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The development of a dynamic leadership coalition between practitioners and researchers/scientists – which is known in Canada as integrated knowledge translation (KT) – can play a major role in bridging the know-do gap in the health care and public health sectors. In public health, and especially in globally oriented public health, integrated KT is a dynamic, interactive (collaborative), and nonlinear phenomenon that goes beyond a reductionist vision of knowledge translation, to attain inter-, multi-, and even transdisciplinary status. Intimately embedded in its socioenvironmental context and closely connected with the complex interventions of multiple actors, the nonlinear process of integrated KT is based on a double principle: (1) the principle of transcendence of frontiers (sectorial, disciplinary, geographic, cultural, and cognitive), and (2) the principle of integration of knowledge beyond these frontiers. However, even though many authors agree on the overriding importance of integrated KT, there is as yet little understanding of the causal framework of integrated KT. Here, one can ask two general questions. Firstly, what “determines” integrated KT? Secondly, even if one wanted to apply a “transfrontier knowledge translation” vision, how should one go about doing so? For example, what would be the nature and qualities of a representative research program that applied a “transfrontier collaboration” approach? This paper focuses on the determinants of integrated KT within the burgeoning field of knowledge translation research (KT research). The paper is based on the results of a concurrent mixed method design which dealt with the complexity of building and sustaining effective coalitions and partnerships in the health care and public health sectors. The aims of this paper are: (1) to present an “integrated KT” conceptual framework which is global-context-sensitive, and (2) to promote the incorporation of a new “transfrontier knowledge translation” approach/vision designed primary for globally oriented public health researchers and health scientists.
In today’s globalized learning economy,1,2 the ability to integrate, share, and disseminate knowledge across functional silos in health care organizations constitutes a major challenge, referred to as a knowledge-sharing (KS) challenge in the knowledge management parlance3–8 or as a knowledge translation (KT) challenge by public health practitioners and scientists.9–14 In the context of contemporary globalization, the difficulty of this dual KS–KT health-related challenge is augmented by the need for social sustainability and eco–socio–efficiency.15–17
Improvements in the intertwined KS–KT aspect of the public health practice and health care are based on the ability to generate and integrate new knowledge into clinical/managerial practice while maintaining sound clinical/managerial processes. However, the acquisition and integration of knowledge is mostly “bit by bit”, fragmented, and unbalanced. Subsequently, and along with many authors,18–25 I believe that an active collaboration or coalition for sustainable KS–KT practices is the cornerstone to establishing effective knowledge-based health care institutions.16 The development of a dynamic leadership coalition between practitioners and researchers/scientists – which is known in Canada as integrated KT – can play a major role in bridging the know-do gap in the health care and public health sectors. The term “integrated KT” refers to both a process and its result. In public health, and especially in globally oriented public health, integrated KT is a dynamic (nonstatic), interactive (collaborative), and nonlinear phenomenon that goes beyond a reductionist vision of knowledge translation (sometimes seen in clinical epidemiology), to attain inter-, multi-, and even transdisciplinary status. The process of integrated KT is based upon: (i) the collaboration of individual and institutional actors and the integration of their respective knowledge bases, (ii) the development of a sustained synergy among knowledge users and knowledge producers, and (iii) the emancipation of postpositivist biomedical paradigms, removal of interdisciplinary barriers, and the development of sectors favoring a collective approach to shared problems and questions concerning health.
Intimately embedded in its socioenvironmental context and closely connected with the complex actions and interventions of multiple actors, the nonlinear process of integrated KT is based on a double principle: (1) the principle of transcendence of frontiers (sectorial, disciplinary, geographic, cultural, and cognitive), and (2) the principle of integration of knowledge beyond these frontiers. Integrated KT thus becomes, according to Lapaige et al a double-process of transfrontier integration that permits: (i) optimization of evidence-based practice, evidence-based health care management, and evidence-informed policy, (ii) the development of ecolearning health care institutions, and (iii) the promotion of evidence-based, equitable, and sustainable public health in response to collective and individual vulnerabilities in a context of globalization.26 However, even though many authors18–26 agree on the overriding importance of integrated KT – the development of sustained partnerships between producers and consumers of knowledge – there is as yet little understanding of the causal framework of integrated KT. Here, one can ask two general questions. Firstly, what “determines” integrated KT? In other words, what are the success factors of coalitions and partnerships in KS and KT that actually (i) improved patient care, and (ii) developed ecolearning health care institutions? Secondly, even if one wanted to apply a “transfrontier knowledge translation” vision, how should one go about doing so? For example, what would be the nature and qualities of a representative research program that applied a “transfrontier collaboration” approach?
This paper focuses on the determinants of integrated KT within the burgeoning field of knowledge translation research. The paper is based on the results of a concurrent mixed method design which dealt with the complexity of building and sustaining effective coalitions and partnerships in the health care and public health sectors. The aims of this paper are: (1) to present an “integrated KT” conceptual framework which is global-context-sensitive, and subsequently (2) to promote the incorporation of a new “transfrontier knowledge translation” approach in health care and (global) public health research.
The paper is divided into four parts: (1) terminological clarifications, and particularly the similarities and differences between KT, KT research, and integrated KT, (2) presentation of the QUAN-qual mixed model design used in my KT research study; based on preliminary results of this study, (3) a conceptual framework of integrated KT, which highlights the growing need for a global-context-sensitive vision in KT and evidence-based decision-making in health care institutions; and (4) in conclusion, presentation of an example of a currently active Canadian research program which has embraced an innovative vision in KT research. This new globally oriented KT approach transcends six types of borders in bridging the know-do gap in health care and public health: it has been called “transfrontier KT approach”.
In today’s information age, the importance of health-related knowledge as a key source of competitive advantage is well established worldwide, as suggested by the increasing literature focusing on health care knowledge creation (generation, production), (re)use, application, exchange, dissemination, and transfer, and the rapid growth of the KT research field in Canada.1,6–8,10–15,17,27–50
Over recent years, there has been a major shift in the world economy from an industrial economy to a knowledge economy.2,51,52 Canada, like other Western societies, has found itself in a context characterized by increasing globalization of production and exchange of goods, services, and capital, as this “new economy” spreads. The importance of knowledge as a source of sustainable competitive advantage has been discussed by a myriad of authors, and managing knowledge has become a major concern for many organizations, including health care institutions.4,5
At the dawn of the 21st Century, knowledge is a crucial resource in the provision of health care, guiding improvements to clinical/managerial decision-making, patient care, health outcomes, workforce quality, and organizational behavior and structure.
In this paper, evidence-based decision-making is discussed not only at the micro level of individuals (clinicians, public health practitioners), but also at the meso level of groups (teamwork) and sectors (health sector, public health field). According to Shortell et al the notions of KT (individual level) and KS (meso level) have been intertwined.46 This paper considers sustainable KS–KT practices – artifact-mediated, experience-mediated, and resource-mediated KS–KT practices (Table 1) – and the determining forces of their success in order to (i) develop ecolearning health care institutions, and (ii) improve patient care, population health, and the working lives of both (public) health practitioners and scientists at a time of changing roles and expectations.
While there is an overlap between these two notions, KT and KS are conceptually distinct (Table 1). They are nevertheless complementary. KT is emerging worldwide as a paradigm to learn and act toward closing the know–do gap in the domain of health care and the field of public health. In this paper, I am focusing on integrated knowledge translation with public health practitioners and health care researchers (Table 1) at the micro (clinical level) and meso (managerial/organizational level) levels. The term “integrated KT” describes a different way of doing research in which researchers and research users work together to shape the research process, starting with collaboration on setting the research questions, deciding the methodology, being involved in data collection and methodological development, interpreting the findings, and helping to disseminate the research results (Table 2).53 This approach, described in terms such as practice-oriented translational research (T2 research), collaborative research, action-oriented research, and co-production of knowledge, should produce findings which are more likely be relevant to, and for, end users.54 Furthermore, in this paper, I consider KS, which is essentially used in the knowledge management parlance3,4 and better tailored for a meso level, as a part of integrated KT (Figure 1).
In this paper, the basic premise is that KT is a multiactor and translevel phenomenon involving different levels of evidence-based decision-making and, correspondingly, different types of knowledge (Figure 1). Health care knowledge is a social construct and the processes of KS, KT, and integrated KT (acquiring knowledge; [re]using knowledge; developing new knowledge) are social processes and entail organizational changes. Linking integrated KT with organizational learning can usefully interconnect different levels within a health care organization: individual, group/team/community, and organization (Figure 1). This link also constitutes a fruitful way of approaching the complexity of managing KS/KT/integrated KT among health care professionals/public health practitioners, and mapping out future directions toward a “transfrontier KT approach” that institutionalized health care KS and KT might take.
Faced with the problem of an ever-mounting growth of information/knowledge, or in some cases “paradoxical information/knowledge”, both collective actors (health care institutions) and individual actors (public health practitioners and health scientists) need solutions. At the same time as the information/knowledge overload is increasing, health costs are expanding. Consequently actors at different levels – health care institutions workers, professionals, and researchers – are faced with the unattractive task of discovering approaches that are “better”, “faster”, and “cheaper”. With these imperatives in mind, new concepts, paradigms, or guiding principles reflective of the contemporary forces driving global change have become prominent in the past decade:
Today’s health care organizations increasingly recognize the need to support the practice of KS and KT among their “employees”. As a consequence, researchers and professionals in clinical, managerial, and policy decision-making environments are collaboratively searching, testing, and using proactive interventions to facilitate KS and the application of knowledge. However, the success of active and efficient collaborations depends on a myriad of factors.
My two-part research study focused on active collaboration for sustainable KS–KT practices in globally oriented (public) health research. It drew on a nonlinear perspective that conceives KS and KT as accomplishing changes not only in technical, but also, and primarily, in cognitive, social and, organizational contexts.
This study was at the crossroads of three specific perspectives of research: (i) KT research,53,56 (ii) critical population health research,57–59 and (iii) the new field of equity in health.60 My research goal was to elaborate an integrated KT conceptual framework designed for public health practitioners and researchers. The methodological design was a concurrenta mixed method design (QUAN + qual)b: (i) the QUAN phase of the QUAN-qual design was a systematic review method,64 and (ii) the qual phase of the QUAN-qual design was a Soft Systems Methodology.65–67 The qualitative strand/phase of this methodological approach enables this two-part study to be look upon as an integrated KT, responding to what is been referred as “Mode II of knowledge production”68,69 (Table 1 and Table 2).
The qual strand was under the umbrella of a larger research program called “PROACTIVE” (Participatory and Evaluative Research Program to Optimize Workplace Management: Application of Knowledge, Transfer of Expertise, Innovative Interventions, Training Transformational Leaders).c The participants were health care managers (as “integrated KT users”; n = 199 [from 34 management teams originating from three Canadian provinces: Quebec, Ontario, and New Brunswick]) and academic partners (as knowledge producers [n = 13]).70 Data collection included different Web-techniques (Web-based journal, Web-based interviews, peer-review Soft Systems Model validation through Web-conferencing), and data analysis was conducted by grounded theory.
The QUAN strand’s main objective was to identity the key elements of the dynamic process of integrated KT within health care institutions. The following research questions were considered in this systematic review: (1) What are: (i) the different definitions of “integrated KT” within health care institutions, (ii) the different types of knowledge and forms of evidence used by health care managers/public health practitioners, (iii) the different types of managerial KS, and/or (iv) the determinants of this KT?, (2) What are the integrated KT conceptual frameworks discussed in the literature?, and (3) What are the key indicators used to assess the KT evolution within health care institutions?
Two search chains (English and French keywords search chains) were used as follows:
The inclusion criteria were: (1) English and French sources, (2) published and unpublished documents or reports, (3) manual searching used as well as electronic databases, and (4) publication period: from 1990 to 2009. The exclusion criteria were: (1) master or PhD thesis, (2) editorials, and (3) success stories. The databases consulted were: ISI Web of Knowledge, EBSCO, Cochrane Library, Current Contents: All EBM Reviews: MEDLINE/Pubmed, EMBASE, CABI, CINHAL, ASSIA, AHA Hospital and Health Administration Index, and BDSP. The references were entered into Reference Manager v.11.0 (Thomson ResearchSoft, New York, NY) and after removal of duplicates, a total of 11,207 references remained. These were further reduced through review of abstracts. Results reported here are based on preliminary analysis of 308 articles.
The development of my conceptual framework was based on the secondary results of the qual strand and the preliminary results of the QUAN strand (systematic review). At the end of each strand/phase of the design, qualitative inferences (predominantly inductive inferences) were made. These inferences were combined/contracted to achieve a fuller picture of the integrated KT process.71 Strategies for integrating these inferences and the role of each (eg, exploratory, triangulation) were more crucial than the priority/dominance of one approach over another (QUAN-qual).72,73
Integrated KT is influenced by many factors/determinants and groups of factors/determinants that are interrelated at many levels, but can be divided into two supra-categories: (i) “upstream” determinants, and (ii) proximal determinants. Each of these supra-categories can be subdivided in the following way:
The usefulness of this framework (Figure 2) is firstly to show the importance of multilevel relationships between: (i) contemporary globalization, (ii) the evidence-based decision-making movement, and (iii) the development of effective and sustainable collaboration between knowledge users and producers.16 Secondly, Figure 2 illustrates that: (i) integrated KT is a nonlinear phenomenon with multiple and complexly intertwined determinants, (ii) integrated KT is a global-context-sensitive phenomenon which is influenced by multilevel factors of life-world and vulnerability (global-level factors, national-level factors, community-level factors, individual-level factors).
Although globalization (Figure 2) can be described as a socio-historical process evolving along with human societies, it is necessary to distinguish “globalization” from other terms such as “internationalization” (political internationalization is the growth of cross-border economic and political activity), “liberalization” (economic liberalization refers to “free-market” strategies), “westernization” (the global spread of companies such as McDonald’s), and “universalization” (global convergence around cultural and institutional forms), terms that are often used interchangeably. The work of Scholte is helpful in this respect.74 This author reserves the term “globalization” to describe social interactions that not only cross national boundaries, but also transcend them, and he sees the emergence of transplanetary relations and the rise of supra-territoriality as genuinely novel features of globalization.74 Satellite communications, the Internet, transplanetary TV, intercontinental production chains, anthropogenic ecological changes (eg, global warming), illicit drug trafficking, transworld migrants, and economic remittances are examples of globalization in this strict sense. It is very important to be aware of how the term globalization is defined, for a looser definition suggests that at least some aspects of what people call globalization are not novel to the late 20th century. A strict definition of globalization as the transcendence of territorial boundaries is distinctive of the transition facing human societies worldwide in recent decades.
A second important question is why globalization is occurring. What are the “forms” and “logics” of globalization? And what are some globalization-related conceptual schemes or “imaginations”?
Furthermore, globalization subscribes to six different “logics”,16 that can be defined as abstract and schematic orders of reasoning that allows an understanding of the complexity of reality. First, there are market logics and productive logics, which are closely related and make up the core of the new globalizing world. Productive logic is the root of the organizational changes in globalization on which production, re-engineering, and “total quality” are based. Market logic extols the marketability of everything and anything. Secondly, at the very core of the capitalist system is velocicratic logic. In the context of globalization, new forms of expression of the human connection to time are effectively emerging: these are urgency, immediacy, instantaneousness, and speed, with acceleration being the common denominator that unites the other forms. The arrival of urgency and instantaneousness in economic life falls right in line with the emergence of a new global space-time. Velocicratic logic therefore joins another type of logic – cyber logic – which, for its part, is related to the ICT revolution. Technoscientific logic, which represents the alliance between science and technology, comes third. Technoscientific logic is inseparable from the performance culture which, when allied with the cult of speed and subjected to the law of market, gives it real meaning. Coming fourth is epidemic logic, which relates to the breakdown of boundaries. Whether we are dealing with a computer virus, the disappearance of borders, the deregulation of the foreign exchange market, a rise in political extremism, or the mad cow crisis, a similar “epidemic” logic seems to guide these apparently social facts.
Moreover, the new globalizing world is shown through various conceptual schemes, or “imaginations”:
These different forms, logics, and imaginations of contemporary globalization influence multiple “levels” of determination of variegated life-worlds. Generally speaking, they cause a profound crisis in public health. More specifically, they can be tied to the development of integrated KT as well as the development of a multilevel vulnerability and the emergence of “inherently global health issues” (IGHIs).
A new category of vulnerability has appeared in the context of contemporary globalization that can be termed a “globo-agentive” vulnerability, referring to the impact of globalization upon agents at various levels of their life-world. This multilevel vulnerability is itself in interaction with the appearance of IGHIs and the public health crisis (see the upper part of Figure 2).
The components of an integrated KT process include both health care characteristics and the determinants of evidence-based decision making which can be characterized as (i) types of knowledge, (ii) evidence typology, (iii) coalition determinants, and (iv) KS determinants (see the lower part of Figure 2). Collectively, in a nonlinear fashion, all of these factors decisively impact the integrated KT process, which in turn influences health outcomes, decision quality, and health equity. Finally, in the case of an integrated KT process involving the development of a learning community, there are traps to be avoided and questions that must be asked to assure the success of the integrated KT.
These characteristics include: the availability of care, the affordability of care (eg, effects of cost recovery, user charges), and the availability of care (eg, adequate health human resources, rural/urban equity).
Five types of knowledge can be distinguished in the health and public health sectors: (i) factual knowledge (propositional knowledge or “Know-About”), (ii) contextual knowledge (“Know-Why”), (iii) procedural knowledge (“Know-How”), (iv) social knowledge, and (v) pragmatic knowledge.77
Types of knowledge can further be distinguished with respect to relative accessibility: (i) easily-accessible explicit knowledge (formalized, codified knowledge), (ii) less-accessible tacit knowledge (subjective, experiential, contextualized, informal knowledge), and (iii) implicit knowledge considered as having “intermediate” accessibility.
With respect to the various types of evidence, the following three aspects should be considered:
Within an integrated KT process, the determinants of coalition have to be taken into account. Empowering people to develop a collective vision and creating systems to capture and share learning (in case of the development of a learning community) is not an easy undertaking. The determinants of coalition are: the structural and functional characteristics of coalition such as formalization, communication, conflict resolution, as well as the commitment to collaborative efforts, the perceived benefits, and the institutionalization of the community.
The determinants of KS include: (i) the KS context, (ii) the KS medium, and (iii) the KS modalities.
In the case of an integrated KT associated with the constitution of a learning community, the integrated KT process can be analyzed by answering to the following questions:
One must also be watchful for the various “traps” that can complicate the successful development of a learning community’s integrated KT:
Success-determining factors of an integrated KT with respect to a given IGHI are numerous, varied, and interrelated in complex ways: their effective application is no easy task. In Quebec, a recently-developed approach that takes into account a maximum number of these factors is being applied to the specific IGHI of climate change. The KT research chair, Climat, santé, écoapprentissages, provides an illustration of an equitable, sustainable, and transborder vision in KT research.78
In the face of the planetary challenge of global warming, all of us must act, as citizens and public health workers, if we hope to see humanity develop in a harmonious, just, and environmentally-friendly way. As public health professionals, we can and must do more than simply echo a general appeal for global ecocitizenship: we can promote, develop, and transfer ecoknowledge conducive to healthy climatic conditions: (1) in prioritizing research on the applications of ecoknowledge (KT research), and (2) by orienting this research so that it focuses on the adaptation of public health to climate change, and on the attenuation of climate change (mitigation).
The research program of this Chair respects the global priorities mentioned in Article 6 of the Climate Convention (United Nations Framework Convention on Climate Change), and the Plan d’action 2006–2012 sur les changements climatiques – Volet santé of the Ministry of Health and Social Services of Quebec.79,80 The recent accumulation of research results flowing from studies on climate change poses the challenge of applying these results to achieve attenuation of climate change as well as adapting public health to the impacts of those climate changes.
The Chair promotes values of social justice, enduring change, and shared responsibility, and the explicit intention is to extend application of research results beyond several frontiers (sectorial, disciplinary, geographic, cognitive, and cultural), and is thus in many senses of the term “transfrontier”. The Chair is also committed to an overarching vision of: (1) an engaged citizenry with leadership shared among individual and organizational members, and (2) a transfrontier application of knowledge that seeks to reinforce the adaptive capacities of health systems, enabling them to promote climatic health that is just, enduring, “transfrontier”, and that entails shared responsibility. The “transfrontier” aspect of this vision78 refers to an application of knowledge that would ideally be:
In conclusion, this transfrontier KT vision is aligned with Wallace’s definition of globalization as “[…] an awareness of how “what affects one affects all”, or a consciousness of our fundamental interdependence as a global community, as well as the resulting process of learning to work collaboratively and share and disperse resources within our global community to ensure social justice, equity, the protection of the human rights, and the sustainability of the planet” (p. 19).81
Such a consciousness and KT approach can also guide the weeding out of the destructive forms, logics, and imaginations of contemporary globalization. Transfrontier collaboration is needed to fully actualize that which is constructive. The drive for globalization, as newly defined, and transfrontier collaboration research are the pillars of the newly emerging KT research field.
Funding has been provided by the Canadian Health Services Research Foundation (CHSRF) and the Canadian Institutes of Health Research (CIHR) (# PDA-1833-05). The views expressed in this paper are those of the author and do not necessarily reflect the position or policy of the Canadian Health Services Research Foundation, the Canadian Institutes of Health Research, or the Laval University. This paper was presented during the 137th APHA (American Public Health Association) Annual Meeting which took place in Philadelphia, PA from November 7–11, 2009. It received positive feedback from Dr. George Washington, the facilitator of Session 4036.0 “Translation of health administration theory and research to health administration practice”. The author equally thanks Dr. Nancy Borkowski, Director of the Chapman Graduate School of Business, from Florida International University, as well as Dr. Lea Ayers LaFave of the New Hampshire Public Health Institute.
When the study was conceptualized and designed, Veronique Lapaige was a CHSRF/CIHR knowledge translation research fellow in the PROACTIVE program (Participatory and Evaluative Research Program to Optimize Workplace Management: Application of Knowledge, Transfer of Expertise, Innovative Intervention, Training Transformational Leaders), a research program directed by Chantal Viens and Sylvie Hains. At the time of the study, the author was mentored by Dr. Chantal Viens (Laval University), Dr. Michel O’Neill (Laval University), Dr. Jean Rochon (Quebec National Institute of Public Health), and Sylvie Hains (Quebec Ministry of Health and Social Services). The author thanks all of them for their thoughtful feedback on the conception of this study.”
The author extends her sincere thanks to Christian Dagenais (Montreal University) and his KT research team (“Valorisation et transfert de connaissances” Team) as well as to Marie Désilet and the Louis-H Lafontaine Hospital’s librarians (Montreal) for their unconditional support during the systematic review.
Her thanks also go to the reviewers for their insights, helpful comments and precious suggestions.
The author reports no conflicts of interest in this work.
aA concurrent mixed method design is a multistrand design in which both qualitative and quantitative data are collected and analyzed to answer a single type of research question (either qualitative or quantitative). The final inferences are based on both data analysis results. The two types of data are collected independently at the same time or with a time lag.61
bMorse, writing in the applied field of nursing, authored an important paper on approaches to quantitative-qualitative methodological triangulation in which she presented a basic terminology and notational system.62,63 Her notational system is the standard currently used in the mixed methods research area. Components of this system include the following: (i) use of the abbreviations QUAN for quantitative and QUAL for qualitative, (ii) use of the plus sign (+) to indicate that data are collected simultaneously (eg, QUAN + qual), and (iii) use of uppercase to denote more priority given to that orientation (eg, QUAN).62,63
c“PROACTIVE” was a sequential program of three research projects focusing on the reorganization of care, services, and work in Canada. This program was led by Chantal Viens and Sylvie Hains from Laval University and Ministry of Health and Social Services, respectively.70 The PROACTIVE program’s main objectives were to support Canadian health care institutions’ managers in carrying out evidence-based decisions on the reorganization of care, services, and work, to promote transformational leadership, and to mentor these managers and their partners.70 Only the secondary results of the PROACTIVE program were considered here.