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The quantity and diversity of conceptual models in translational science may complicate rather than advance the use of theory.
This paper offers a comparative thematic analysis of the models available to inform knowledge development, transfer, and utilization.
Literature searches identified 47 models for knowledge translation. Four thematic areas emerged: (1) evidence-based practice and knowledge transformation processes; (2) strategic change to promote adoption of new knowledge; (3) knowledge exchange and synthesis for application and inquiry; (4) designing and interpreting dissemination research.
This analysis distinguishes the contributions made by leaders and researchers at each phase in the process of discovery, development, and service delivery. It also informs the selection of models to guide activities in knowledge translation.
A flexible theoretical stance is essential to simultaneously develop new knowledge and accelerate the translation of that knowledge into practice behaviors and programs of care that support optimal patient outcomes.
There is a burgeoning array of models, definitions, and nomenclature in the field of evidence-based practice (EBP) and translational science. Limited awareness of the range of models and their respective utilities constrains the dissemination and adoption of research findings. Moreover, a lack of conceptual clarity makes it difficult to interpret the results of dissemination research and to synthesize the outcomes of knowledge transfer and utilization activities1. Several authors have 2-8 recently urged attention to conceptual development in the field of knowledge translation.
Our purpose is to contribute to such conceptual development by critically analyzing the available models for EBP and translational science. Thematic analysis was applied to characterize and compare the available conceptual approaches to EBP and translational science. In so doing, we demonstrate the span of available theoretical models for translational science, distinguish the various conceptual approaches, and illustrate how model selection differentially shapes the aims, methods, and outcomes evaluation of a specific knowledge translation initiative. This thematic analysis distills the large number of translational science models into a schema that can be used by clinicians, policy makers, and researchers to guide rational selection of conceptual models for EBP initiatives, organizational efforts to accelerate the adoption of best practices, and the design and interpretation of dissemination and implementation research. An understanding of the full range of conceptual models across the translational science continuum also contributes to mapping the state of knowledge development in a particular substantive content area, thereby highlighting gaps in our knowledge base and framing possible strategies to address those gaps. Such an approach helps to ensure that our scientific agenda remains focused on systematically building a knowledge base across the translational science continuum that is highly relevant to nursing practice and programs of care.
Articles discussing theoretical models for EBP, knowledge uptake and adoption, and translational science were systematically gathered through electronic searches of PubMED, CINAHL, PsychInfo, and Web of Science. Using the key words of translation, translational science, EBP, research utilization, knowledge translation, knowledge transfer, dissemination, implementation, adoption of innovation, and theory, framework, and conceptual model, 830 articles were obtained. An additional 244 articles were identified for review by hand-searching the reference lists and by examining citations identified in the electronic databases as related references. Search strategies were repeated five times during the project as the literature was updated, and results are current to October 2009.
Abstracts of the publications identified through these searches were screened by the first author, a doctorally prepared nurse scientist, to reduce the search results to a core collection for further analysis. Papers selected for further analysis were English language reports, and had as their primary objective:(i) to describe a theoretical model for knowledge translation or translational science, or (ii) to describe a minor or major modification of a previously identified model. Retained publications represented non-duplicate descriptions of theoretical models for EBP; research utilization; knowledge dissemination, translation, or implementation; dissemination research; or translational science. Papers addressing organizational behavior, change theory, or systems theory more generally, rather than knowledge translation explicitly, were excluded.
The non-duplicate publications resulting from the search strategies described above yielded 47 distinct conceptual models addressing EBP and translational science. Two of the authors, both doctorally prepared, independently analyzed the attributes of these 47 conceptual models, extracting from each the (i) purposes, (ii) major constructs, (iii) tenets and assumptions, (iv) logical consistency, generalizability, parsimony, and testability, and (v) utility for translational science. From this critical appraisal, four distinct thematic areas emerged under which the conceptual models could be arranged. Definitions for each of the thematic areas were then developed. The definitions were designed to achieve mutually exclusive yet not exhaustive categories. Ultimately, the goal was to develop an organizing schema that would assist clinicians and researchers, wherever they were engaged along the translational science continuum, to make a coherent match between the aims of a specific initiative and the theoretical model chosen to guide that work.
The classification of models into the thematic categories was independently verified by a third doctorally prepared investigator. Classification discrepancies were discussed among the team members and definitions for each of the four thematic areas were further refined until consensus was achieved. This analysis supported the existence of four themes under which the conceptual models could be organized.
Thematic analysis placed the 47 conceptual models into 4 thematic areas representing: (1) EBP, research utilization, and knowledge transformation processes; (2) strategic and organizational change theory to promote uptake and adoption of new knowledge; (3) knowledge exchange and synthesis for application and inquiry; and (4) designing and interpreting dissemination research. The critical attributes of the models within each thematic area and the distribution of the models across the four thematic areas are summarized in Table 1.
Conceptual models under this thematic area9-16 direct a systematic approach to synthesizing knowledge to improve patient outcomes and the quality of care. Several of the models within this thematic area specify a series of processes designed to: 1) Identify a question/topic/problem in healthcare; 2) retrieve evidence that is relevant to that focus; 3) critically appraise the level and strength of the evidence; and 4) synthesize and apply the evidence to improve clinical outcomes. Other models emphasize the process by which knowledge is transformed from primary research findings into a format (e.g. clinical practice guidelines, technology assessment, standards of care) that has utility for decision-making in clinical practice. Some of the models do address outcomes evaluation, however the measurement of outcomes is designed to determine if a practice change produced the expected clinical outcome or to compare actual with ideal practice (thereby identifying unacceptable practice variation) rather than to understand the mechanism by which the outcome was achieved or to draw conclusions about what interventions are effective in a specific population. Models in this thematic area diverge relative to what constitutes evidence (empirical evidence versus guidelines); what action should be undertaken if there is inadequate evidence; and the extent to which patient/family preferences and practitioner expertise/craft knowledge are prominent.
Models within thematic area two17-35 describe the mechanisms by which individual, small group, and organizational contexts affect diffusion, uptake, and adoption of new knowledge and innovation. Many of these models propose that specific interventions—such as facilitation, use of opinion leaders, and real-time feedback about individual or aggregated patient outcomes—positively affect these mechanisms. Feedback to practitioners about their variation from best practice is proposed to promote practitioners' adoption of practices that are based on best evidence. Thus within these models, feedback regarding both patient and practitioner outcomes is seen as a change strategy. Models within this second thematic area address constructs and stakeholders from the perspective of the individual, team/unit, institution, and the healthcare system. An important distinction to note is that the lexicon for this thematic area tends to be directional from researchers to adopters/users; which may inadvertently imply that adopters possess limited knowledge of effective practice, although some models begin to suggest an interaction between researcher and end-user of knowledge.
Models within the thematic area of knowledge exchange and synthesis for application and inquiry36-45 propose that a formalized process of regular and ongoing interactions among practitioners, researchers, policy makers, and consumers accelerates the application of new discoveries in clinical care. They suggest such interactions also increase the likelihood that researchers will focus on problems of importance to clinicians. Thus, these models simultaneously address both the generation of new knowledge (inquiry) and efforts to make that knowledge available to clinicians, policy makers, and consumers/community in a format that promotes immediate application. In contrast to thematic areas one and two in which the flow of information tends to be directional from researchers to practitioners, models under thematic area three emphasize engaging researchers, practitioners, public policymakers, consumers, and communities in bi-directional collaboration across the translational continuum. This collaboration supports the sharing of expertise and knowledge exchange to strengthen decision-making and action for all involved parties. Creating and sustaining a climate of mutuality and consensus is an essential element of models within this theme.
Models in thematic area four7, 46-69 identify aspects that structure the design and interpretation of dissemination research. Dissemination research refers to studies designed to evaluate the effectiveness of an intervention in a population and/or to evaluate a process of transferring the knowledge, skill, and systems support needed to deliver an intervention to a target audience57, 70. That target audience could encompass practitioners, healthcare consumers, communities, and public policymakers. Dissemination research develops generalizable empirical evidence to determine the effectiveness of an intervention with widespread application. This approach is distinct from smaller scale studies designed to establish the efficacy of a proposed intervention. As a methodology, dissemination research also determines the best implementation methods to help target audiences receive, accept, and use information and interventions68, 71, 72. Within this thematic area, conceptual models emphasize the measurement of immediate and longer-term patient, process, and system outcomes in order to evaluate intervention effectiveness with widespread application. Dissemination research designs also aim to identify the variables that explain (predict, interact, mediate or moderate) a target audience's awareness, acceptance, and use of knowledge and innovation. Models in thematic area 4 also underscore the importance of addressing intervention fidelity, tailoring, and feasibility (e.g. cost, acceptability to patients, adherence, satisfaction etc.) when studying wide-scale implementation of an intervention.
Diversity in the origins, development, and reach of conceptual models is evident. Within the four thematic areas, the models and their underlying concepts are specified at varying levels of precision, abstraction, complexity, and scope. Some models are linear and directional, while others demonstrate a non-linear, multi-directional, or cyclical pattern of divergent and convergent activities. Though the EBP/RU models were found predominantly in the nursing literature, models within the other three thematic areas crossed several disciplines including health services research, behavioral science, and organizational psychology. We also observed differences among the models relative to whether they were developed empirically and inductively20, 34, 44, 50, deductively and based on theoretical propositions17, 25, 27, 36, 55, or whether a combination of inductive and deductive processes were used32, 37, 48. Although there were notable exceptions21, 41, 73, few of the models have been explicitly tested.
The four thematic areas can be arranged within the overarching translational science continuum74. As depicted in Figure 1, the translational science continuum provides an overview of the process by which discoveries are generated, developed, and implemented into effective and widely available clinical applications. A number of representations of the translational research process have been proposed70, 75-80. Although there is variation among these representations relative to terminology and the number of identified phases, all describe a recursive sequence of activities from basic science discoveries through adoption in routine clinical practice81. Factors that impede the transfer of research to application may be historic, political, economic, scientific, cultural, or organizational33, 67, 82, 83.
A wide variety of activities are encompassed by the translational science continuum including comparative effectiveness research, implementation research, dissemination, diffusion, knowledge transfer, uptake, research utilization, adoption, and sustainability. The lack of standardized terminology reflects the fact that translational science is a nascent and multidimensional field incorporating many disciplines and organizations, both within the health sciences, and in the fields of marketing, communication, education, and management84-86. Table 2 provides definitions for selected key terms.
Familiarity with models across the translational science continuum is a fundamental requirement if we are to take an encompassing view of a process that spans scientific discovery, the development of those discoveries into novel interventions, and the implementation of those innovations by practitioners, policy makers, and communities. Our thematic framework for organizing the diverse range of conceptual approaches to knowledge development and translation assists researchers, practitioners, and change agents when selecting a model to guide a specific initiative in translational science. For example, when planning activities to promote knowledge uptake, depending upon their purposes and the stakeholders involved, an individual or organization might select from among EBP/RU models or strategic change models. On the other hand, if partnering with researchers, policy makers, or communities, one of the models addressing knowledge exchange and synthesis for application and inquiry might be most useful.
The thematic areas can also be applied to structure empiric findings within a particular area, thereby highlighting gaps that exist in that knowledge base. In this way, the thematic areas facilitate identification of challenges across the knowledge translation continuum which require greater scientific and programmatic attention. Knowledge of the different approaches encompassed by each thematic area also contributes to framing the scope of an issue and to developing specific hypotheses that can be empirically tested.
The four thematic areas also distinguish the contributions made by researchers and by end users (clinicians, policy makers, communities, or patients) at each phase along the translational science continuum from discovery through development, dissemination, and implementation in practice. Each of the thematic areas also differentially focuses on design, implementation, and evaluation considerations relative to scientific discovery, early and late translation, and dissemination and adoption of new approaches. Using the issue of tobacco cessation, we demonstrate this capacity of the thematic areas to inform problem framing, and we illustrate how each thematic area is associated with a distinct emphasis and different action strategies.
Tobacco use, in all its forms, including smokeless tobacco, is a significant health behavior concern affecting children, adolescents, and adults and is associated with substantial morbidity and mortality. However, despite these serious health consequences and a substantial body of scientific knowledge concerning effective strategies for prevention and cessation of tobacco use across settings (schools, communities, clinics, and hospitals), the prevalence of tobacco use worldwide is increasing. Literature in the field of tobacco prevention and cessation illustrates how theoretical approaches within each thematic area differentially frame the strategies to develop and implement knowledge to achieve tobacco abstinence.
Relative to an EBP, research utilization, and knowledge transformation processes approach (thematic area 1), activities in the field of tobacco cessation have included critically appraising and synthesizing the research evidence concerning effective strategies for tobacco cessation87, 88, developing and distributing evidence-based guidelines for clinical intervention89-91, devising an interdisciplinary tobacco cessation protocol for inpatients92, refining the measurement of clinical outcomes of smoking cessation programs93, and developing curricula for health-professional education94, 95. Such knowledge synthesis efforts are fundamental in bridging from late translation to dissemination and adoption63. Specific knowledge synthesis formats can be subsequently tested, compared, and refined through dissemination research. The dissemination of practice guidelines and narrative reviews also contributes more generally to building system capacity for the delivery of smoking cessation interventions96.
Approaches to promote uptake of research findings through specific interventions such as expert facilitation97, audit and feedback98, decision-support delivered at the point of-care99-101, and the use of opinion leaders and policy changes 102-104 (thematic area 2) have demonstrated effectiveness in increasing the adoption of tobacco cessation interventions into routine clinical practice. Such approaches focus on the processes of strategic and organizational change and give limited attention to measuring intervention effectiveness (e.g. initial and long-term smoking abstinence rates).
Models that emphasize knowledge exchange and synthesis for application and inquiry (thematic area 3) formalize a bidirectional collaboration process among researchers, clinicians, policy makers, and consumers/communities. As an outcome of this collaboration, technology and expertise relative to tobacco cessation are exchanged to benefit decision-making and action for all involved stakeholders. As an example of this, a recent report describes a community of practice that developed around web-assisted tobacco interventions105. Engaging a variety of disciplines, and representing clinicians, researchers, consumers, and policy makers, collaboration in the community of practice produced a recommended minimum dataset of items for use in web-assisted tobacco interventions, guidelines for developing web-assisted tobacco interventions, and a strategy to engage consumers. These outcomes simultaneously enriched the delivery of web-assisted tobacco intervention, improved linkages among participants in the network, and strengthened the research infrastructure. McDonald and Viehbeck have also described a collaborative model of research translation for tobacco cessation known as The North American Quitline Consortium (www.naquitline.org)106. Comprised of researchers and program providers from Canada and the United States, the consortium collectively focuses on developing and sharing evidence to improve telephone-based counseling for tobacco cessation. Strategic goals and priorities for the consortium are mutually negotiated through web-based seminars, teleconferences and face-to-face meetings. Topics for discussion include, but are not limited to, potential funding opportunities, clinical and research outcomes evaluation, and identification of gaps in the current evidence base for tobacco cessation intervention comparative effectiveness106.
Exemplifying the application of models emphasizing elements in the design and interpretation of dissemination research (thematic area 4) are three recent studies that examined the effectiveness of delivering smoking cessation interventions in inpatient settings107, 108 and primary care practices109 within single-payer networks. Across the studies, a variety of approaches were deployed to promote clinicians' routine delivery of smoking cessation interventions, including training of providers in the delivery of bedside smoking cessation counseling, electronic medical record innovations to facilitate prescription of pharmacotherapy for cessation, computerized referral of motivated inpatients for telephone counseling, and practice facilitation, expert feedback, and monitoring. Intervention effectiveness was assessed by initial and prolonged smoking abstinence rates, likelihood of receiving a prescription for pharmacotherapy for smoking cessation (the ‘reach’ of the intervention), and the incremental costs per quitter. In addition, researchers evaluated the process of transferring to practitioners the attitudes, knowledge, skills, and system supports required. Implementation outcomes, such as the barriers and facilitators to clinicians' implementation of smoking cessation guidelines and the factors mediating the adoption of recommended practices (e.g. clinician self-efficacy for providing smoking cessation) were also examined.
Dissemination research outcomes suggested by models within thematic area four and evaluated in studies of tobacco cessation interventions include implementation fidelity, treatment potency, patient and clinician acceptability or satisfaction with the interventions, and cost effectiveness 110-112. Illustrating this, Kobus and Mermelstein describe the Partners with Transdisciplinary Tobacco Use Research Centers (TTURCs) Partners initiative113. The initiative was developed to fill the gap between scientific discovery and research translation, extending basic and applied research in tobacco cessation through studies that examine the policy and practice implications of specific tobacco cessation interventions. The research emphasizes the extent to which findings from tobacco dependence studies are transferable to real-world settings and serve to enhance policy development. For example, TTURC Partners' studies have explored the factors associated with physicians' receptivity to adopt novel smoking cessation approaches into practice, and have examined the health economics of tobacco cessation from the perspective of the employer (e.g. impact of cessation on worker productivity and reduced healthcare expenditures)113. Ritzwoller and colleagues have similarly described the importance of including cost analyses in trials of smoking cessation interventions in order to develop more precise and generalizable implementation cost estimates for behavioral interventions, since settings can have unique needs relative to intervention resources114.
We have argued that despite an expanding number of conceptual models, theoretical development relative to EBP, knowledge utilization, and translational science in nursing has been attenuated. There is an abundance of terminologies in use, sometimes employing the same terms with somewhat differing meanings115. Yet, without conceptual clarity, this expanding literature base complicates rather than advances the use of theory in translational research. Using comparative analysis, our purpose has been to illuminate the span of theoretical models available to inform knowledge development, transfer, and utilization. This analysis has also attempted to map the significant convergences among conceptual models within each thematic area and the linkages among thematic areas. Further, it has advanced the recommendation that an eclectic, pluralistic approach to model usage is necessary to accelerate the development of new knowledge and the application of evidence by practitioners and policymakers.
We acknowledge that in an effort to place the models within discrete categories, we may have enlarged the separation between the thematic areas. Each identified thematic area is not fully discrete, and several of the models incorporate elements from more than one thematic area. For example, most models that focus primarily on EBP and the transformation of research findings into knowledge useful for clinical practice also mention the importance of the change process and facilitation (e.g. EBP mentors116-118, organizational readiness119, factors that affect the adoption of innovation11, and the importance of a supportive infrastructure120). However, EBP models are not explicitly focused on providing theory that explains the mechanisms for uptake and adoption, as in thematic area 2, or the mechanisms for awareness and acceptance of an innovation, as in thematic area 4.
The conceptual model selected to guide a specific knowledge translation initiative substantially influences the aims, design, methods and evaluation of outcomes1, 121 21. Science leaders should carefully examine the phenomenon of interest and select models that address all aspects of a phenomenon. For example, the singular use of models that emphasize the problem-solving approach of EBP may fail to fully account for the processes of strategic change and aspects of organizational climate and culture that impact the adoption of innovation. Moreover, at specific stages in the translational science continuum, models from one thematic area may perform better than those from another thematic area. For example, models that emphasize the design of dissemination research or those that emphasize the process of strategic change may offer greater specificity in selecting variables and interpreting study results than models that emphasize the process of bidirectional exchange between researchers and clinicians. On the other hand, where integration and dialogue across disciplinary boundaries is needed, models emphasizing knowledge exchange, synthesis, and application might be most suitable. A thoughtful, flexible approach to model selection is necessary to advance the use of theory in translational science.
While there are multiple models for EBP and substantial areas of convergence across those models, less attention has been given to theoretical development in the areas of knowledge exchange and dissemination research. The results of this analysis can be incorporated to promote continued evolution of the current models for EBP, and to encourage theoretical developments that promote a level of multi-directional engagement among all stakeholders (practitioners, consumers, administrators, policy-makers, community leaders, and researchers) and benefit decision-making for all involved parties. Several recent papers summarizing the state of the science in treating tobacco dependence122, proposing an agenda for tobacco dependence research123, and outlining an agenda for public policy in the area of tobacco cessation124, 125 offer examples of this capacity for the thematic areas to promote problem framing and policymaking.
The prominence of EBP models in the nursing literature raises the question as to whether the discipline's approach to translational science has been constrained by an overemphasis on models in thematic area 1. We do not suggest that as nursing reaches higher levels of scholarly engagement in translational science that models focused on EBP or on strategic change to promote adoption of knowledge are abandoned. Rather, we urge leaders to use theory as a tool for translational science and to apply a flexible theoretical stance to guide their work. Evolution towards a pluralistic conceptual approach for translational science encompasses both strategies to facilitate practitioners' efficient access to research evidence and point-of-care decision support, together with interventions to sustain an organizational culture that is ‘research-minded’ 8, 121, 126. Flexible pluralism also supports the development of actionable messages for decision-makers such as public policy makers, health managers, and corporate executives, the development of knowledge uptake skills in target audiences and knowledge transfer skills in research organizations, and the systematic evaluation of the impact of knowledge translation activities by both service delivery and research organizations. Thus, a pluralistic approach gives simultaneous attention to creating organizational cultures and climates that favor the adoption of innovation, and to strategies that create greater proximity, dialogue, and affinity between the generation of knowledge by researchers and its application by health professionals, patients, communities, and public policymakers127, 128. Within a stance of theoretical pluralism, leaders consciously select, depending upon setting, context, and purpose, from this full range of theoretical models to guide translational science efforts.
Adoption of a pluralistic theoretical approach to translation has implications for clinicians, administrators, educators, and researchers. For clinicians seeking to improve clinical outcomes through the application of best evidence, EBP and research utilization models offer a systematic approach to clinical decision-making129. However, one limitation of these models is that many place comparatively less emphasis on outcomes evaluation and on the features of an organization that promote the adoption of innovation.
Advanced practice nurses and nurse researchers can utilize the thematic areas to provide context for their respective involvements in knowledge translation efforts. For example, models in thematic area 3 that emphasize a bi-directional collaboration between researchers, clinicians, and policy-makers offer a useful context for researcher-clinician collaboration in tailoring and then testing an intervention in a naturalistic setting.
Theoretical pluralism is a particularly essential skill for the researcher. Sales, Smith, Curran, and Kochevar have argued that without explicit attention to theory, study findings are difficult to interpret, and essential implementation strategies needed to promote a practice change may be overlooked121, 130. Researchers can use models in thematic area 4 to identify the mediators, moderators, and outcomes that should be examined when testing the effectiveness of an intervention in a population, or to distinguish in an implementation trial, the individual and organizational features that promote adoption of an innovation into routine care settings47.
While we and others3, 4, 7, 27, 121, 131, 132 have attempted to place some conceptual structure and parsimony on the large number of available models for EBP and translational science, there remains a need for these models to be tested and refined through empirical study. There is also a continued need for nursing, as a discipline, to give attention to the lexicon for translational science. Within the field of translational science more generally, there are considerable inconsistencies in terminology and meaning84, 133. Evolving a shared understanding of these inconsistencies within and across research/practice sectors will take interdisciplinary collaboration, and such efforts are in progress4, 8, 134-137. However to contribute effectively to that dialogue, nursing leaders must be equipped with a sufficiently broad and nuanced understanding of the concepts, terminology, and controversies within and across practice and research sectors. Lastly, graduate curricula must include an exposure to both the theory base138-141 and the methods83, 142-150 for translational science so that emerging leaders are equipped to take a flexible conceptual approach to research design, leadership, and change management across the translation continuum.
This thematic analysis maps the diversity of conceptual approaches to translational science. It arranges the models into thematic areas, making it easier for leaders and researchers to access theory and to narrow or broaden the set of models they consider to guide their work. Rational selection of a conceptual model to guide a specific initiative in translational science is predicated on familiarity with models in all four thematic areas. Knowledge translation theories for the health sciences are in need of continued testing and refinement. At the same time, fostering theoretical pluralism is essential if we are to simultaneously advance EBP and translational science. This flexible, pluralistic approach may also mitigate the individual and organizational challenges encountered in translating evidence into practice behaviors and programs of care that optimize individual and community health outcomes.
We gratefully acknowledge Josanne Revoir, RN, MS, National Institutes of Health Clinical Center for her assistance with development of figures. This work was supported by the National Institutes of Health, Clinical Center, Nursing Research and Translational Science, Nursing and Patient Care Services.
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