Despite a substantial evidence-base for pediatric pain management, pain is not always well managed in clinical practice. Appreciative Inquiry (AI) is an innovative knowledge translation (KT) intervention that is compatible with the Promoting Action on Research in Health Services (PARiHS) framework. A prospective, repeated-measures, mixed-methods case study was conducted to (a) explore the implementation process of AI as a KT intervention in pain, (b) examine the beginning effects of AI on pain related outcomes, and (c) describe extraneous factors related to the PARiHS framework. Outcomes were measured at six and three weeks pre-intervention and three and six months post-intervention, ending with a semi-structured interview on the acceptability of the intervention. Data were analyzed using descriptive and inferential statistics, and quantitative and qualitative content analyses. Twelve nurses (nine staff and three administrative/clinical leaders) from a surgical unit at a pediatric hospital participated in the study. They perceived their context to be relatively complex, with a culture focused on clinical competence, family-centered care, and teamwork, and a transformational leadership style. Overall, participants were satisfied with the intervention structure, which consisted of four three-hour, interactive sessions delivered over two weeks to promote change based on positive examples of pain management on the unit, and suggested only minor refinements. The intervention was delivered with high fidelity and most participants (n = 11) attended all four sessions, where they developed an action plan to enhance evidence-based pain assessment documentation. There was a statistically significant improvement in participants’ pain knowledge and attitudes post-intervention. This outcome was significantly and positively correlated with participants’ attitudes towards research. Both of these factors had a significant relationship with participants’ effort to document pain assessments. Participants named AI a ‘refreshing approach to change’ because it was positive and democratic, with a focus on building on existing practices. They felt the process cultivated a positive reception to change, broadened their horizons around pain, and enhanced their team spirit. The facilitators were considered credible with effective communication skills. Given the promising results of this study, the refinement and evaluation of the AI intervention are warranted in other contexts and for other clinical practices.

Since 1995, a thrombolytic therapy, rt-PA, has been approved for use with acute stroke that significantly reduces, and sometimes reverses, neurological damage. Treatment has to be given within a few hours of the start of symptoms and can only commence once a CT-scan has confirmed a particular type of stroke. In the evidence-based medicine and knowledge translation literature, variations in practice are constituted as a problem to be solved. It is assumed that a physician decides whether or not to use this therapy based on his/her evaluation of the scientific evidence. In this thesis, I demonstrate that what are less evident in many of these claims are issues related to the social production of knowledge. Little attention is paid to who conducts research, who promotes its findings, and who is expected to implement them. The positivist discourse of evidence-based medicine assumes that research produces knowledge that is neutral and can be translated into treatment that is in the patient’s best interest. Yet these assumptions remain empirically unexamined, despite social science critiques of these processes. Institutional Ethnography is an approach in sociology developed by Dorothy Smith. Based on Smith’s understanding of the social organization of knowledge, it allows for an examination of the complex social relations organizing people’s experiences of their everyday working lives. Beginning in the experiences of physicians who provide acute stroke services, this dissertation explores an example of how best practice medicine is developed, translated, and taken up in practice across various sites in the province of Ontario. For Smith, texts mediate and organize people’s experiences. In my study, the discourses of both evidence-based medicine and knowledge translation, designed to improve patient care, come into view as managerial tools designed to control the delivery of care. I render visible how in fact things work as they do in real life settings in a way that links back actual people to the texts, or discourse, organizing their experiences. In so doing, I am able to uncover some of the assumptions and hidden priorities underlying the current emphasis on translating scientific knowledge in medicine into practice.

Despite a substantial evidence-base for pediatric pain management, pain is not always well managed in clinical practice. Appreciative Inquiry (AI) is an innovative knowledge translation (KT) intervention that is compatible with the Promoting Action on Research in Health Services (PARiHS) framework. A prospective, repeated-measures, mixed-methods case study was conducted to (a) explore the implementation process of AI as a KT intervention in pain, (b) examine the beginning effects of AI on pain related outcomes, and (c) describe extraneous factors related to the PARiHS framework. Outcomes were measured at six and three weeks pre-intervention and three and six months post-intervention, ending with a semi-structured interview on the acceptability of the intervention. Data were analyzed using descriptive and inferential statistics, and quantitative and qualitative content analyses. Twelve nurses (nine staff and three administrative/clinical leaders) from a surgical unit at a pediatric hospital participated in the study. They perceived their context to be relatively complex, with a culture focused on clinical competence, family-centered care, and teamwork, and a transformational leadership style. Overall, participants were satisfied with the intervention structure, which consisted of four three-hour, interactive sessions delivered over two weeks to promote change based on positive examples of pain management on the unit, and suggested only minor refinements. The intervention was delivered with high fidelity and most participants (n = 11) attended all four sessions, where they developed an action plan to enhance evidence-based pain assessment documentation. There was a statistically significant improvement in participants’ pain knowledge and attitudes post-intervention. This outcome was significantly and positively correlated with participants’ attitudes towards research. Both of these factors had a significant relationship with participants’ effort to document pain assessments. Participants named AI a ‘refreshing approach to change’ because it was positive and democratic, with a focus on building on existing practices. They felt the process cultivated a positive reception to change, broadened their horizons around pain, and enhanced their team spirit. The facilitators were considered credible with effective communication skills. Given the promising results of this study, the refinement and evaluation of the AI intervention are warranted in other contexts and for other clinical practices.

Osteoporosis is a major public health concern, affecting over 200 million people worldwide. There is valid evidence outlining how osteoporosis can be diagnosed and managed, but gaps exist between evidence and practice. Graham’s “Knowledge to Action” (KTA) process for knowledge translation and the Medical Research Council (MRC) framework for complex interventions were used to address these gaps. The first 4 KTA steps were collapsed into 3 phases of the PhD research plan. In PhD Phase 1, a systematic review was conducted to identify tools that facilitate decision making in osteoporosis disease management (DM). Results showed that few DM tools exist, but promising strategies were those that incorporated reminders and education and targeted physicians and patients. PhD Phase 2 used the findings from the systematic review and consultation with clinical and human factors engineering experts to develop a conceptual design of the tool. Multiple components targeted to both physicians and patients at the point of care, and which could be used as a standalone system or modifiable for integration with electronic health record systems were outlined. PhD Phases 3a and 3b were devoted to the assessment of the barriers to knowledge. In Phase 3a, a qualitative study of focus groups was conducted with physicians to identify attitudes and perceived barriers to implementing decision support tools in practice, and to identify the features that should be included in the design. Findings from 4 focus groups combined with aging research, and input from design and information experts were used to transform the conceptual design into a functional prototype. In Phase 3b, each component of the prototype was tested in 3 usability evaluation studies using an iterative, participant-centered approach to assess how well the prototype met end users’ needs. Findings from the usability study informed the final prototype, which is ready for implementation as part of the post PhD plan to fulfill the requirements of the remaining steps of the KTA and MRC frameworks.

Leadership is important to quality improvement initiatives in healthcare. However, few studies have evaluated leadership interventions to enhance nurses’ use of guideline recommendations in the field of knowledge translation. Purpose: To develop and evaluate an intervention designed to operationalize a leadership strategy composed of relations, change, and task-orientated leadership behaviours, and to examine its influence on nurses’ use of guideline recommendations in home-care nursing. Design: Sequential mixed methods pilot study with post-only cluster randomized controlled trial. Methods Phase I: Intervention Development 1. A participatory approach was used at a community healthcare organization with 23 units across the province of Ontario, Canada. The guideline selected was developed by the Registered Nurses’ Association of Ontario for the assessment and management of foot ulcers for people with diabetes. 2. Integrative literature review, qualitative interviews, and baseline chart audits were conducted. 3. Four units were randomized to control or experimental groups. 4. Clinical and management leadership teams participated in a 12-week intervention consisting of printed materials, interactive workshop, and teleconferences. Participants received summarized chart audit data, identified priority indicators for change, and created a team leadership action plan to address barriers and influence guideline use. Phase II: Evaluation 5. Chart audits compared differences in nursing process and patient outcomes. Primary outcome: eight-item nursing assessment score. 6. Qualitative interviews evaluated the intervention and leadership behaviours. Results: No significant difference was found in the primary outcome. A significant difference was observed in nurses’ documentation of five priority indicators chosen by the experimental groups (p=.02). Gaps in care included: 53%, 76%, and 94% of patients not assessed for ulcer depth, foot circulation, or neuropathy (respectively); 75% and 93% did not receive wound debridement or hydrogel dressings. Receiving data to identify priority indicators for change and developing a leadership action plan were reported as useful to guideline implementation. The experimental group described using more relations-oriented leadership behaviours conducting audit and feedback, and sending reminders. Conclusion: Findings from this pilot study suggest that leadership is a team process involving relations, change, and task-oriented behaviours enacted by managers and clinical leaders. A leadership model is proposed as a beginning taxonomy to inform future leadership intervention studies.

Aim: This paper is a report on a study that explored the professional development of intensive care unit nurses in journal clubs. Background: Evidence-based practice is important in nursing care (Krom, Batten, & Bautista, 2010). However few nurses feel comfortable using evidence to guide their practice (Pravikoff, Tanner, & Pierce, 2005). Journal clubs are a way to establish science as conversation (Wright, 2004) and foster knowledge translation for evidence-based nursing practice (Goodfellow, 2004). Methods: Monthly journal club meetings were held with the participation of a total of 71 healthcare professionals (65 nurses, 2 physicians, 2 pharmacists, 1 physiotherapist, and 1 respiratory therapist), who worked in two intensive care units of an Ontario hospital. After six months of meetings, 21 individual interviews were conducted with nurses, physicians, pharmacists, and nurse educators. Additional data collection included two focus groups, surveys, a review of staff meeting minutes, and researcher field notes. Findings: Journal clubs provided nurses with incentive to read research articles, improved nurses’ confidence in reading research, created a community of peers who worked collaboratively to improve clinical practice, provided a structure for nurses to reflect-on-practice, and led to reported changes in clinical practice. However, the data suggests that any gains in competence of nurses with the critical appraisal of research articles were probably modest. Barriers to participating in journal clubs and evidence-based practice are also identified. Conclusion: Journal clubs can foster knowledge translation and evidence-based practice through creating a community of practice and by providing nurses with motivation, structure, and confidence to read research articles. However, nurses reported a lack of critical appraisal skills and uncertainty about how to implement evidence into practice. Journal clubs may have a greater impact when implemented alongside other knowledge translation strategies such as working with clinical nurse specialists in order to enhance evidence-based practice.

Background and Rationale: There is a well-documented practice gap in the rates at which evidence-based smoking cessation treatments are delivered to patients in primary care settings. Multi-component intervention that combine practice, provider, and patient-level supports have been shown to increase the rates at which primary care providers deliver smoking cessation treatments to patients and increase rates of smoking abstinence amongst patients. The incremental value of adjunct telephone-based smoking cessation counselling when delivered as part of a multi-component intervention has not been examined. Aim: The primary objective of this study was to determine whether adjunct telephone-based smoking cessation follow-up counselling (FC), when delivered as part of a multi-component intervention program within primary care clinics is associated with increases in (a) the delivery of evidence-based smoking cessation treatments, (b) patient quit attempts, and (c) patient smoking abstinence when compared to the provision of practice and provider supports (PS) alone. The secondary objective of this study was to determine whether the introduction of a multi-component smoking cessation program is associated with increased delivery of evidence-based smoking cessation treatments by primary care providers and patient smoking outcomes, compared to pre-intervention rates. The study also sought to examine the association between patient, provider, clinic and implementation factors, and study outcomes. Methods: A two-group, pre-post cluster randomized controlled trial was conducted. Eligible clinics were randomly assigned to the PS group or FC group. Both groups were supported with implementing a multi-component intervention program that involved outreach facilitation visits, provider training, real time provider prompts and patient tools, and performance feedback. Clinics assigned to the FC group were also able to refer patients who smoke to a telephone-based follow-up support program for supplemental counselling support. An exit survey was completed with a cross-sectional sample of patients who smoked daily at each study clinic before and after the introduction of the intervention program, and all patients were contacted 4 months later to complete a brief telephone-based interview. Outcome measures included the rate at which evidence-based smoking cessation treatments (5As: ask, advise, assess, assist, arrange) were delivered to patients, the number of patients who made a quit attempt, and patient smoking abstinence at the 4-month follow-up. All data was analyzed using multi-level hierarchical modelling. Results: Seven family medicine clinics and 115 providers were enrolled in the study. A total of 12,585 patients were screened, and 835 eligible patients (mean age 45.8 SD± 14.6, 41% male) who smoke participated in the study. Contrary to the study hypothesis, a higher and statistically significant 7-day point prevalence abstinence (OR 6.8, 95% CI 2.1-21.7; p=<0.01) and continuous abstinence (OR 13.7, 95% CI 2.1-128.3; p=<0.05) rate was observed in the PS group compared to the FC group at the post-assessment after controlling for differences in smoking cessation rates between intervention groups during the baseline period. The introduction of the multi-component intervention program was associated with higher rates of provider 5As delivery and patient quit attempts compared to baseline, with no differences between groups documented. The odds ratios (OR) and 95% confidence intervals (CI) for 5As delivery between the pre- and post-intervention assessments for both intervention groups combined were: “ask” (OR 1.5; 95% CI 1.1, 2.0); “advise” (OR 2.0; 95% CI 1.5, 2.7); “assess” (OR 2.1; 95% CI 1.6, 2.9); “assist” with cessation (OR 2.30; 95% CI 1.70, 3.12); “arrange” (OR 1.9; 95% CI 1.2, 3.0); and “patient quit attempts” (OR 1.4; 95% CI 1.04, 1.94). Differences in 7-day point prevalence abstinence were not statistically significant between the pre- and post-intervention assessments (OR 1.5; 95% CI 0.94, 2.5). The study documented intra-provider variability in the rates at which evidence-based smoking cessation treatments are delivered to patients. Patient characteristics (readiness to quit, time to first cigarette, previous quit attempt in the last year), and the purpose of the clinic visit being for an annual health exam were associated with higher rates of 5As delivery. Conclusion: This is the first study to evaluate a multi-component smoking cessation intervention within the primary health care setting in Canada. The study findings demonstrate that the introduction of a multi-component intervention program in primary care settings was associated with significant improvements in the rates at which providers deliver evidence-based smoking cessation treatments, and increase patient quit attempts. The added value of adjunct telephone counselling was not evident at the 4-month follow-up. The conclusions that can be drawn from the present study are limited by the study design and sample size. A larger trial is required to conclusively determine the impact of the program on long-term smoking abstinence and examine the importance of clinic-level variables in explaining observed differences between study clinics.

The purpose of this study was to create a model for student learning in knowledge translation and transfer in Ontario. The study was informed by two focus groups, each associated with a student research communications skill development program at the University of Guelph, called Students Promoting Awareness of Research Knowledge (SPARK). One focus group (n=9) consisted of current and former SPARK participants. The second focus group (n=10) consisted of SPARK stakeholders who had variously supported SPARK through projects or benevolence, or had helped administer the program. Based on focus group feedback, a conceptual model was developed showing how SPARK participants translate knowledge from university researchers and transfer it to members of society, various communities (agriculture, health, environment, etc.) and stakeholders including the media, government and industry.

Serious gaps between best and actual stroke rehabilitation practices continue to exist, even with the plethora of evidence and guidelines for stroke best practice management. To address this knowledge gap with an effective knowledge translation (KT) intervention, six steps of the Knowledge to Action (KTA) Model were applied to these specific research objectives: 1) to conduct a systematic review to examine evidence on the effectiveness of single/multi-component KT interventions for improving knowledge, attitudes, and rehabilitation practice behaviors of occupational therapists (OTs) and physical therapists (PTs), in order to inform the design of a KT intervention; 2) to conduct usability testing to explore factors that facilitate or hinder OTs' and PTs' use of an evidence-based, stroke rehabilitation-specific e-learning resource (Stroke Engine; www.strokengine.ca), as a preliminary step in its potential use as a KT intervention; and, 3) to conduct a KT intervention study to determine the extent of knowledge acquired regarding stroke rehabilitation best practices by OTs and PTs while using Stroke Engine as an e-learning KT intervention for three months. A sub-objective was to identify the association between knowledge acquired and factors related to the clinician, their work environment, and adherence to the KT intervention. Main findings from this research agenda suggested that use of active, multi-component KT interventions resulted in some knowledge gains among physical therapists, but additional research was needed to understand impact of these strategies on occupational therapists. During Stroke Engine testing, factors hindering its use were identified and the website was modified to maximize its usability as an e-learning KT intervention. Clinicians were satisfied with Stroke Engine as it provided them with the latest stroke evidence in a quick, user-friendly format. Finally, significant improvements in clinicians' proportion of 'evidence-based' responses on the Stroke Rehabilitation Knowledge Questionnaire were observed between baseline and following Stroke Engine use as a KT intervention. Intensity of Stroke Engine use was the most significant predictor for clinicians' improved 'evidence-based' knowledge on the Questionnaire. It was concluded that Stroke Engine has promise as an effective e-learning KT intervention for enhancing rehabilitation clinicians' knowledge of stroke best practices.

Model Forests were developed to bridge the gap between the emerging policy and the practice of sustainable forest management (SFM) in the early 1990s and, as such, to facilitate uptake of research findings into practice. The purpose of this study was to explore mechanisms that may explain why some research results are used in the policy and practice of SFM and others are not. Based on interviews in three Model Forests in Canada, the most prominent factors influencing research utilization identified were (1) relevance of the research findings to users’ needs, (2) effective research design and scientific credibility, and (3) user involvement in the research process. However, it was evident that there is no one factor that influences uptake, but rather a combination dependent upon the circumstances of each situation. This study also deepens understanding of the science–practice/policy interface by exploring the notion of Model Forests as boundary organizations.