An examination of the factors influencing evidence uptake that appear in Tables 3-2 through 3-5 (summarized in Appendix A), provides us with a better understanding of why there is a knowledge-to-action (KTA) gap. The factors also reveal the complex processes involved in diffusion of knowledge and behavior change. The complexity may be
reduced with early and ongoing involvement of researchers, practitioners, policy-makers and patients (Innvaer, Vist, Trommald, & Oxman, 2002; Landry, Amara, & Lamari, 2001; Lomas, 2000; McWilliam et al., 2009; Roux, Rogers, Biggs, Ashton, & Sergeant, 2006; Straus, 2009). The translation of knowledge or evidence into clinical practice is an active process. In the KTA model the process is “iterative, dynamic, complex, concerning both knowledge creation and application (action cycle) with fluid boundaries between creation and action components” (Graham et al., 2006; Straus, 2009, p. 6).
Both the creation of knowledge and application of knowledge in practice are social processes and as such communities of practice have the potential to reduce the KTA gap, assist with knowledge diffusion and be facilitators of practice change. One of the primary advantages in terms of diffusion of knowledge and clinical practice behavior change is that by collaborating with practitioners we have individuals who will know how to “grease the implementation wheels and provide a road map to the potential mine fields inherent in attempting to introduce change in any organization” (Graham & Tetroe, 2009, para. 11).
Communities of practice (CoPs) are comprised of individuals who share common concern or enthusiasm about a topic or problem, and who deepen their knowledge and expertise about the area by frequently interacting with one another (Barwick et al., 2005; Li et al., 2009; Wenger, McDermott, & Snyder, 2002). Initially described in 1991, the term CoP has evolved to be defined as a group of people with a unique combination of three structural concepts: the domain of knowledge, a community of people, and shared practice (Barwick, 2008; Barwick et al., 2005; Li et al., 2009; Wenger et al., 2002). The domain creates mutuality and a common focus regarding the key issues among members and inspires them to contribute their knowledge and ideas. The community creates the social structure that is imperative for knowledge creation, collective learning, inquiry, relationships and trust. The shared practice are resources created, used and shared by the group that include documents, ideas, information, ways of knowing, and experiences (Barwick, 2008; Roux et al., 2006; Wenger, 2005). When the three structural concepts of CoPs work together they can optimize the creation and dissemination of knowledge thereby facilitating the KTA process (McWilliam et al., 2009).
3.10.1 Value of a community of practice for pediatric audiology
Approximately 30% of children in North America who are fitted with hearing aids are receiving care that is inconsistent with evidence-based CPGs (Bess, 2000; Lindley, 2006). In a 2003 paper, it was noted that, “There is a current trend to develop test protocols that are “evidence based.” . . . But, before we develop any new fittingguidelines, maybe we should first try to understand why there is so little adherence to the ones we already have” (Mueller, 2003, p.26). In the area of pediatric audiology every effort is made to ensure that CPGs are developed using systematic reviews and the best available evidence. A review of the literature indicates that to date no systematic appraisal of pediatric amplification CPGs or their implementation has been conducted. Therefore, it is difficult to say whether it is the guideline or implementation factors that account for the fact that these children are not receiving care based on current CPGs. Appendix A provides us with information on why we may have adherence issues. Utilizing a collaborative and integrated KT approach to the development and subsequent
implementation of knowledge into clinical practice may provide insight into how to reduce the barriers and facilitate the movement of evidence into practice.
Brown and Duguid (2001) state that “knowledge runs on rails led by practice” (p.204). Developing a CoP in pediatric audiology could facilitate the knowledge creation cycle in an integrated KT approach by utilizing an engaged community with a shared
understanding of the knowledge needed and who would have the ability to assist in tailoring or customizing the knowledge for better use among intended users (Fung-Kee- Fung et al., 2009; Gajda & Koliba, 2007; 2008; Koliba & Gajda, 2009; Salisbury, 2008a; 2008b; Stahl, 2000). CoPs provide an opportunity for the creation of knowledge and knowledge products to include the tacit knowledge that experienced practitioners have accumulated through years of practice (Allee, 2000; Brown & Duguid, 2001; McWilliam et al., 2009; Serrat, 2008). This tacit knowledge makes it possible for them to be
advocates and facilitators in the development of resources that reflect accumulated ways of knowing, and experiences which will meet the cognitive needs of novice practitioners and the experiential needs of expert practitioners (Salisbury, 2008a; 2008b; Stahl, 2000).
3.10.2 Examples of communities of practice in health care
The next section of this paper will provide a description of two successful Canadian- based CoP programs in healthcare. The first, Cancer Care Ontario/Program in Evidence- Based Care (Browman et al., 1995; Browman, Makarski, Robinson, & Brouwers, 2005; Evans, Graham, Cameron, Mackay, & Brouwers, 2006; Fung-Kee-Fung et al., 2009; Stern et al., 2007) is of interest because it focuses on the use of practitioners during the guideline development process. The second, Ontario Children’s Mental Health Child and Adolescent Functional Assessment Scale, (CAFAS) Initiative (Barwick, Boydell, & Ormin, 2002; Barwick, Peters, & Boydell, 2009; Barwick et al., 2005) is of interest because it relates to work in the pediatric population.
3.10.3 CPG Development: Guiding practice of cancer care in Ontario
Since 1995, the development and maintenance of CPGs guiding the practice of cancer care in Ontario has been a joint venture between Cancer Care Ontario (CCO) and theProgram in Evidence-Based Care (PEBC) at McMaster University. The development of CPGs follows a cycle of development described by Browman et al. (2005). The
guidelines are initially developed by guideline panels, working groups and medical experts. The report created includes the guideline questions, the literature search strategy, a systematic review of the literature, the consensus of the panel on the interpretation of the evidence and draft guideline recommendations. This document and a standardized feedback survey are then sent to a wide group of physicians who might find the guideline relevant (Brouwers, Graham, Hanna, Cameron, & Browman, 2004). The physicians are asked to respond to the survey questions and to provide comments, suggestions and opinion on how the guideline might be improved so that implementation into clinical practice will be facilitated. The practitioners who review the CPGs developed by the Program in Evidence-Based Care (PEBC) panel can be defined as a community of practice (CoP). Evans et al. (2006), Browman et al. (2005), and Browman and Brouwers (2009) describe some of the benefits experienced by CCO and the PEBC by including this CoP feedback into the CPG cycle:
1. Feedback improved the quality of the documents and, on occasion led to substantive changes to the CPG;
2. By requesting feedback on the CPG, physicians had to review the document and therefore were made aware of and educated about the guideline;
3. The review stimulates learning within the CoP and increases dialogue on important topics;
4. Despite rigorous adherence to the development of guidelines by experts, practitioner suggested improvements/changes were incorporated into 44% of CPGs;
5. By sending the guideline to practitioners for comment/review it provided a ‘heads-up’ to practitioners that a guideline was about to be finalized and released.
A recent publication (Stern et al., 2007) described the results of using oncologists ‘in-the- field’ to facilitate CPG development and adoption of guidelines into practice. A reduction was seen in operative mortality of pancreatic cancer and the improvement in harvesting lymph nodes in colorectal cancer. Significant improvements were made in the area of colorectal and pancreatic cancer indicators, with a mean reduction in 30 day operative
mortality from 10.2% in 1988-1996 to 4.5% in 2002-2004 and compliance with treatment guidelines increased from 27% in 1997-2000 to 69% in 2005. Therefore it was concluded that active participation of practitioners and a CoP approach were essential components to changing practice and improving quality care in surgical oncology practices in Ontario.
3.10.4 Ontario Children’s Mental Health Child and Adolescent
Functional Assessment Scale, (CAFAS) Initiative
Since 2000, 117 Child and Mental Health Organizations in Ontario have been mandated to adopt an electronic version of a standardized outcome measurement tool called The Child and Adolescent Functional Assessment Scale (CAFAS; Hodges, 2003). For this group of first-users of the CAFAS, Barwick et al. (2002) used a knowledge-to-action approach to develop software training, web, wiki, email and telephone support systems. They also provided face-to-face group and individual consultation and training services to facilitate implementation of the CAFAS. Recently another group of new CAFAS users were mandated to adopt the outcome tool. Barwick and colleagues (2005, 2009) used this opportunity to study the use of a community of practice (CoP) approach to
implementation versus a practice as usual (PaU) approach. Both the CoP and PaU groups received standard two day training on the use of the functional assessment scale
(CAFAS) in clinical practice. The CoP approach included six meetings over 11-months where additional support / training were provided. The research questions focused on the use of a CoP model to facilitate practice change and increase the use of the functional assessment scale; knowledge of the scale; satisfaction with support, as well as satisfaction with materials for implementation of the functional assessment scale relative to the practice as usual group. Although some methodological concerns have been raised about this study (Archambault et al., 2009), results generally suggest that the use of CoPs might facilitate implementation of evidence into practice. Practitioners in the CoP group
demonstrated greater use of the tool in clinical practice. They also demonstrated better knowledge of the tool at the end of one year, and more satisfaction with the