Background: Intensity Modulated Radiation Therapy (IMRT) is a method of delivering high-dose radiation to tumours while sparing surrounding healthy tissues. Despite its wide availability IMRT utilization varies across Ontario. The study’s objective was to examine key steps in the implementation process and identify factors that facilitate or impede IMRT implementation. Research Methods: An embedded multiple case study design, utilizing document analysis and key-informant interviews, was employed. Four cancer centres were selected and key-informant interviews were conducted with radiation oncologists, physicists, radiation therapists, and administrators. Results: Eighteen of 21 invited key-informants participated (86% participation rate) providing a range of insights on the factors influencing IMRT implementation. Overall, three cases made progress in the implementation of IMRT, while one case had limited implementation over the same time period. Conclusion: These findings help explain the observed variation in IMRT implementation across Ontario, which is multifaceted and reflects ongoing processes of change and reinvention.

Background: Laparoscopic surgery for colorectal cancer is a novel healthcare technology, for which much research evidence has been published. The objectives of this work were to compare the oncologic outcomes of this technology across different study types, and to define patterns of adoption on the basis of the literature. Methods: A comprehensive systematic review of the literature was conducted using 1) existing systematic reviews, 2) randomized controlled trials (RCTs), and 3) observational studies. Outcomes of interest were overall survival, and total lymph node harvest. Outcomes were compared for congruence. Adoption was evaluated by means of summary expert opinions in the literature. Results: 1) Existing systematic reviews were of low to moderate quality and displayed evidence of overlap and duplication. 2) Laparoscopy was not inferior to open surgery in terms of oncologic outcomes in any study type. 3) Oncologic outcomes from RCTs and observational studies were congruent. 4) Expert opinion in the literature has been supportive of this technology, paralleling the publication of large RCTs. Conclusions: The evaluation of laparoscopic surgery for colorectal cancer in RCTs and observational studies suggests that it is not inferior to open surgery. Adoption of this technology has paralleled RCT evidence.

Clinical decision rules improve health care fidelity, benefit patients, physicians and healthcare systems, without reducing patient safety or satisfaction, while promoting cost-effective practice standards. It is critical to appropriately and consistently apply clinical decision rules to realize these benefits. The objective of this thesis was to understand how physicians use the Ottawa Ankle Rules to guide radiography decision-making. The study employed a clinical judgment survey targeting members of the Canadian Association of Emergency Physicians. Statistical analyses were informed by the Brunswik Lens Model and Social Judgment Analysis. Physicians’ overall agreement with the ankle rule was high, but can be improved. Physicians placed greatest value on rule-based cues, while considering non-rule-based cues as moderately important. There is room to improve physician agreement with the ankle rule and use of rule-based cues through knowledge translation interventions. Further development of this Lens Modeling technique could lend itself to a valuable cognitive behavioral intervention.

Background: Little is known about the use of pain management evidence in Jordanian Pediatric Intensive Care Units (PICUs). Purpose: To assess the existence, content, and the factors influencing the use of pain management evidence in Jordanian PICUs. Methods: Three studies were guided by the Promoting Action on Research Implementation in Health Services (PARiHS) framework. 1. A scoping review of the literature to identify pain management interventions in the PICU; 2. A cross-sectional and multisite survey to determine the current pain management practices, and the availability and content of practice guidelines in Jordanian PICUs; 3. A correlational and multisite survey to examine the relationship between the contextual factors and nurses’ use of pain management research evidence in Jordanian PICUs. Results: 1. Twenty-seven studies were included in the scoping review. The majority of the studies focused mainly on pharmacological interventions (n= 21, 78%). Morphine and fentanyl were the most commonly used pharmacological agents for pain management in the PICUs. The use of non-pharmacological interventions was limited. 2. Four of six eligible PICUs participated in the cross-sectional study. All four units had written pain management guidelines. Fentanyl was the most commonly used pharmacological agent in two units. Intravenous infusions of opioids were not administered for patients on mechanical ventilation in two units. The use of non-pharmacological interventions was reported in one unit. 3. From the four participating units, 73 nurses completed the correlation study survey. Social capital predicted both the instrumental and conceptual research use for pain management by Jordanian PICU nurses. Structural and electronic resources predicted the instrumental research use for pain management by Jordanian PICU nurses. Conclusions: Pain management practices and supporting guidelines varied in Jordanian PICUs. Context influences Jordanian PICU nurses’ use of research for pain management. Not all of the pain management practices in Jordan are evidence informed. There is an opportunity for improvement in pain management in Jordanian PICUs.

A adaptaÃÃo do Conhecimento em saÃde vem sendo adotada para descrever mÃtodos utilizados para a disseminaÃÃo de evidÃncias cientÃficas para os diversos atores sociais relacionados. A intenÃÃo à que estas evidÃncias estejam mais acessÃveis aos seus usuÃrios finais (pacientes, profissionais de saÃde, organizaÃÃes e gestores da saÃde) para cooperar na tomada de decisÃes sobre saÃde. Assim, a AdaptaÃÃo do Conhecimento objetiva diminuir a lacuna temporal e conceitual que hà entre a produÃÃo do conhecimento e a prÃtica do usuÃrio final. Ela à essencial para se ter melhores resultados em cuidados de saÃde, alÃm de contribuir para a diminuiÃÃo de custos na utilizaÃÃo do conhecimento, disponibilizando o conhecimento certo, para a pessoa certa, em tempo certo. Este trabalho realiza um estudo analÃtico sobre o processo de AdaptaÃÃo do Conhecimento em sistemas integrados de saÃde. A pesquisa tomou como base o modelo Knowledge to Action (KTA), desenvolvido por pesquisadores da Universidade de Toronto e do Canadian Institute of Health Research - CIHR e que tem servido de referÃncia ao sistema de saÃde canadense. Como prova de conceito do estudo analÃtico realizado utilizou-se, como cenÃrio de aplicaÃÃo, o LARIISA, uma plataforma para a tomada de decisÃo em sistema de governanÃa em saÃde. O LARIISA utiliza, na especificaÃÃo de sua arquitetura, o modelo Knowledge to Action (KTA). Ele faz uso de sistemas inteligentes e da tecnologia de sensibilidade ao contexto (context-awareness), em sua concepÃÃo. O mÃtodo de coleta de dados utilizado foi a AnÃlise Documental do livro Knowledge Translation in Health Care e os cinco domÃnios de aplicaÃÃo da plataforma LARISSA: clÃnico-epidemiolÃgico, normativo, gestÃo do conhecimento, administrativo e gestÃo compartilhada. Isto permitiu a elaboraÃÃo de mapas conceituais que traduzem a abrangÃncia local e global do projeto LARIISA, resultando na construÃÃo de cenÃrios de aplicaÃÃo. Assim, este estudo caracteriza-se como um primeiro esforÃo analÃtico sobre a gestÃo do conhecimento na plataforma LARIISA, cujo resultado propÃe alteraÃÃes na proposta inicial da arquitetura do LARIISA. / Knowledge Translation in health care has been adopted to describe the methods used for dissemination of scientific evidence to several other related social actors. The intention is for this evidence to become more accessible to its final users (patients, health professionals, organizations and health managers) to cooperate in making decision in health. In this manner, Knowledge Translation has as objective to reduce the temporal and conceptual gap that extends between knowledge production and practice for the final user. This is essential in order to obtain better results in health care, along with contributing to the reduction of costs in knowledge utilization, providing the correct knowledge, to the correct person, at the correct moment. This is an analytic study on the Knowledge Translation process in integrated health systems. The study was based on the Knowledge to Action model (KTA), developed by researchers at the University of Toronto and the Canadian Institute of Health Research â CIHR, which has served as reference for the Canadian health system. As conceptual proof of the analytic study performed, we used as application scenario, LARIISA (Laboratoire Application RÃseaux Intelligence IntÃgration SantÃ), a platform for decision making in the governance of health systems. LARIISA uses, in its framework specification, the KTA model. It uses intelligent systems and context-awareness technology in its conception. Data collection method used was documental analysis from the âKnowledge Translation in Health Careâ book and the five application domains from the LARIISA platform: clinical-epidemiological, normative, knowledge management, administrative and shared management. This permitted the elaboration of conceptual maps that translate the local and global coverage of the LARIISA project, resulting in the construction of application scenarios. Thus, this study is characterized as the first analytic endeavor on knowledge management in the LARIISA platform, whose results propose alterations in the initial proposal of LARIISA framework.

Submitted by Luciana Ferreira (lucgeral@gmail.com) on 2015-05-18T15:29:38Z No. of bitstreams: 2 Dissertação - Alexandre Bellotti Ferreira - 2013.pdf: 4657575 bytes, checksum: 881b1f7144b77397266ea80272d3ff50 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Approved for entry into archive by Luciana Ferreira (lucgeral@gmail.com) on 2015-05-18T15:32:32Z (GMT) No. of bitstreams: 2 Dissertação - Alexandre Bellotti Ferreira - 2013.pdf: 4657575 bytes, checksum: 881b1f7144b77397266ea80272d3ff50 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Made available in DSpace on 2015-05-18T15:32:32Z (GMT). No. of bitstreams: 2 Dissertação - Alexandre Bellotti Ferreira - 2013.pdf: 4657575 bytes, checksum: 881b1f7144b77397266ea80272d3ff50 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Previous issue date: 2013-02-28 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES / Providing evidence from clinical research is necessary but not enough for the provision of optimal care. Knowledge creation, distillation and dissemination are not enough in their own to ensure the use of knowledge in decision-making. Recognition of this issue has created interest in knowledge translation, also known as KT, which is defined as the methods for closing the gaps from knowledge to practice. In the context of dental implants, technological advances and the evolution of knowledge grew exponentially in the last decade, but little is known about the application of this knowledge in clinical practice. In particular, at the practice of those who should be in a first level, the knowledge multipliers (Masters / PhD). Goal: Identify changes at clinical behavior of a group of specialists which had additional training in the strict sense level (masters and / or PhD), how these changes were perceived, which methods of knowledge translation were reported and the barriers that act as an impediment for the knowledge translation process. Methodology: In this exploratory and qualitative research, the instrument used was an audio recorded interview, open, semi-structured and in-depth. The target population was composed of four dentists experts who work with dental implants and had additional training in the strict sense level (Masters/PhD). They were interviewed one at a time by the same interviewer (researcher). The interviews were manually transcribed by the interviewer and structured into categories and sub-categories that emerged according to the research objective. Results: The results showed that there were changes in clinical practice of these professionals and that, methods such as reading scientific articles and conversations with colleagues were important in this process. The lack of interest and ability to pursue scientific articles were reported as barriers to KT. Conclusions: Changes in clinical practice occurred in this group and that the combination of different methods and visualization colleagues in clinical practice are important factors in KT process. Deepening on these methods, which effectively are able to change clinical practice, opens new perspectives in the teaching / learning process focus on evidence-based practice. / As evidências científicas são importantes e necessárias, mas não são suficientes para garantir a excelência no cuidado à saúde, ou seja, a simples criação, sistematização e disseminação do conhecimento não garantem, por si só, o uso desse conhecimento na prática clínica. É crescente a busca do entendimento e aprimoramento do que se denominou “Tradução do Conhecimento”, termo utilizado para descrever os métodos de transpor a distância existente entre o conhecimento e a sua aplicação na prática clínica. No contexto dos implantes dentários, os avanços tecnológicos e a evolução do conhecimento tiveram um crescimento exponencial na última década, mas pouco se sabe a respeito da aplicação desse conhecimento na prática clínica. Em especial, na prática daqueles que deveriam ser, em um primeiro nível, os multiplicadores do referido conhecimento (mestres/doutores). Objetivo: Identificar as mudanças no comportamento clínico de especialistas que trabalham com implantes dentários, que tiveram formação adicional em nível estrito senso (mestrado e/ou doutorado), bem como de que forma essas mudanças foram percebidas, quais métodos de tradução do conhecimento foram importantes neste processo e quais barreiras forma relatadas como impedimento. Métodos: Nesta pesquisa exploratória e qualitativa, o instrumento utilizado foi uma entrevista gravada em áudio, aberta, semi-estruturada e em profundidade. A população alvo foi composta por quatro cirurgiões-dentistas especialistas, que trabalham com implantes dentários e teve formação adicional em nível estrito senso (mestrado e/ou doutorado). Estes foram entrevistados um de cada vez pelo mesmo entrevistador (pesquisador). As entrevistas foram transcritas manualmente pelo entrevistador e estruturadas em categorias e subcategorias que emergiram de acordo com o objetivo da pesquisa. Resultados: Os resultados mostraram que houve mudanças na prática clínica dos profissionais investigados e que métodos como leitura de artigos científicos e conversas com colegas foram importantes nesse processo. A falta de interesse e de habilidade em buscar artigos científicos foram barreiras relatadas com impedimentos para a mudança da prática clínica. Conclusões: Mudanças na prática clínica ocorreram nesse grupo, que ao longo de suas formações profissionais tiveram contato com diversos métodos de tradução do conhecimento e que a associação de diferentes métodos e a visualização de colegas na prática clínica são fatores importantes nesse processo de tradução. Aprofundar sobre esses métodos, que de forma efetiva, são capazes de mudar a prática clínica nos abre novas perspectivas no processo ensino/aprendizagem com foco na prática baseada em evidências científicas.

Background: Laparoscopic surgery for colorectal cancer is a novel healthcare technology, for which much research evidence has been published. The objectives of this work were to compare the oncologic outcomes of this technology across different study types, and to define patterns of adoption on the basis of the literature. Methods: A comprehensive systematic review of the literature was conducted using 1) existing systematic reviews, 2) randomized controlled trials (RCTs), and 3) observational studies. Outcomes of interest were overall survival, and total lymph node harvest. Outcomes were compared for congruence. Adoption was evaluated by means of summary expert opinions in the literature. Results: 1) Existing systematic reviews were of low to moderate quality and displayed evidence of overlap and duplication. 2) Laparoscopy was not inferior to open surgery in terms of oncologic outcomes in any study type. 3) Oncologic outcomes from RCTs and observational studies were congruent. 4) Expert opinion in the literature has been supportive of this technology, paralleling the publication of large RCTs. Conclusions: The evaluation of laparoscopic surgery for colorectal cancer in RCTs and observational studies suggests that it is not inferior to open surgery. Adoption of this technology has paralleled RCT evidence.

Clinical decision rules improve health care fidelity, benefit patients, physicians and healthcare systems, without reducing patient safety or satisfaction, while promoting cost-effective practice standards. It is critical to appropriately and consistently apply clinical decision rules to realize these benefits. The objective of this thesis was to understand how physicians use the Ottawa Ankle Rules to guide radiography decision-making. The study employed a clinical judgment survey targeting members of the Canadian Association of Emergency Physicians. Statistical analyses were informed by the Brunswik Lens Model and Social Judgment Analysis. Physicians’ overall agreement with the ankle rule was high, but can be improved. Physicians placed greatest value on rule-based cues, while considering non-rule-based cues as moderately important. There is room to improve physician agreement with the ankle rule and use of rule-based cues through knowledge translation interventions. Further development of this Lens Modeling technique could lend itself to a valuable cognitive behavioral intervention.

Background: Depression is a major health concern and self-management of depressive symptoms using patient-initiated strategies has the potential to reduce the burden of this condition. A better understanding of behaviour change related to these patient-initiated strategies is needed. Method: This randomized controlled trial study used an online survey and Knowledge Translation and Transfer theory-based educational intervention to examine the Theory of Planned Behavior model in the context of nine patient-initiated strategies for the self-management of depression and low mood. Results: Perceived Behavioural Control was identified as the single greatest predictor of Intentions to engage in strategies. Attitudes predicted Intentions to a lesser degree. Subjective Norms were not identified as unique predictors. Theory of Planned Behavior antecedent variables together explained over one third of the variance in Intentions. Intentions to engage in patient-initiated strategies were shown, in some cases, to significantly predict actual engagement in strategies. Level of depressive symptoms did not meaningfully impact any of the antecedent variables or Intentions. Results also suggest that an educational intervention based on Knowledge Translation and Knowledge Transfer principles significantly improved both Attitudes and Subjective Norms – Physician towards patient-initiated strategies. Perceived Behavioural Control and Intentions were not improved as a result of the educational intervention. Theoretical Conclusions: Findings suggest that the Theory of Planned Behavior functions well in the context of patient-initiated strategies for depression and low mood. Perceived Behavioural Control was identified as the greatest predictor of Intentions to engage in patient-initiated strategies. Results also suggest mood difficulties are not captured by the model’s antecedent variables but instead should be included as an additional variable in this model. The findings of the current study support an integrated model of Knowledge Translation and Transfer and Theory of Planned Behavior. Practical Conclusions: The current study’s findings provide a better understanding of behaviour change in the context of patient-initiated strategies and will help guide interventions aimed at improving engagement in these behaviours. Findings also provide support and recommendations for the use of Knowledge Translation and Transfer theory-based educational interventions to improve self-management of depression and low mood.

Background: Mentoring is an intervention for implementing evidence into practice, but little is known about this intervention. The overall aim of this dissertation was to examine mentoring as a knowledge translation (KT) intervention to inform clinical practice. Methods: 1) A systematic review was used to determine the effectiveness of mentoring as a KT intervention. 2) An interpretive descriptive qualitative study was conducted to explore the use of mentoring in the Registered Nurses' Association of Ontario’s Best Practice Guidelines Implementation/ Knowledge Transfer Fellowship program. Findings: 1) Of 10,669 citations from 1988 to 2012, 10 studies were eligible. Findings showed that mentoring alone (n = 1 study) improved one behavioral outcome. When mentoring was used as part of a multi-faceted intervention (n = 9), there were various effects on knowledge, beliefs/attitudes, use of research evidence in clinical practice, and the impacts on healthcare professionals, patients and organizations. 2) Qualitative interviews with 6 fellows, 8 mentors and 4 program leaders revealed that mentoring involved building relationships, establishing a learning plan, and using teaching and learning activities. Mentors were described as accessible, dedicated, and having expertise; fellows were described as dedicated, self-directed, and having mixed levels of expertise. Mentoring was described as positively impacting upon mentoring relationships, fellows, mentors, and organizations. Participants reported no negative outcomes. Conclusion: Mentoring was used as a KT intervention to support the implementation of evidence into clinical practice. The systematic review and qualitative study findings informed the Mentoring for Guideline Implementation model. Mentoring involved mentees selecting more experienced mentors who provided individualized support based on mentees’ learning needs, which resulted in mutual benefits for mentees and mentors. Future research is required to validate this new mentoring model, develop an instrument to measure the mentor-mentee relationship, and evaluate the effectiveness of mentoring as a KT intervention for guideline implementation in nursing.