'Where is the Life we have lost in living?

Where is the wisdom we have lost in knowledge?

Where is the knowledge we have lost in information?'

-Choruses from the Rock, T.S. Eliot, 1934

Background

For healthcare practitioners beginning professional life, Eliot's words are striking. For a dietitian, he cut to the core of 5 years of training in sciences - ranging from biology to chemistry, physiology to psychology - before being let loose on the healthcare system as a 'knower' of nutrition. No longer is being a dietitian about dispensing knowledge; it is about helping people embrace and apply relevant, practical knowledge to everyday lives. Socrates once said 'one thing only I know and that is I know nothing'. Based on a study of healthcare and research, from historical, occupational and health services research perspectives, the concept of knowing is multidimensional and multi-meaning. Healthcare is steeped in the empirical perspective, perhaps due to the task-oriented environment, and/or the biological, physiological and chemical sciences on which some healthcare knowledge and resulting decisions are based. This, in turn, leads to a traditional, fixed, view that there is indeed an objective reality. The dominance of empiricism may also perhaps be due to the need for providers to have a certain level of confidence and objective knowing to make decisions and provide care. As a practitioner, it is difficult to provide care unless one feels confident in the knowledge used. As a healthcare client, a practitioner's confident provision of care manifests in confidence regarding the care received.

Knowledge translation (KT) encompasses the interchange of knowledge between producers and users.1 Thus, KT is crucial to ensuring healthcare practitioners provide current, safe and effective care that meets client needs. KT requires useful, relevant knowledge available when necessary and applicable to real-life issues as perceived by the knowledge end-user (i.e. client). However, in current KT discourse, academic researchers are culturally viewed as knowledge producers, while practitioners are seen as knowledge users.2,3,4 This perspective of knowledge, and by extension KT, assumes a 'fixed, orderly reality that can be objectively studied'.5 In other words, knowledge and KT are rooted in the empirical paradigm. This can be seen in how we train healthcare professionals in academic settings, where knowledge is viewed as a portable commodity2 acquired through study and demonstrated to be sufficient through exams. This occurs in both undergraduate and graduate education as well as practitioner continuing education and professional development. Critically, however, the application of knowledge in real-life healthcare delivery is not so linear, controlled nor clear-cut.

To better root KT strategies in professional practice requires looking at KT from both practitioner and knowledge-user perspectives, with perhaps less dependence on the academic (knowledge producer) perspective. The former are referred to as user-pull, while the latter as producer-push strategies.4 User-pull strategies challenge the empirical perspective of knowledge, and KT, in that knowledge in the practitioner realm is often based on users' experiences and constructed to meet user needs. This is more consistent with constructivism than empiricism.6 For KT to best serve professional practice, it may require producer and user roles to be exchangeable and dynamic, and the user considered more broadly as the practitioner-client dyad.

The goal of this essay is to compare and contrast knowledge and KT from the empirical and constructivist perspectives. It will then relate KT to professional practice discourse and conclude with thoughts on what constructivist KT strategies in healthcare might look like. Given the emphasis of much healthcare research on empirical knowledge production and rational application, this essay will provide a valuable alternative perspective to KT specifically and healthcare literature more generally. In so doing, it brings the knowledge user into focus and perhaps more importantly helps to redefine the roles of knowledge producers and users, while recognising the client as the ultimate end-user or recipient of KT; a fact not often discussed in KT discourse. This is important to healthcare practitioners who strive to improve the quality of care provided, as determined by the recipient of that care, and who want to collaborate in the production of, and contribute to, the evidence base that informs healthcare delivery.

Discussion

Knowledge

Before discussing the finer points of knowledge creation and translation, the term 'knowledge' requires clarification. Dopson and Fitzgerald2 reflect on knowledge as relevant to evidence-based healthcare, and describe knowledge as information or 'refined data' providing added value, subjected to some validation or truth-test, but also fragile, politicised, not necessarily objective, portable, or reflective of human participation. Tsoukas and Vladimirou7 add that knowledge is not just a mental attribute, but involves individual judgment, action and appreciation of both context and theory. With this constructivist perspective, they bring the definition closer to a verb than a noun. Webster's dictionary8 classifies knowledge as a noun and defines it as 'acquaintance with facts, truths or principles, as from study or investigation [horizontal ellipsis] that which is or may be known; information' (p. 793).

Reducing knowledge to facts, information or refined data tends to decontextualise it, emphasising its 'scientific' character from an empirical perspective. This commodified knowledge is conducive to gathering and warehousing for search and use, 'off the shelf' by others. Virtual warehouses of knowledge, such as Cochrane Collaboration and Practice-Based Evidence in Nutrition (PEN), are information databases available to practitioners for use in practice. Warehouses are effective for KT when the information sought is readily available and specifically answers the question at hand. Problems arise when the information, although well researched and truth-tested, is so decontextualised or of sufficiently narrow application for any practical utility. For example, attempts to use both Cochrane (http://www.cochrane.org)9 and PEN (http://www.pennutrition.com/index.aspx)10 to determine effective strategies to meet haemoglobin A1C (HGA1C) targets for an elderly person with diabetes results in evidence related to medication and disease influences on HGA1C levels; however, no clear answer regarding effective strategies for an elderly person can be drawn.

Critics of evidence-based healthcare suggest that 'it places an overly rigid and reductionist emphasis on scientific evidence, as the primary determinant of clinical practice' (p. 133).2 Thus similarly, although part of the puzzle, virtual information warehouses also fall short with regard to effective or relevant KT.

Knowledge translation and KT strategies

Knowledge translation is defined as:

'the exchange, synthesis and ethically-sound application of research findings within a complex set of interactions among researchers and knowledge users. In other words, knowledge translation can be seen as an acceleration of the knowledge cycle; an acceleration of the natural transformation of knowledge into use.' Within the context of health research, KT therefore aims to 'accelerate the capture of the benefits of research [horizontal ellipsis] through improved health, more effective services and products, and a strengthened health care system' (CIHR, 2004).11

This definition appears to situate and segregate knowledge production into the academic/research arena, and knowledge use into the practitioner domain. In essence, it roots much of KT in the empirical paradigm: a fixed commodity is transferred from producer to user for application to a clear-cut problem within an orderly reality.

As a result of this knowledge and KT perspective, KT strategies are also generally rooted in the empirical paradigm. For example, Graham et al.3 discuss several strategies including interactive educational interventions to address limitations in users' knowledge, attitudes and/or habits, with other KT strategies to be implemented at the organisational level such as modifying documentation systems or staffing levels. These strategies appear to demonstrate primarily one-way dissemination of empirical knowledge. Other KT strategies include planned interpersonal contact between researchers and decision-makers, and use of knowledge brokers to facilitate transfer of knowledge between producers and users.12 These latter strategies convey more of a two-way exchange of knowledge, making them less empirical in nature. The former strategies appear to assume knowledge is a fixed commodity that can be implemented in a finite time frame. When used, these empirical strategies are intended to facilitate evidence-based care. Difficulty arises when the evidence practitioners require is not clear-cut, the problem has not been thoroughly studied, evidence is contradictory or conceptualised as weak, or the problem is entangled in the complexity of an individual client's life. Moreover, empirically based KT (particularly in the professional context) often tells users what they already know, even if intuitively (e.g. hand washing education for infection control).

The empirical discourse of KT can, however, have specific advantages especially in the area of evidence-based practice. For example, when a dietitian helps someone manage their hypertension, PEN10 provides a clear 'summary of the graded evidence supporting the prevention and treatment [horizontal ellipsis]' The empirical perspective of KT is well suited for translation of objective knowledge, such as fibre recommendations for hypertension management. In this example, knowledge to inform the decision - increase dietary fibre intake, especially soluble fibre, to recommended levels10- is clear of confounding variables, well researched and reasonably easy to implement/act on. Difficulties arise when contextual variables, such as socioeconomic, geographical, physiological or psychological factors that affect fibre intake and/or tolerance, complicate the decision.

Another problem with the empirical perspective of KT is that it often focuses on knowledge that is being created, to an extent, outside of the dynamic uncontrolled real world. When knowledge creation emphasises sound research methodology and truth-testing, it focuses the origin of knowledge on filling a gap in the scientific literature. This may move the focus away from the real-world setting of answering a question that is practitioner- or client-driven.

Finally, some knowledge, for example weight regulation, is not particularly clear-cut, or value or context free, but rather multifactorial, client-specific and sometimes pejorative. Consequently, KT regarding weight control information is complicated. Where does a practitioner begin - with weight regulation scientific evidence, that is, an empirically driven energy regulation view, or with the client and their specific context, that is, client-focused/driven? These contradictory perspectives pit the professional practice discourse of evidence-based practice against that of client-centred care.

Professional practice and KT

For many practitioners, a tension exists between client-centred and evidence-based practice. Client-centred care considers the client as an equal participant and decision-maker in care whereas evidence-based care privileges empirical knowledge use, which may de-emphasise the client's position. As with other conflicting perspectives, the practice reality likely exists somewhere in the middle but remains context-dependent. When it comes to client-centred professional practice, academically driven KT, rooted in the empirical paradigm, may not meet either practitioner or client need. Such KT strategies may miss the practical, context-specific requirements important to client-centred care. For example, difficulty arises when moving empirical knowledge into client-centred approaches that support strategies like self-management for chronic disease. As professional practice discourse evolves towards client-centred care, more emphasis is being placed on self-management. Astin and Closs13 state that 'self management is a sub-set of self-care and is defined as "the individual's ability to manage the symptoms, treatment, physical and psychosocial consequences and lifestyle changes inherent in living with a long-term disorder" ' (p. 105). Within this definition, self-management may be very complex when a client is faced with managing several comorbidities, such as diabetes, obesity, hypertension, renal disease and depression. In situations like this, even the interdisciplinary team may have difficulty prioritising necessary care. In such complex situations, effective KT is even more important. This prioritisation is an area where academically driven empirical KT may aid practitioners if designed accordingly, that is, to indicate which disease parameters/symptoms to address first.

Continuing education or professional development, going through its own evolution of taxonomy, has a long history in professional practice much of which is also rooted in the empirical paradigm. For example, historically and continuing today, the culture for updating practice is academically driven. It primarily consists of in-person/audio-conferences (historically), and now with the internet, webcasts/webinars, and literature provided by academic researchers sharing their evidence. How this evidence relates to practice and how to incorporate the learnings is left in the hands of practitioners to sort out. Some discussion of this evidence may ensue in practice settings or meetings after the event; however, a formalised process for discussing practical application of knowledge or for KT does not exist. Despite this, practice continues to evolve; partly through practitioners' discussion of methods to apply empirical knowledge in practice, and partly through sharing of heuristic talent and development of tacit knowledge. The former, heuristic talent, is that informal knowledge actively generated in problem solving;7,14 that is, what works in certain contexts. The latter, tacit knowledge, is that intuitive 'knowing how' which comes with personal experience and application of learned knowledge, the 'knowing that'.15,16 An example here is knowing when to talk and when to listen when counselling a stressed client.

Evidence-based practice may be more attainable for those types of practice or decisions where empirical evidence is available. When it is not, evidence-based decision-making has to shift to integrate heuristic talent, tacit knowledge and critical thinking. One difficulty with heuristic talent and tacit knowledge, however, is defining and capturing it. Great clinical insight may come from complex reasoning that a clinician is not aware of and cannot explain.14 This is akin to asking a great skier, 'how do you do it?' for which the answer is nebulous and may not apply to one's own skiing. Although tacit knowledge may be so inherently personal that it cannot be converted to explicit knowledge and thereby captured,7 the capture of heuristic talent - years of practical experience that may be lost to future generations of practitioners if not captured and shared - may be achievable if KT strategies are designed with this capture in mind. Examples of such strategies, like storytelling, include those that support practitioners' discovery of their strengths and constructed solutions, then test these in their practice, and reflect on this knowledge when sharing with others.17 Or, in other words, KT strategies rooted in the constructivist paradigm.

KT in the constructivist paradigm

'Constructivism is a theory about knowledge and learning [horizontal ellipsis] [it] describes knowledge not as truths to be transmitted or discovered, but as emergent, developmental, non-objective, viable constructed explanations by humans engaged in meaning-making in cultural and social communities' (p. ix).18 In this paradigm, knowledge is constructed to satisfy social needs and experiences of knowers and therefore has multiple perspectives.6 As such, 'observation cannot be pure in the sense of altogether excluding the interests and values of individuals' (p. 705).19 In contrast, in the empirical paradigm, knowledge is conceptualised as observable, verifiable, objective and, importantly, external to mind and context.6

Knowledge translation strategies rooted in empiricism are well suited for objective knowledge; however, they may miss the mark for constructed, context-dependent knowledge. They may also fail practitioners drowning in a sea of literature/evidence while trying to meet daily practical client needs. Constructivism focuses on practical understanding, rather than technical control as empiricism does.20 Seeking understanding and knowledge, in its multiple forms, from practitioners' everyday practice/culture may facilitate capture of practice-based evidence that can then be shared with the broader healthcare system, including clients, through KT. This KT would include more storytelling, conversations, reflection, dredging experience, etc. The knowledge or evidence can then be validated empirically if desired. This practitioner-driven constructivist KT can be rooted in practice in several ways. It can be woven into processes to train/integrate new graduates into the healthcare system, captured in practitioner-driven provision of continuing education, and through practitioner collaboration in research via action research approaches. Each of these is reviewed in turn below.

Training

With regard to healthcare education program admission, Eva and Reiter21 question the practice of accepting students chiefly based on grades. Beyond the primarily empirical admission protocols and their outcomes, once students are accepted, training may be provided largely by academics who may or may not have recent, real-world experience with delivering healthcare to clients. As Mitton and Bate22 explain, the existing reward structure for academics - publishing and tenure - results in the perception that researchers are at cross-purposes with decision-makers. In other words, their academic backgrounds may not encompass much practical healthcare experience. Consequently, educational content is primarily based on an empirically driven curriculum. In most healthcare professions, the practical training component is provided via internship experience in healthcare settings. The internship preceptors are practitioners and core competencies (skill-sets) guide the training. Although practical, this training is still primarily empirically driven. The traditional empirical model has the preceptor as 'autocratic knower and the learner as the unknowing [horizontal ellipsis] practicing what the teacher knows' (p. ix).20 To align with constructivism, approaches to training can be developed to situate preceptors as facilitators providing learners opportunity for contextually meaningful experiences, trial-and-error, questioning, interpretation of previous learnings in new contexts and reflection.18

Continuing education (professional development)

Practitioner-driven continuing education may enable capture, and also sharing and evolution, of practical knowledge and heuristic talent. This roots KT in constructivism. It also directly engages practitioners in knowledge production thus providing an opportunity to integrate constructivist thinking into both content and delivery. Consistent with adult learning theory,23 practitioners value information more if actively involved in its production and/or acquisition than if it is just handed over.24 Along these lines, acknowledging and validating professional expertise by facilitating practitioner input to the knowledge base may contribute to individual and community confidence. As illustrated earlier, confidence in healthcare is conducive to good care. To facilitate practitioner-driven KT, attention must be paid to the current practitioner reality. Space and culture - that is, funding, time, incentives and expectations - are required for practitioners to capture and share practical knowledge.

Action research

When it comes to blending academic and practitioner knowledge pursuit within healthcare, some research methodologies may be more conducive to practitioner participation and constructivist KT. As mentioned earlier, knowledge in the practitioner realm is often based on users' experiences and constructed to meet their needs. Thus, practitioner collaboration in research is necessary. It facilitates integration of empirically derived knowledge with experience.

Researchers and practitioners bring different skills to research. Coordination of their activities via action research methodology may create praxis - that is, application of knowledge - more readily than research designed with empirical rigour as the primary focus.25 Defining action research appears to be as difficult as defining knowledge. Perhaps this is due to the empirically driven act of defining anything which is context- and knower-dependent. Regardless, Reason and Bradbury25 define action research as 'a participatory process concerned with developing practical knowing in the pursuit of worthwhile human purposes. It seeks to bring together action and reflection, theory and practice, in participation with others, in the pursuit of practical solutions to issues of pressing concern to people' (p. 4). As such, action research places researchers and practitioners together as interdisciplinary colleagues rather than in a hierarchical relationship with empirical knowledge on top. When hierarchical mandates and influences are removed, collaboration becomes easier. In this structure, roles become less compartmentalised and boundaries blur facilitating meaningful two-way KT. This may reduce the need for a middle-man or knowledge broker, which may help ensure knowledge as constructed and shared is equally valued and understood by all players. When more people are enlisted to distribute knowledge, the more likely knowledge is to change according to the participants. Think back to the grade-school game where a secret is passed through all students in class. The message at the end is often quite different from the one at the start. This adds further complexity to an already intricate KT process.

Summary

The aim of this essay was to relate KT to professional practice discourse and review possible approaches to move towards practitioner-driven, constructivist KT. Much of KT in healthcare is rooted in the empirical realm, perhaps limiting and, at times, possibly even conflicting with its usefulness in providing client-centred care. KT strategies embedded in a constructivist paradigm may help bridge the limitations of empiricism, just as empirical KT strategies may address the limitations of constructivist KT strategies. The empirical tradition does have its role in KT, especially where evidence is available and relevant; however, answers are seldom clear-cut.26 Constructivism does not place boundaries on knowledge but rather seeks broad understanding, which more closely aligns KT with client-centred care. In this way, clients, practitioners and academics work as equals to provide for an individual's health; or in Eliot's words, to embrace the wisdom lost in knowledge.

Acknowledgements

EC receives funding from the Western Regional Training Centre for Health Services Research. CM is funded by the Michael Smith Foundation for Health Research.

References