Chapter 2Learning from the literature

Notes on the literature search

This review updates and builds on work previously carried out by Bullock et al.;⁶⁶ therefore, literature searches for the preparation of the current document were limited to publications post 2010. A broad search was carried out on Web of Science, PubMed, Ovid MEDLINE, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCOhost and Google Scholar^™ (Google Inc., Mountain View, CA, USA) using appropriate forms of the terms, ‘knowledge AND transfer AND healthcare’, ‘knowledge’ AND (transfer OR translation OR mobili*ation) AND healthcare’, ‘innovation AND healthcare AND implementation’, knowledge AND (transfer OR exchange OR mobili*ation OR intermediatr* OR boundary spanners), ‘knowledge AND broker OR intermediary AND healthcare’, and ‘CLAHRC’. In addition, we sourced earlier papers from the citations of relevant papers and were vigilant for notifications of papers/reports as they were published. We complemented the electronic search by hand-searching two key journals (Implementation Science and Journal of Health Services Research and Policy) and searching the NIHR Journals Library of completed projects (www.journalslibrary.nihr.ac.uk). Grey literature relating to KIT policy in England and Wales was also reviewed (see Appendix 1).

Knowing knowledge

Knowledge is perhaps the most easily grasped of our terms, but the most difficult to define. Some authors have classified knowledge according to the degree of analysis or inherent conceptual complexity.^69,70 Furthermore, literature on knowledge transfer is not narrowly limited to the transfer of facts to answer ‘how’ questions. Rather, although knowledge in this context is seen to include facts and information, importantly, it is also recognised as being about understanding. Knowledge in this sense can be both theoretical and practical, derived from education and experience. However, it is useful to illuminate the interpretation of terms, as they embody implicit assumptions about how knowledge may be transferred, exchanged and mobilised. The different terms used are associated with different concerns and values, and these have practical consequences. Conceptualising knowledge as empirical information, facts or data decontextualises and commodifies it as something that can be ‘moved around’.^4,71 Alavi and Leidner,⁷² writing about the conceptual foundations of knowledge management, describe the relationship between knowledge and values, experience and context. They explain how knowledge ‘originates and is applied in the minds of knowers’ and how in organisations ‘it often becomes embedded not only in documents or repositories but also in organizational routines, processes, practices and norms’.⁷² This quotation raises the distinction between explicit knowledge, written and recorded in documents, and the implicit or tacit knowledge held by individuals, often without awareness of it and revealed in organisational customs.

Related to the tacit–explicit dimension of knowledge is whether it is understood as individual or social.⁷² The distance between tacit (residing in the individual, difficult to transfer) and explicit knowledge (socially and organisationally located) underscores the challenge of identifying, articulating and transferring individually held knowledge.^73–76 Szulanski⁷⁷ also describes how the ‘stickiness’ of knowledge can hamper its movement, and distinguishes different points at which stickiness is important, including initiation stickiness (which may be affected by competing priorities, for example) and implementation stickiness.

These issues are relevant to knowledge transfer and innovation, as they define what counts as knowledge, and influence how and if it can be transferred. A study of knowledge transfer necessarily gives greatest focus to explicit knowledge, and academic research in particular.

Knowledge and evidence

One issue that is particularly important in the health-care context is the relationship between knowledge and evidence. Knowledge and evidence are contested concepts. In health-care literature, knowledge is often synonymous with evidence and aligned with the principles of evidence-based medicine. Innvaer⁷⁸ notes that a ‘call for evidence-based [decision-making] is also a call for the use of scientific methods in data collection and in the validation of information’. However, in health care, as well as evidence of effectiveness derived from traditional randomised controlled trials, evidence also needs to encompass feasibility, acceptability and appropriateness.⁷⁹

The implicit position of the NIHR,⁸⁰ in relation to this field of inquiry, is complex. In the commissioning brief for this study, they noted the use of various terms and chose to adopt the term ‘innovation and knowledge transfer’. However, this did not appear to be associated with limited positivistic interpretation of research evidence, and, earlier, they recognised that ‘engagement with research is socially and organisationally situated and heavily dependent on local context’. In this interpretation, knowledge is socially situated, generated by a number of participants and methods⁸¹ and intertwined with practice.⁸² It allows for the idea that knowledge can be coproduced and co-owned, and recognises the importance of tacit knowledge associated with organisational norms and customs.⁷² Likewise, in the Promoting Action on Research Implementation in Health Services (PARiHS) framework,³ in addition to research, evidence includes ‘professional craft knowledge, patient preferences and experiences, and local information’. Harvey and Kitson⁸³ have recently introduced the i-PARiHS (integrated PARiHS) framework. The ‘i’ stands for integrated and reflects how ‘evidence is incorporated within the broader concept of innovation to reflect the dynamic and iterative way in which knowledge to inform practice is generated and applied’. Neither of these definitions fit well with more formal definitions of evidence.

For clarity, we would prefer to hold the two terms as conceptually distinct, although connected, using the term ‘evidence’ to relate to a sort of knowledge defined by the way it was generated. Yet it is imperative that we use both terms as they are applied by the participants in the study in order to understand the terms and their significance from their perspective. Therefore, knowledge transfer will include forms of knowledge as relevant to participants, not simply the transfer of research findings from the positivist tradition.

The Research Supporting Practice in Education⁸⁴ group at the Institute for Studies in Education, University of Toronto, has devised a potentially useful set of questions that help to clarify different aspects of knowledge and knowledge use. These questions are:

• What knowledge (e.g. tacit, research, evidence, best practice)?
• In whose interests (e.g. organisations, researchers, practitioners, knowledge brokers)?
• For what purposes (e.g. change, influence, practice, decisions, empowerment)?
• In what context (e.g. communities, workplaces, universities, boards)?
• What techniques (e.g. guidelines, training and workshops, facilitation, communities of practice)?
• With what impact (e.g. instrumental, conceptual, changing practice)?

Innovation

This study is interested in the transfer of innovation and knowledge. Therefore, we also need to give attention to ‘innovation’, a term that has increased in usage since publication of the Carruthers report,²⁷ concerned with the adoption and diffusion of innovation in the NHS. This report places innovation at the top of the service agenda and sets out recommendations to encourage quicker transfer of new practice.²⁷

Carruthers’ definition of innovation built on Rogers’⁸⁵ interpretation of innovation as a new idea, practice, or object but requiring that it is applied. According to Carruthers,²⁷ innovation is ‘an idea, service or product, new to the NHS or applied in a way that is new to the NHS, which significantly improves the quality of health and care wherever it is applied’. Given the focus of our study on the benefits of innovation to patient care, this explicit inclusion of application in the definition seems helpful.

Alongside policy runs a literature looking at aspects of innovation in more detail. For example, Terwiesch and Ulrich⁵² have drawn a distinction between innovation that is ‘conceptual’ (new to a field) and innovation that is ‘contextual’ (new to an organisation). This is a potentially helpful distinction, allowing the term innovation to cover a range of ideas, services and products.

Implicit in the application of new ideas, services and products is a change in organisation and or individual behaviour. Birken et al.⁸⁶ explain that innovation implementation is a process in which organisational members become proficient in their use of a new practice. Walshe and Davies²² adopt a broad interpretation of innovation that encompasses both ‘clinical practice and service design’ and they explain that ‘service innovation means people at the front-line finding better ways of caring for patients’. Innovation in this sense may not involve formal and explicit knowledge transfer, unless these better ways are transferred outward to other colleagues and organisations. Walshe and Davies’²² perspective serves as a reminder that the focus of our study is anywhere in the health-care system that is relevant to managers’ ultimate role of improved care for patients within public service constraints, but with particular attention paid to the application of new ideas, services and products that are transferred into an organisation rather than those that emerge in an organic manner from within. It is also worth noting that while innovation can ‘go either way’ in terms of impact on care, most literature and policy appears to start from the assumption that innovation is good.

In terms of the application of innovation, Brockman and Morgan⁸⁷ argue that knowledge transfer facilitates innovation, and Strach and Everett⁸⁸ write that the ability to seek and maintain knowledge transfer capability facilitates a higher level of innovation. Radaelli et al.⁸⁹ found that individuals who share knowledge are also more likely to be engaged in creating and implementing innovations. This reflects a prevalent assumption that knowledge transfer is (or should be) a means to innovation. Knowledge is something you have; innovation is something you do. Innovation does not transfer, but knowledge about it does.

Transfer

The final element of KIT relates to transfer. This is a well-developed area of literature; in its commissioning brief, NIHR noted the multiplicity of terms. Prefaced by ‘knowledge’, ‘transfer’ is just one option of many. Others include ‘exchange’, ‘mobilisation’ ‘translation’, ‘management’, ‘mediation’, ‘dissemination’, ‘diffusion’, ‘utilisation’. Likewise, those working in roles to support this activity attract a variety of labels, including: ‘knowledge brokers’, ‘translators’, ‘boundary spanners’, ‘diffusion fellows’, ‘research navigators’, ‘research liaison officers’, and so forth.¹³ There is both confusion of terms and confusion in the meaning of terms.⁹⁰ Knowledge translation, for example, can refer to the job of ‘translating’ lengthy and complex research reports into digests more suitable for busy practitioners; the translation of knowledge into action or practice arising from collaboration between researchers and practitioners;^82,91 or the ‘transfer’ of research from one group to another with little interpretation or amendment.⁷

Transfer needs to be understood in relation to definitions of knowledge and different models of KIT will prescribe the role for people and organisations responsible for enabling it.

Context factors

Macro-level context factors relating to the wider social, political and economic environment in which the health-care service, researchers, collaboration and KIT agents sit have been suggested to affect the success of KIT.^6,132 Factors in the external environment known to inhibit KIT include the rapid turnover of policies, ministers and civil servants. Major shifts in health care and other policy, singly and in combination, can have disruptive effects on knowledge transfer and mobilisation.⁵⁶

External context factors relating to funders or commissioners of research are a recognised, and under-researched, translational gap.⁹⁰ At an organisational level, short-term funding does not support sustainable partnerships.^94,133 Operating within a ‘closed system or fixed budget’,¹³⁴ commissioners with shorter time horizons risk losing the insight that can arise from longer-term studies, and can be too preoccupied with immediate policy priorities, government targets and financial imperatives, all subject to change at short notice.⁹⁴ Thematic funding has also been suggested to engender fragmentation.¹³⁵ Restricted time and resources can also limit effective brokering or mobilisation.^15,93,134

Meso- or organisation-level context factors are often overlooked,^4,136 but have a major impact.¹³⁴ A key factor in the internal context relates to the nature of the organisation – its attitude to research, to knowledge, to change – and the ability of the organisation to receive and process information.^113,137,138 In tune with Currie et al.,⁴³ Kitson et al.³ reported that contexts that had ‘transformational leaders . . . learning organisations, and . . . feedback mechanisms’ were better able to implement evidence into practice. A similar conclusion was reached by others: when attempting to implement innovations, organisations face challenges such as professional barriers, inertia,¹³⁹ misaligned incentives and competing priorities.^139,140 The supporting infrastructure needs ‘effective and inspiring institutional leadership’^64,141 to create a ‘consistent and psychologically safe culture’.¹³⁴ An evaluation of CLAHRCs revealed a lack of emphasis on leadership (the ‘L’ in CLAHRCs) and concluded with an argument for the selection of leaders with a more systems-level approach who ‘have the capability to work across organisational and professional boundaries’.⁴³

King et al.⁹⁹ explain variation in outcomes and impact by differences in the ‘individual and organisational receptiveness’ or the state of preparedness of the workplace environment. The organisational value of using evidence may be limited.¹⁰⁰ The organisational culture needs to be adaptive¹⁴² or absorptive if it is to make use of knowledge, and increasing emphasis is given to organisational readiness.^{18,82,138,143} The level of an organisation’s ‘absorptive capacity’^144–147 is defined as ‘a firm’s ability to recognise the value of new information, assimilate it, and apply it to commercial ends’.¹⁴⁶ This ‘adaptive and responsive capacity’ is important to knowledge use in practice and is affected by the organisation’s ‘prior related knowledge, a readiness to change, trust between partners, flexible and adaptable work organisations and management support’.¹⁴⁵ Implementing innovations is demanding – cognitively, emotionally, physically, and spiritually.¹³⁹ If this capacity to learn, demand and generate new knowledge for the purposes of improvement is absent, then the impact of a KIT agent or knowledge broker is likely to be limited. Traynor et al.¹⁴⁸ concluded that the use of knowledge brokers had increased both individual capacity (improved knowledge searching, appraisal and application skills) and organisational capacity (management support and policies) of the target group.

Oborn¹⁴⁹ indicates that ‘absorptive capacity is a strategic level capability which should be developed and nurtured by leadership teams’. Differences in hierarchical structures, leadership, power and professional cultures¹³⁰ contribute to organisational receptiveness and cross-professional communication.^104,130,150 Cross-organisation and cross-discipline communication and collaboration are seen as vital.^134,150,151 However, Tasselli¹⁵⁰ reported that professionals tend to be ‘embedded in distinctive professional cliques’.

Other studies have identified personal challenges for KIT agents around professional boundaries.¹³⁷ Career pathways and progression may be uncertain for KIT agents, particularly those in dedicated knowledge brokering roles.^133,137 Support, in the form of collective forums (i.e. communities of practice) and a physical home,¹³⁷ help individuals to navigate the isolating aspect of the role. The provision of space benefits others; Dopson et al.¹¹⁵ found that having access to ‘formative spaces’, removed from their organisational context, where managers could engage with knowledge, aided their appraisal of research.¹¹⁵

Content factors

The work of some KIT agents entails the identification of the relevance of research to practice and the tailoring of findings to service need. Walker et al.¹²⁸ use the term ‘content factors’ to refer to the changes being implemented. It is perhaps more helpful to borrow from the PARiHS framework and include in the term issues around the nature of evidence or knowledge. Thus content factors can also relate to the nature and type of knowledge (explicit or tacit) that may be more or less readily transferred and mobilised, and to the type of evidence, varying from research findings to professional experience and local information. It concerns the social nature of knowledge and evidence; what counts, to whom and when.

Before knowledge or innovation can be implemented, the new evidence needs to be interpreted for the local context, integrated with existing knowledge and discussed. Arguably, decision-makers and researchers differ in their view of research;^115,140 researchers look at the information for academic rigour, whereas decision-makers assess its local relevance.¹⁴⁰ At both the local and national level, new evidence may be supported or sidelined; it may address or be at odds with local needs;^39,141,152 it may require change that is demanding (transformational and rapid) or the change may be incremental and require only fine-tuning. Relevance and benefit to the participants is an important enabler.¹⁵³ Decision-makers are more likely to engage if the project suits their needs. For example, an evaluation of the Québec Social Research Council (CQRS)’s partnership programme found that all respondents reported benefits to them as a reason for success. The research had relevance because it was linked to wider policy concerns (saliency).¹⁵⁴

Ross et al.¹⁵² similarly found that decision-makers were more likely to engage with the research team when the research questions aligned with their interests, but also when they perceived their contribution to be essential to the success of the project (e.g. bringing local knowledge). Making a meaningful contribution drives practitioners. Bartunek et al.⁷⁵ suggested that short-term relationships, which focus on data collection, might result in the practitioners feeling exploited. Being able to help shape research questions is an important activity for some practitioners.¹⁵⁵

Competing agendas and priorities between partners can be a barrier to success^156,157 and need acknowledging and managing.^{114,155,156,158,159} Academics and commissioners alike have recognised deficiencies in the communication of research findings across boundaries. Researchers felt they should be involved more closely in the calls for research proposals; commissioners were more concerned that the users of research – policy colleagues and public service managers – should be involved more closely to ensure prioritisation of practical over academic concerns.⁵⁶ Commissioners found academics preoccupied with creating new knowledge suitable for publication in high-impact journals rather than policy-driven outputs.⁵⁶ Arguably, the ‘impact case studies’ that are a part of the Research Excellence Framework¹⁶⁰ have gone some way to address this. However, a review of a sample of impact case studies indicated that impacts were relatively short term, often with limited direct impact on patient outcomes such as morbidity and mortality, and with limited consideration of the processes and interactions that may lead to indirect impact.¹⁶¹ The time lag between identifying a demand for new knowledge and its synthesis for use in decision-making has also been noted, and decision-making time scales are short compared with research time scales.¹⁶² Information relating to the ‘here and now’ is more likely to be used.¹⁰

Process factors

In Walker et al.’s¹²⁸ model, process factors refer to actions undertaken by the change agents. In this sense, agents include all those parties involved in the process of change, not just the KIT agents themselves. Gagnon¹⁶³ suggests that all parties should ‘plan for collaboration with an explicit description of roles and responsibilities and a commitment to regularly assessing its effectiveness’. The lack of clarity of brokering roles can limit success.^{16,35,135,164} Against this, flexibility is also seen as important;⁶⁶ brokerage roles may differ for different individuals¹²⁷ or at different times.^165,166 Ross et al.¹⁵² conclude that individual partnerships need to be flexible; one size does not fit all and finding the right person for a particular role is key.

Agreeing roles, goals and expectations is a common recommendation.^{16,41,42,152,155,163,167} Roles can take time to be established, and may take on different forms based on specific local organisations.^137,168 One reason given for the success of the CQRS’s partnership programme was that participants were expected to show measurable results.¹⁴¹ Bullock et al.⁶² found examples of interactions between the knowledge brokers and their managers that resulted in frustration because expectations had not been openly articulated. Additionally, individuals in the roles will embrace brokering and linking functions at different paces or not at all. In a study of hybrid physician–manager roles, the authors identified three different groups which they term ‘innovators’, ‘sceptics’ and the ‘late majority’ reflecting the different pace of role adoption.⁴⁸ Collaborative policy-setting has been suggested as a mechanism for ensuring needs-led evidence is produced, but it was noted that this method can be more time-consuming.¹⁶⁹

Collaborative partnerships seem to work best where there are effective links between researchers and practitioners. Communication and trust-building, and motivation and commitment by all the organisations involved in the CLAHRC partnerships have been shown to be central to making collaborations work.^36,49,50,58 Effective solutions cannot be ‘developed from the knowledge base in the absence of those who will apply the knowledge’.¹⁷⁰ The key to knowledge mobilisation impacting on organisational performance rests on ‘the transfer of knowledge to locations where it is needed and will be used’.⁷² KIT agents typically act as a facilitator of this transfer, using guided interaction to support the uptake and use of knowledge.¹⁷¹ Their work requires a ‘multi-level, multi-strategy approach’.¹⁷² Current evidence suggests that there is benefit in gaining the bidirectional support of middle managers within organisations:¹⁷³ ‘they may disseminate information vertically from top managers to front-line employees and from front-line employees to top managers, and horizontally, across top managers and across front-line employees’.⁸⁶

Building successful long-term, trusting partnerships between knowledge producers and knowledge users supports the use of research in informing decision-making.¹⁷⁴ However, this takes time and commitment.^{137,152,156,159,175} Partnerships need people to attend meetings.^152,155 Bartunek et al.⁷⁵ suggest a number of physical links between the two communities – web-based discussion boards, practice-focused meetings and conferences. Baumbusch et al.⁹¹ explain how project meetings were used to feed back emerging findings for practitioners to action, and for practitioners to provide context that would assist interpretation of the findings. Kislov et al.⁴⁰ describe such events and artefacts as ‘boundary objects’. Others also write of the importance of colocating the partners, which facilitates not only formal face-to-face meetings but also informal discussion ‘at the water cooler’.¹³⁷

Knowledge transfer and innovation carries costs. For example, the time required to develop the necessary skills and relationships with organisations takes people away from other tasks and, therefore, imposes financial costs^91,113 for both employers and decision-makers.¹⁵² Financial restrictions impede knowledge mobilisation;¹⁵⁹ those in the roles are often unable to use their backfill because of organisational pressures.^106,176

Individual dispositions

Walker et al.’s¹²⁸ final area of concern relates to ‘individual dispositions’. This focuses on the KIT agents themselves, but needs to be located more broadly; KIT agents are limited by the context and the character and dispositions of their organisations and colleagues. Evidence suggests that other aspects influence their capacity to transfer knowledge and bring about innovation, not only factors to do with their disposition (e.g. patience and approachability).¹⁴⁸ This includes their role and seniority within the organisation and how they are perceived by others; for example,⁶⁶ Soper et al.⁴⁴ note the importance of ‘understanding each other’s incentives and constraints’.

However, the skills and attitudes of the KIT agent or knowledge broker are a recurrent theme in the literature. Alongside excellent communication skills,^176,177 they need to have a good understanding of both the research evidence and policy issues, and be able to transform that knowledge into something that is salient to their practitioner collaborators.^91,159 Platt¹⁷⁸ warned of the risk of relying solely on ‘intermediaries’ who might not have the skills needed to interpret the evidence or be motivated by their own interests.

There is an argument that knowledge brokers in hybrid roles (e.g. clinical managers) may be best placed for mobilising both explicit and tacit knowledge because of their membership of multiple communities.⁵⁴ However, challenges may arise related to dimensions of their role and interorganisational factors.^179,180 For example, those in hybrid roles have been found to show preference to one aspect of the dual role over the other, to broker knowledge only within their professional sector, or to not be best placed to reach all levels of the organisation.^{179,181–183}

Mutual trust and respect are frequently reported as enablers.^{74,91,114,155,158,175} The issues of trust and reciprocity feature prominently in the management literature on planned collaborations.^184,185 Other reported beneficial dispositions include clinical credibility, being known and having a good reputation^60,186 and having good knowledge of the organisation’s culture.^187,188 For those from outside sectors, willingness to learn about the other community is stated rarely,^75,188 but would seem to be essential.

For researchers to take part in interactive exchange models of knowledge mobilisation, it is likely that they need to have accepted a broad notion of ‘knowledge’.⁷⁵ Researchers’ ‘arrogance’ and power differentials can introduce problems.¹⁷⁵ Engagement with potential users of knowledge may be seen as signifying a lack of independence and objectivity in the work.⁵⁷ Concerns about academic rigour and violations to objectivity can be off-putting to academics – ‘if what is required is for researchers to do what policy-makers want them to do, then research may fail to fulfil one of its most important functions, namely to be objective, reliable and unbiased’.¹⁸⁹ Ross et al.¹⁵² note that none of the researchers in their study identified this as an issue.