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Knowledge transfer and exchange frameworks in health and their applicability to palliative care: scoping review protocol Lucia Prihodova, Suzanne Guerin & W. George Kernohan Accepted for publication 4 February 2015

Correspondence to S. Guerin: e-mail: [email protected] Lucia Prihodova MSc PhD Postdoctoral Research Fellow School of Psychology, University College Dublin, Ireland Suzanne Guerin BA PhD Senior Lecturer in Research Design & Analysis School of Psychology, University College Dublin, Ireland W. George Kernohan BSc PhD Professor of Health Research Institute of Nursing and Health Research, School of Nursing, Ulster University, Newtownabbey, Co Antrim, Northern Ireland, UK

P R I H O D O V A L . , G U E R I N S . & K E R N O H A N W . G . ( 2 0 1 5 ) Knowledge transfer and exchange frameworks in health and their applicability to palliative care: scoping review protocol. Journal of Advanced Nursing 71(7), 1717–1725. doi: 10.1111/jan.12642

Abstract Aim. To review knowledge transfer and exchange frameworks used in health, to analyse the core concepts of these frameworks and appraise their potential applicability to palliative care. Background. Although there are over 60 different models of knowledge transfer and exchange designed for various areas of the fields of health care, many remain largely unrefined and untested. There is a lack of studies that create guidelines for scaling-up successful implementation of research findings and of proven models ensuring that patients have access to optimal health care, guided by current research. Design. The protocol for this scoping review was devised according to the guidelines proposed by Arksey and O’Malley (2005) and Levac et al. (2010). Methods. The protocol includes decisions about the review objectives, inclusion criteria, search strategy, study selection, data extraction, quality assessment, data synthesis and plans for dissemination. Discussion. The review will allow us to identify the currently used models of knowledge transfer and exchange in healthcare setting and analyse their applicability to the complex demands of palliative care. Results from this review will identify effective way of translating different types of knowledge to different PC providers and could be used in hospital, community and home based PC and future research. Keywords: knowledge transfer and exchange, nurses/nursing, palliative care, research implementation, scoping review

Introduction Due to an ageing population and increasing number of patients with malignant and chronic diseases, there is an increased need to find effective ways of translating © 2015 John Wiley & Sons Ltd

knowledge for palliative care (PC) into practice. Even the most compelling research findings, which could influence practice, can do so only if adopted and embedded across all levels of healthcare systems (Grimshaw et al. 2006). Bero et al. (1998) in their review of interventions promoting the implementation of research findings conclude that 1717

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Why is this review needed? ● Findings on effective knowledge transfer and exchange strategies from one clinical setting cannot always be extrapolated to other setting. There is, however, lack of innovative studies that inform the application of knowledge transfer and exchange strategies across various healthcare settings to enable evidence-based practice. ● Applying research findings into practice in palliative care is difficult due to its broad, holistic and interdisciplinary approach, which offers complex interventions and comprises multiple interacting components and dimensions. ● Analysis and synthesis of existing knowledge transfer and exchange frameworks would identify their commonalities and core concepts, appraise applicability of different frameworks for different contexts of palliative care services but it also may lead to creation of a new mid-range model. ● There is a lack of studies exploring knowledge transfer

(Clark 2007) and is now recognized as a dynamic medical specialty with an implicit interdisciplinary nature (Grant et al. 2009). Although traditionally focused on patients with advanced cancer, recent studies show that there is an increasing proportion of older people with a chronic nonmalignant condition in need of PC (Gomez-Batiste et al. 2014). It is estimated that in a middle-high income countries, 75% of all deaths are from chronic progressive disease (Gomez-Batiste et al. 2012) and at least 63% of all deaths may need palliative care (Murtagh et al. 2014). Access and provision of PC across and within regions varies, especially for older people and those living with nonmalignant disease who were identified as two underserved groups with limited access to specialist care in Europe (Pivodic et al. 2013). Globally, there is an increasing need for palliative and end-of-life care due to ageing population and increasing cancer prevalence, making PC a major but often neglected public health issue (May et al. 2014).

models and methods in the setting of palliative care. As part of a large scale international innovative study, findings from this review will inform palliative care practice development.

undertaking reviews in the area of knowledge transfer and exchange (KTE) is complicated by the inherent complexity of process and ‘the variability in the methods used and the difficulty of generalizing study findings across various healthcare settings’ (Bero et al. 1998, p. 468), such as PC which is provided in both community and in inpatient settings. Applying research findings into practice in palliative services is especially difficult as PC is, by definition, based on broad, holistic and interdisciplinary approach and offers complex interventions, which often comprise multiple interacting components and dimensions (Morrison & Meier 2004, Currow et al. 2009, Evans et al. 2013). In addition, although there is a large number of studies in KTE in health, the predominant focus remains on the policy-makers and physicians, while only limited number of studies explore the KTE methods in the frontline staff such as nurses, social care workers, family carers or the stakeholders themselves (Gagliardi et al. 2011). This protocol is the first part of a larger international innovative study aimed at development and practice and policy implementation of KTE model and tools designed specifically for palliative care for children and adults in Republic of Ireland and Northern Ireland.

Background Palliative care has long tradition (Lutz 2011), however, its development rapidly accelerated over the last 50 years 1718

Palliative care The World Health Organisation provides separate definitions of adult and paediatric palliative care, both emphasize its complexity and holistic approach by addressing physical, psychosocial and spiritual needs, the necessity to support family of person undergoing palliative care and its continuity starting with the time of diagnosis of a life-threatening illness and continues throughout it. The definition of adult palliative care additionally focuses on maintenance of quality of life and prevention and relief of suffering, while the one of paediatric palliative care also stresses the requirement of a broad multidisciplinary approach and the possibility of provision of in different settings, including children’s homes (World Health Organisation 1998, Sepulveda et al. 2002). Although the definition is explicit in the importance of addressing the needs of body, mind and spirit, recent studies indicate that some physicians find it difficult to talk openly with their patients about their endof-life needs (Fitzsimons et al. 2007) and that even though most patients do receive physical care at the end of life, the level of psychosocial and spiritual care provision is often lagging behind (Van den Block et al. 2008) and thus the psychosocial and spiritual needs of patients and their caregivers often remain unmet (Fitzsimons et al. 2007, Ventura et al. 2014). Family carers play an important role in supporting palliative patients both at home and in inpatient settings (Ferrell et al. 2008, Stajduhar & Cohen 2008). Caring for terminally sick family member can be demanding as carers face several challenges, such as accessing community services (Fitzsimons et al. 2007). Family carers often become aware © 2015 John Wiley & Sons Ltd

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of the extent of their role after they accept it (Mehta et al. 2014) and to carry it out effectively and avoid distress and frustration, they require education and care (Ferrell et al. 2008, Stajduhar & Cohen 2008, Mehta et al. 2014). Continuous support and education is also essential for medical staff and the patients themselves. A study conducted by Wilkie and Ezenwa (2012) on pain management in PC identified the consequences of gaps between research and application of its findings to practice. Their findings indicate that pain and symptoms are inadequately assessed and managed in PC and end-of-life care, due to barriers related to patients such as misconceptions, fears and concerns about pain medication and side effects and due to barriers related to the providers such as lack of knowledge and skill in pain assessment, analgesics and side effects (Wilkie & Ezenwa 2012). In essence, palliative and end-of-life care, requires complex and yet individual-specific service delivery (Mularski et al. 2007). There is a need for studies that create guidelines and a roadmap for scaling-up successful implementation and dissemination of proven models of care to cater to the needs of all patients (Unroe & Meier 2013) their caregivers and healthcare staff.

of terms and discrepancies in language, the various definitions of KTE capture communication of knowledge to relevant stakeholders through a variety of methods (Pentland et al. 2011) with the ultimate aim to improve the healthcare system and the health of individuals (Graham et al. 2007). Published reviews have also identified over 60 different models of KT across the fields of health care, social care or management, many of which remain largely unrefined and untested (Graham et al. 2007, Mitton et al. 2007, Ward et al. 2009, Wilson et al. 2010). There is a consensus that in approaching the KTE field, development of testable and useful interventions should be guided by a defined framework and that it is critical to find a fit between the chosen theoretical perspective of the framework and the context of its application (Armstrong et al. 2006, Estabrooks et al. 2006). Some researchers argue that since there is an imperfect evidence base to support decisions about the likelihood of efficacy of particular KTE strategy in different circumstances, there is a need for further research to develop and validate a new coherent KTE model (Grimshaw et al. 2004, Colquhoun et al. 2014), while others stress that rather than developing a new KTE framework, research should evaluate the applicability of existing ones. Mitton et al. (2007) conclude that when it comes to KTE frameworks, ‘one size does not fit all’ and there is a need for more research to inform the application of KTE strategies across various contexts (Mitton et al. 2007). Findings from one clinical setting cannot always be extrapolated to other setting (Sinuff et al. 2013), as the effectiveness of interventions depends on the context (Brouwers et al. 2011, LaRocca et al. 2012, Scott et al. 2012). Analysis and synthesis of existing frameworks could therefore allow us to identify their commonalities, their core concepts, appraise applicability of different frameworks for different contexts but it also may lead to creation of a new mid-range model. This review is a part of a large scale innovative study designed to explore a KTE in palliative care and its’ output – a KTE model will be implemented and evaluated in palliative care practice in a later study. The fact that PC can now consider KTE is a testament to the growth of its evidence base and it is important to explore the most effective ways of disseminating and implementing existing evidence into practice (Kutner 2011). To date, only a few studies have explored the application of KTE methods in PC. Cooper and Hewison (2002) conducted a study where action research methodology and audit process were combined to create a framework for intervention to increase quality of service (Cooper & Hewison 2002). Chan et al. (2012) carried out a KTE project aimed to promote public awareness

Health care implementation challenges Diffusion of innovation is a challenge in all industries including health care. Although health care is rich in evidence-based innovations, they often disseminate slowly, which results in under-use of effective care, over-use of unhelpful treatments and thereby in negative outcomes in patients (Berwick 2003). Evidence-informed decision-making does not imply that all health policy and practice decisions should be determined by research evidence only, but rather that research evidence should be ‘considered in the context of the setting or circumstance, societal expectations, healthcare resources and professional expertise’ (Dobbins et al. 2009, p. 2). There are as many as 100 terms that explore, describe and promote the use of research in practice (McKibbon et al. 2013), such as implementation science or research utilization in the Europe or dissemination, diffusion, knowledge translation or knowledge transfer in North America (Straus et al. 2009). In this protocol we use the term knowledge transfer and exchange (KTE), which has been historically used to describe variety of activities such as applied health research linkage and exchange and dissemination (Graham et al. 2006) and is defined by Kiefer et al. (2005) ‘as an interactive and iterative process of imparting meaningful knowledge between research users and research producers’ (Kiefer et al. 2005, p. I-13). Despite the plethora © 2015 John Wiley & Sons Ltd

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and appreciation of the benefits of end-of-life care through exhibitions aimed at general public and 2-day workshop for medical staff on advance planning (Chan et al. 2012). Tieman (2012) created an automated search filter and an online hub for GPs and primary care workers to provide them with a profession specific content and enable rapid and direct access to relevant resources (Tieman 2012) and finally Kaufert et al. (2013) applied the theory of ethical safe space to facilitate community debate between policy-makers, researchers and end point users (Kaufert et al. 2013). All four studies considered their results as successful; however, whether their interventions were based on a theoretical framework is unclear as is the possibility of application to other cohorts.

The review Aim The purpose of this review is to describe frameworks of KTE used in health sciences and to appraise their suitability for palliative care. Objectives The main objectives of the scoping review proposed in this protocol are:

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to identify and describe published frameworks/concepts of knowledge transfer and exchange used in health sciences, to analyse the core concepts of these frameworks, to appraise the relevance and suitability of these components for different providers of palliative care, such as family carers or nursing staff, for different settings, such as homecare or inpatient care and for the transfer of specific dimensions of palliative care, such as physical, psychosocial and spiritual.

Methodology Study design This is a protocol for a collaborative scoping review that will use tools of thematic/narrative analysis to interpret the results. This protocol and the future scoping review are conducted as a result of collaboration between University College Dublin (UCD), the University of Ulster (UU) and the All Ireland Institute for Hospice and Palliative Care (AIIHPC) to ensure production and sharing of relevant and practicable new knowledge. Collaborative research production and dissemination was established as

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an effective way to identify the knowledge needs and practicability of its results (Pentland et al. 2011). The authors will consult the stakeholder throughout the project to increase the usability of the review products and link it to current practice (Saul et al. 2013). The protocol was designed and approved by co-authors as and circulated for review by the Research Steering Committee of the AIIHPC. A scoping review methodology will be used to conduct this study. Unlike systematic reviews, scoping reviews aim for breadth and comprehensiveness, rather than depth (Arksey & O’Malley 2005). The protocol is a guide for performance of the review and will be revised as needed. The scoping review is designed accordingly with the rigorous methodology proposed by Arksey and O’Malley (2005) and the guidelines proposed by Levac et al. (2010). The review will follow the six steps of scoping review:

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Identification of research question Identification of relevant studies (search for relevant studies) Study selection Quality appraisal and data extraction Collation, summarization and report of results Dissemination of findings to the stakeholders.

Since the focus of the review will be to explore the concepts of KTE, we will base our review on systematic literature review method used commonly for clinical research but will include comparative and thematic/narrative synthesis rather than quantitative analysis. Therefore, at step number 5 – Collation and report of results – we will additionally use techniques of thematic/narrative analysis of the results to identify the common components of the KTE frameworks and determine their relevance and applicability to palliative care. Search methods We have consulted a research librarian to develop and implement search strategies to identify evidence relevant to the review objectives. Our search strategy is designed to be as extensive as possible to identify all possible eligible studies, which will be then refined according to the inclusion and exclusion criteria. Electronic searches The following databases will be included in the search:

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MEDLINE, EMBASE (Elsevier), CINAHL Plus (EBSCO),

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Knowledge transfer and exchange in palliative care: review protocol

PsycINFO (Proquest), Social Services Abstracts, Applied Social Sciences Index and Abstracts (ASSIA).

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The reference lists from included studies will be screened to ensure literature saturation.

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Search terms The primary search terms will include four main terms and their variations: knowledge (evidence, research, information, data), transfer (exchange, generation, translation, uptake, mobilization, dissemination, implementation), framework (model, concept) and health care (health system, health service, healthcare provider). As recommended by the research librarian, we will apply proximity operators of 15 between first two search terms ‘knowledge’ and ‘transfer’ to ensure the search yields results where the phrases are used in a sentence. The exact search commands are listed in the supporting information Data S1.

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Identification

Inclusion/exclusion criteria We will include all studies that comply with inclusion criteria:

Records identified through database searching (n = )

Introduce an original (or adapted) explicit framework, model or concept of KTE. Provide a detailed description and explanation of the framework/concept. Are applied in health care setting. Are implementation studies, i.e. discuss implementation of a specific KTE strategies Published in or before 2014. English language only. Published in peer-reviewed publications only.

We will exclude studies that:

• • •

Refer to KTE in a wider context, without providing any details about the process elements. Present KTE methods and tools without a clear reference to any framework or underlying concept. Non-implementation papers.

Search outcome The studies yielded in the search will be imported into EndNote and a duplicate analysis will be run to identify and remove any duplicates. The remaining titles and abstracts of studies will be reviewed to determine their relevance and to ensure they fit the inclusion criteria. If it is impossible to

Additional records identified through other sources (n = )

Included

Eligibility

Screening

Records after duplicates removed (n = )

Records screened (n = )

Full-text articles assessed for eligibility (n = )

Records excluded (n = )

Full-text articles excluded due to not fitting the inclusion criteria (n = )

Studies included in qualitative synthesis (n = )

Studies included in narrative analysis (n = )

Figure 1 Flow diagram of the systematic review (modified from Moher et al. (2009)) © 2015 John Wiley & Sons Ltd

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determine the relevance of the study from its title and abstract, the full text will be evaluated (Figure 1). Two researchers will independently undertake screening of the study titles and abstracts without conferring and will confer once they have individually agreed which papers they wish to consider for full-text screening. Only then they will meet to discuss which papers should be included in the review. If the two researchers cannot agree, a third one will be asked to arbitrate. Quality appraisal While the methodology proposed by Arksey and O’Malley (2005) intentionally omits quality appraisal of the studies included in a scoping review (Arksey & O’Malley 2005), it has been identified as one of its possible methodological drawbacks (Levac et al. 2010). For the purposes of this review it was deemed to be important to apply a low threshold quality appraisal to the studies fitting the inclusion criteria outlined above. The threshold will be defined using the quality appraisal of ‘fatal flaws’ as described by Dixon-Woods et al. (2006). This appraisal consists of five questions concerning the methodological quality of studies considered for review (Dixon-Woods et al. 2006; Table 1). Data extraction A data extraction protocol will be used to extract data from each study. Two researchers will independently read each article and extract relevant data. A descriptive analytical method will be used to extract the information from each study. Studies will be classified as either ‘seminal’ (where a new model was proposed) or ‘implementation’ (where a specific model was appraised in practice). Charting will be considered as an iterative process – we will continually extract data and update the data-charting form and where additional categories may be identified through completion of the search and communication with team mem-

Table 1 ‘Fatal flaws’ appraisal criteria (Dixon-Woods et al. 2006). Yes Are the aims and objectives of the research clearly stated? Is the research design clearly specified and appropriate for the aims and objectives of the research? Do the researchers display enough data to support their interpretations and conclusions? Do the researchers provide a clear account of the process by which their findings were produced? Is the method of analysis appropriate and adequately explicated?

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No

bers. The data extraction form will include at least the following items:

• • • • •

General information on the publication (Authors, Title, Date, Type) Study details (Aims, Location, Setting, Participants) KTE framework (Name, Description, Objectives, Intended outcomes) Method used by the framework (Description, Type, Facilitator, Duration) Outcomes (Outcomes measures used, Cost data)

Two authors will test the extraction list by applying it to two studies selected randomly from the pool of studies included for full-text screening. Based on this test, items will be added or removed, to ensure the comprehensiveness of the list. Synthesis The data arising from our data collection will be collated and summarized in a quantitatively (using a simple numerical count) and qualitatively (drawing on narrative/thematic synthesis). Data synthesis and analysis will be conducted by the authors and discussed in the research team to ensure validity and consistency of the synthesis. Due to the diversity of the models, a narrative approach will be used for synthesis. Consequently, we will conduct a thematic/narrative analysis of the results to extract the common components of the KTE frameworks and use them as a basis for identifying recurrent themes. We will then determine their relevance and the transferability for the palliative care and identify their applicability in different contexts, such as hospital care, home care and providers, family carer, nurse, social worker, etc.

Ethical considerations This study operates with secondary findings from primary research and therefore no formal approval or consent is necessary. Reviewers will make an explicit declaration of conflict of interest with any of the studies included/ excluded for the review. This study will be subject to peer review from the University College Dublin, Ulster University and All Ireland Institute of Hospice and Palliative Care.

Validity and reliability/rigour The scoping review will be carried out consistent with the methodology presented by Arksey and O’Malley (2005) © 2015 John Wiley & Sons Ltd

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and further recommendations published by Levac et al. (2010).

Discussion There are several different terms, definitions and model describing the process of application of research findings in practice. This review will allow us to identify the models of KTE used in healthcare settings and analyse their possible applicability to the complex demands of palliative care. As a part of a larger innovative study, the resulting KTE model will be stress-tested in several case studies to appraise its efficacy, before disseminating it to PC practice in the Republic of Ireland and Northern Ireland.

Limitations The lack of consistency in the KTE terminology may impede our search, in spite of the broadness of proposed search terms. Additionally, although there is currently a large number of models and frameworks of KTE, it is possible that several studies will not be included in this review due to insufficient description of the model and its intended application. Nevertheless, wherever possible we will contact the authors to obtain clarification to ensure comprehensive approach is adopted.

Conclusions Results from this review will identify effective way of translating different types of knowledge to different PC providers and could be used in hospital, community and home based PC and future research.

Funding This research was funded by All Ireland Institute of Hospice and Palliative Care and the Health Research Board.

Conflict of interest No conflict of interest has been declared by the authors.

Author contributions All authors have agreed on the final version and meet at least one of the following criteria [recommended by the ICMJE (http://www.icmje.org/ethical_1author.html)]: © 2015 John Wiley & Sons Ltd

Knowledge transfer and exchange in palliative care: review protocol

• •

substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content.

Supporting Information Additional Supporting Information may be found in the online version of this article at the publiser’s web-site.

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Knowledge transfer and exchange in palliative care: review protocol

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Knowledge transfer and exchange frameworks in health and their applicability to palliative care: scoping review protocol.

To review knowledge transfer and exchange frameworks used in health, to analyse the core concepts of these frameworks and appraise their potential app...
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