1] research, and I know why, but Category 2 and 32 research is often more direct, translational research, and that seriously is not valued within the faculty or within the university. And that is a real problem I think. And it could be using the Category 2 and 3 research to leverage off with all types of benefits and were not doing that all, I’m not seeing that. (8:Rb)

Ease of Undertaking KT The influencing effect of external and internal drivers was a major feature within this theme. Many participants referred to competing pressures on their time, relating to the metrics by which their performance was assessed in terms of journal outputs and grant income. . . . our lives are, apart from the science, are consumed by having to maintain our funding. So, if it was something that increased the likelihood of productivity—so, outputs and chance of getting, and career advancement, then to be honest that would be the way to go about it. But sometimes it’s not, it’s an awful lot of hard work for not much return. And at the moment it’s difficult. (6:R)

This position was further exacerbated by a sense that those people engaged in translation and implementation

People who are doing very applied research, whether it be clinical, organizational, or health, they are researching it and then applying it. They are not writing papers about it and citing it, therefore raising that person’s profile. (6:R)

There was also a view which expressed that research funding did not cover the whole KT process, particularly at the point of implementation. Very few research projects are funded to get beyond a certain point in implementation . . . for most of us the point is at a stage where we think we’ve got a bunch of stakeholders on side around a particular set of research outcomes, but the next bit would be unfunded activity to lobby for that to get in to legislation, policy, or guidance documents. (8:HOS)

These pressures relating to metrics and funding sat alongside a number of other issues, including individual skills, knowledge, and confidence and the level of willingness and ability to network and collaborate. But I think people get comfortable just doing their own little thing. So, the problem is we are fairly successful research wise, and my feeling would be that success may be counterproductive in some people, in the sense that you get the champion [researchers] . . . and whether it is so easy to get those people to understand that if we collaboratively integrate some of our data to make it more relevant at the bedside, or the clinic or in society . . . (5:HOS) . . . everyone is spread out and you don’t get conversations going. Even this, the design of this building, you don’t bump in to people, you don’t see people, so I don’t think we do enough of those sort of academic discussions . . . we just don’t have a forum, or even a location, or even a place where we all get together and get this information, or any sort of information really, where we exchange . . . Sometimes, you will be doing something, and you will get quite a surprise to find out that on another floor above you, there’s been someone doing that technique for the last 5 years and you don’t even know it. (6:Rb)

A final issue related to the timescales involved for some research studies to get to the point of translation and implementation. Some researchers expressed concerns that with the influence of media pressure and the need to

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engage with stakeholders and get the message out, there might be a tendency to “over-sell too quickly” (4:R).

What Needs to Happen to Achieve KT A large number of suggestions were put forward as potential solutions to the challenge of translation. These reflected Carlile’s descriptions of syntactic, semantic, and pragmatic boundaries. For example, at the level of syntactic and semantic boundaries, a common suggestion was that KT needed to be made more explicit. This would require awareness raising and attention to creating a shared understanding of the concept, as well as keeping it anchored in the real-world and connecting to prevailing motivation and drivers. Look, what I’d suggest is that it is about selling it. What’s in it for them? And I think there are multiple benefits probably, and people will vary as to what they see as benefits. So I think we have to first of all capture that and sell a compelling message. I think in terms of then getting them to engage and educate themselves and take part in training opportunities I think making it as flexible and interesting as possible . . . So, they are not being taken too far out of their comfort zone, or not thinking that they have to do something completely different because that’s not the case. (6:HOS)

There was also evidence of more pragmatic boundaries that needed to be addressed, not only linked to the previously described performance metrics and (perverse) incentives in academia but also arising from the perceived silo ways of working within the faculty. As such, deliberate strategies to network and connect with other colleagues were proposed to build awareness and understanding of each other’s work and to break down the existing barriers. This required people to move out of their existing silos and be willing to work across disciplines. In turn, this would involve respecting and valuing others’ opinions and contributions. I am convinced that, some of that happens by getting people out of their traditional silos like scientists talking to clinicians, and clinicians talking to scientists, etc. It will mean finding ways that people can understand, and it will mean going across the traditional disciplines as well . . . acquaint scientists with actual clinical problems because what often happens in basic science is that someone comes up with a solution to a problem that doesn’t exist. (3:R) I think one of the things is to break down the communication barriers, so I think people communicating better across the different parts of the pipeline. That actually involves, yeah, breaking down those silos, not being limited by the language that we use with each other. This involves a little bit of being vulnerable but also showing respect for the people who aren’t your neighbors, but they are just a little bit culturally

different to you . . . understanding and valuing people’s opinions . . . (6:Rc)

Views about who needed to develop skills in KT differed; some participants thought this should be targeted generally at academic staff, others believed there was a need to find and support the people with existing expertise in KT. I think the thing I would like really, that I want to emphasize is that I think this should be done well, not done badly, and so going in there and saying “everybody has to do it” is a real problem. (8:Rb)

Practical suggestions put forward to achieve some of the ideas included undertaking a “stock-take” to identify people with knowledge and expertise in KT, as well as demonstration projects that clearly highlighted KT in action. The importance of paying attention to KT in learning and teaching was also emphasized, “We need teachers that understand, so that they can bring along the next generation” (1:L&T).

Indicators of Success Various indicators that could be used to evaluate progress with KT were identified. These ranged from staff-related measures such as increased awareness and understanding and greater inter-disciplinary working through to evidence of impact at a patient and community outcomes level. Within this was a strongly expressed view that research should be focused on real problems. We would have groups of people, perhaps working to solve common problems that really exist. Um, and not just something that you can get funding for. (3:R) You haven’t translated anything unless you’ve actually improved human condition in some way . . . or you’ve stopped it from getting worse . . . because you may have a lovely process but nothing at the end of it. (6:Ra)

However, others talked about future success using the more conventional metrics of income and kudos for the university, commenting that the university needed to follow the example of business and learn from others who have made “big bucks” (5:R) via entrepreneurship in the field of translation. Over the longer term, some participants described an aspiration that KT would become embedded and an integral part of the academic culture, so that, for example, there would be much more of a translational “flavor” in research grant applications and within research projects themselves.

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Harvey et al. I suppose success would mean that this wasn’t something we had to consciously think about so much because . . . it’s not an issue, it’s just culture rather than something we have to target . . . They are doing it naturally yes . . . and they are naturally gearing themselves towards it, they are getting their students in to it as well, they are teaching. You know, it just permeates. (4:R)

Unintended Consequences of Focusing on KT The final theme concerns the perceived unintended or unwanted consequences of focusing on KT. This was an issue raised by several of the participants and particularly relates to the effect the growing focus on KT might have on discovery research. . . . I think it’s important that we don’t throw out the idea that knowledge discovery for its own sake has value, and there is a risk of doing that. If we start assessing everything just for its translational utility then that is a frightening situation. (6:Rc)

For some participants, this was seen to be rather shortsighted and could lead to a future situation where there was not sufficient “blue sky” research to inform translational activity. Others raised related concerns about the loss of the serendipitous research finding because of an over-emphasis on KT. Linked to the comments around timescales (raised under Theme 3, “Ease of undertaking translation”) and how long it can take to get from discovery through to wide-scale implementation, a view was also expressed that there was a danger of raising public expectations too soon. “I think it can actually raise people’s hopes falsely, you know Phase 1 and 2 clinical trials can actually still be quite far away from being able to be used clinically” (4:R). For one participant, there was a related concern around limited resources to fund health care, leading to ethical issues around rationing and whether treatments should or could be made available regardless of cost.

Discussion Returning to the aims of our study, the key question is how can we use the findings to help us design, implement, and evaluate a faculty-wide KT strategy? And how might our learning be useful and transferable to other academic communities within health care? In terms of current perceptions and understanding, it is encouraging that the majority of interviewees recognize the complex and iterative nature of KT, consistent with the Canadian Institutes of Healthcare definition (Straus et al., 2009). However, there are clearly some individuals for whom this is a new concept and others who see it as a more linear-rational process. This highlights the potential

for the epistemological differences cited in the literature (Harvey, 2013). For most staff, it appears that KT is undertaken in a self-directed and often implicit way, with people learning “on the job.” This suggests a need to raise the profile of KT and find ways to make it a more explicit activity within research and learning and teaching, with concurrent attention to developing the related skills and knowledge among staff. Some significant barriers to engaging in KT are also apparent, notably, the observed silo ways of working, lack of skills and confidence, and a perceived lack of incentives. On this latter point, our findings raise some challenging questions about incentives and motivation within the academic sector. KT in health care is fundamentally concerned with applying researchbased evidence to improve the health care experiences and outcomes of the population. Yet in our study, respondents predominantly referred to success as measured against internally focused metrics such as number of research grants obtained and indicators of esteem. This highlights the importance of paying attention to incentives to engage in KT—and perhaps, more worryingly, the perverse incentives that could mitigate against a commitment to KT if it is not seen to contribute to individual goals and career progression. These findings illustrate that an organization—in our case a Faculty of Health—cannot simply adopt KT as a mission or aim and expect people to understand, interpret, and embrace it in the same way. Rather, deliberate strategies need to be put in place that attempt to build a shared understanding and purpose around KT and address the likely barriers to engagement. To explore these issues further, we will review the findings through the theoretical lens of boundaries and, in particular, Carlile’s (2002) concept of syntactic, semantic, and pragmatic boundaries. Although these were originally described in relation to the movement of internal knowledge, we apply them here to examine faculty members’ understanding and interpretation of KT. Evidence of all three types of boundaries is apparent within the data, as Table 5 illustrates. At the syntactic level, there are clearly issues relating to the language and terminology of KT, which is familiar to some and not to others. Similarly at the semantic level, there are different meanings attached to the concept of KT, for example, a pipeline versus a cyclical process and commercialization of a new product versus an activity that encompasses community engagement. At the pragmatic level, a number of potential barriers were identified related to incentives and rewards for KT and physical boundaries that minimized interaction within and across different disciplines. From a strategic perspective, one implication of the different types of boundaries is the need to think about specific activities or interventions that are tailored to a particular boundary (Table 5). For example, issues related

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Table 5.  Syntactic, Semantic, and Pragmatic Boundaries Identified in the Data and Strategies That Can Be Applied to Address the Boundary Issue. Type of Boundary

Evidence From the Study Data

Potential Strategies to Address the Boundary Issue

•• Unfamiliarity with the language of KT •• Use of alternative terminology, e.g., applied research, scientist practitioner

•• Creating a faculty-wide KT working group with representation from all schools •• Establishing forums to discuss and debate KT •• Agreeing a shared working definition of KT Semantic •• Pipeline vs. cyclical •• Building a interpretation of KT common vision •• Community engagement and strategy vs. commercialization of •• Creating new products opportunities •• Explicit vs. implicit to embed KT activity in learning and teaching and (new and existing) research projects Pragmatic •• Feeling that KT is •• Creating imposed by others opportunities •• Disincentives created for networking by university and wider and engaging research environment with colleagues •• KT not rewarded across traditional •• Geographical barriers boundaries to networking •• Establishing and meeting other mechanisms colleagues to encourage •• Culture of silo working and reward involvement in KT Syntactic

Note. KT = knowledge translation.

to developing a common language (syntactic boundary) might be tackled by creating an inter-disciplinary forum or working group to discuss KT and agree a definition that can be shared and refined with a wider group of staff. Other challenges such as differences in the interpretation of KT (semantic boundary) could be addressed through educational interventions and creating opportunities for staff to interact and discuss and learn about KT. However, barriers such as those related to incentives and rewards for KT (pragmatic boundary) are likely to require more sustained and negotiated discussions with a range of stakeholders within the wider university and academic policy context. This reinforces Carlile’s (2004) observation that

as the boundary becomes more complex, then efforts to navigate the boundary need to become more sophisticated and intensive. Clearly, there are no easy solutions to solving complex issues such as the metrics by which research activity is judged and rewarded, but awareness of this type of boundary provides an important insight into individuals’ motivation to engage in KT. In the longer term, it also poses questions to be considered at a policy level about how activity in KT can be incentivized and rewarded. Recent examples of attempting to assess research impact, for example, in the United Kingdom (Research Excellence Framework, 2014) and Australia (Group of Eight & Australian Technology Network of Universities, 2012), illustrate a shifting focus to value and recognize translational initiatives within an academic environment. Building on the concept of boundaries and how best to manage them, it is also helpful to return to Szulanski’s (1996) notion of “sticky knowledge” and his emphasis on developing strategies to enhance relationships and learning capacity. As the data illustrate, there is clearly a need and an opportunity to find ways to help staff “connect and communicate” across traditional disciplinary boundaries. This, in turn, means thinking about how to overcome geographical barriers, with staff based in a range of disparate locations and academic groupings, which minimize the likelihood of opportunist encounters, such as the water cooler or coffee room conversation. At this point in time, our focus is on using the insights gained from our qualitative research to engage colleagues in developing a shared vision and commitment to KT, both within the research they undertake and the courses they teach. As illustrated in Table 5, this involves a number of different activities that are beginning to address the syntactic and semantic boundaries identified through the initial qualitative study. We recognize that there will be more difficult and complex issues to deal with as we attempt to tackle pragmatic-level barriers relating to academic metrics and incentives. However, by investing time in raising the profile of KT; building staff and student awareness, knowledge, and skills; and creating more deliberate opportunities for staff to network and connect with each other, we hope that this will enhance our ability to create more meaningful partnerships and collaboration between producers and users of research in the future. Our experience suggests that undertaking this type of mapping exercise would be of benefit to other academic– health departments that are interested or engaged in KT to gain a better understanding of the context in which they are attempting to undertake translational activity.

Conclusion To our knowledge, this is the first description of how a faculty is attempting to introduce a KT strategy in a

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Harvey et al. systematic and engaged way. We believe that our study has provided valuable insights into the intra-organizational challenges that need to be addressed on the journey to maximizing the impact of our academic endeavor on patient, practice, and population health outcomes. Entering into major research partnerships might be premature or doomed to failure if we do not invest time and energy into exposing, understanding, and tackling internal barriers to KT. At the same time, it is important to acknowledge the potential limitations of our study, notably, the fact that it was insider-researchers conducting both the interviews and analysis of results, which (while unlikely) risks a biased interpretation of the findings. Also, we report the results of a single case study of one university faculty and that data collection took place at a single point in time with a purposive sample, which raises questions about the representativeness and transferability of the findings. Some of these limitations will be compensated for with our follow-on work, which is engaging with a much wider cross-section of colleagues in the university over a longer period of time. This will provide us with longitudinal data that we can use to build upon and refine the findings presented here. By sharing our study within this article, we also aim to stimulate discussion among other academics, which we hope will provide further insights into the confirmability of our findings. In terms of the next steps, we are using the findings from the qualitative study to formulate our KT strategy along the lines described. This includes establishing a faculty-wide KT working group with representation from all schools, developing a definition of KT that faculty members can sign up to, presenting a draft KT framework that encapsulates the contribution of different groups and disciplines within the faculty, and running a series of engagement events to share the study findings and co-create the KT strategy. This process is not going to provide a “quick fix” to the research–practice gap, but we believe that it will put us in a stronger position to raise the profile of KT within the faculty and the wider university and to apply more explicit and more effective KT approaches in our future work. Moreover, we are attempting to model a collaborative and iterative way of working that is consistent with the approach to KT that we are aiming to promote. Building a shared, inclusive, and visionary approach to KT within an academic–health sciences community, we believe, is an essential part of the challenge to translate research evidence into health care. Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The authors received no financial support for the research, authorship, and/or publication of this article.

Notes 1.

2.

While the word pragmatic in everyday use implies notions of realism and practicality (as opposed to idealism), Carlile draws on philosophical theories of pragmatic reasoning and uses the term in a specific sense to refer to the consequences that exist between things that are different yet dependent on each other. Research grant income in Australia is categorized according to the source of funding. Category 1 refers to funding from research schemes/programs listed on the 2009 Australian Competitive Grants Register, Category 2 to other public sector research income, and Category 3 to industry and other research income.

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Kitson, A., Roycroft-Malone, J., Harvey, G., McCormack, B., Seers, K., & Titchen, A. (2008). Evaluating the successful implementation of evidence into practice using the PARIHS framework: Theoretical and practical challenges. Implementation Science, 3. doi:10.1186/1748-5908-3-1 McKibbon, K. A., Lokker, C., Wilczynski, N., Ciliska, D., Dobbins, M., Davis, D., . . . Straus, S. (2010). A crosssectional study of the number and frequency of terms used to refer to knowledge translation in a body of health literature in 2006: A Tower of Babel? Implementation Science, 5, Article 16. Miles, M. B., & Huberman, A. M. (1994). Qualitative data analysis: An expanded sourcebook (2nd ed.). Thousand Oaks, CA: SAGE. Nutley, S. M., Walter, I., & Davies, H. T. O. (2007). Using evidence: How research can inform public services. Bristol, UK: The Policy Press. Research Excellence Framework. (2014). Impact case studies. Retrieved from http://www.ref.ac.uk/about/guidance/faq/ impactcasestudiesref3b/ Rycroft-Malone, J., Seers, K., Titchen, A., Harvey, G., Kitson, A., & McCormack, B. (2004). What counts as evidence in evidence-based practice? Journal of Advanced Nursing, 47, 81–90. Rycroft-Malone, J., Wilkinson, J., Burton, C. R., Harvey, G., McCormack, B., Graham, I., & Staniszewska, S. (2013). Collaborative action around implementation in collaborations for leadership in applied health research and care: Towards a programme theory. Journal of Health Services Research & Policy, 18(3 Suppl.), 13–26.

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Author Biographies Gill Harvey, BNurs, PhD, is a professorial research fellow at the School of Nursing, University of Adelaide, Adelaide, South Australia, Australia, and professor of Health Management, Manchester Business School, University of Manchester, Manchester, United Kingdom. Rhianon J. Marshall, BPsych (Hons), MPsych (Clin) is a psychologist in the private sector and a research assistant for the School of Nursing at the University of Adelaide, Adelaide, South Australia, Australia. Zoe Jordan, BA, MA, PhD, is an associate professor, the acting head of School of Translational Health Sciences, and the director of communication science at the Joanna Briggs Institute at the University of Adelaide in Adelaide, South Australia, Australia. Alison L. Kitson, RN, BSc (Hons), DPhil, is a professor, dean of the School of Nursing at the University of Adelaide, and the executive director of nursing in SA Health CALHN in Adelaide, South Australia, Australia.

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Exploring the Hidden Barriers in Knowledge Translation: A Case Study Within an Academic Community.

Debates about knowledge translation (KT) typically focus on the research-practice gap, which appears to be premised on the assumption that academics a...
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