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Knowledge mobilisation – the icing on the cake?

I bet Mary Berry could teach me a thing or two about knowledge mobilisation.

This rather unusual thought came to me a few days ago as I was deciding what to bake for our Team’s weekly cake and coffee get together.  It’s just an informal gathering, time to catch up with colleagues, and a bit of time out from systematic reviewing to eat cake: there really is no pressure to create the most awesome amazing cake at all….honestly, it’s not a competition.

This led me on to thinking about the book my husband bought me for my birthday last year… through which I should be learning how to turn Everyday Bakes into Show Stoppers (jazz hands please). For me, the essence of the book seems to be that you can go to a lot of effort to choose a great cake recipe, pick good quality ingredients, mix it carefully, bake it sensitively, but if you don’t make an effort decorating it, you’re really not doing it justice. You know you’ve failed in cake baking if you find yourself presenting it saying ‘Don’t worry, it tastes much better than it looks…’

Which is a bit like research knowledge mobilisation isn’t it?

We Researchers work carefully to create research which is relevant, useful and elegant. We think about the methods, the questions, the data we’re gathering, we write it all up, considering where we’ll publish. So we have our cake. But we need a way to tempt others into using it. Research without a clear sense of how it will be shared/translated/disseminated/mobilised is like baking a gloriously moist red velvet cake, and then not decorating it to look like a life-sized baby : a colossal missed opportunity. (the faint-hearted might not want to click this link, it gets quite gruesome! OR, scroll forward to 56sec to get to the action).

In fact, knowledge mobilisation isn’t a discrete event at the end of a research process at all, and it’s not the cherry on the icing on the cake; it is part and parcel of research. So, what we can learn from Mary Berry about knowledge mobilisation? Well, in the same way that I can’t ever imagine Mary Berry presenting a naked cake for eating, I don’t think I can ever imagine research without thinking how it will be mobilised…

The cake I almost created…..wait…. those are dead squirrels, aren’t they?

Click Bait

 

The why and how of mobilisation: on researching KM processes

I heard recently about a funding application involving knowledge mobilisation that involved non-participant observation. It was rejected and one of the negative comments from a reviewer was that participant observation wasn’t appropriate because “you can’t see knowledge mobilisation happening”. Can you observe KM taking place? I think so; for example, John Gabbay and Andrée le May used it in their work on ‘mindlines’ among primary care doctors (2004) – but it took them a long time and it’s unlikely to be an easy way to gather data since it’s likely to depend on a detailed understanding of contextual phenomena that may often be implicit and hard to spot.

So what other methods might be useful if we are interested in understanding KM processes? Doing it important; after all, an important part of KM is an assessment of the barriers and facilitators involved (Grimshaw et al. 2012). Rather than trying to observe what’s going on, a more direct way of achieving such an assessment is to ask people about it: interview those who are doing the work and ask them what prevents or enables KM.

But this apparently straightforward approach also presents problems, if not approached with care. US sociologist Howie Becker urged research interviewers, when they want to understand the reasons something is the way it is, not to ask “why” but instead to ask “how”. So instead of asking:

“why did you decide to give that child a tonsillectomy, contrary to the evidence?”

we might ask

“how did you decide that a tonsillectomy was the right treatment for that child?”

And instead of asking

“why did you decide to start using that intervention (for which there is no evidence that it works)?”

we might ask

“how did you come to take the decision to start using that intervention?”

Becker summarised the rationale behind this thinking in a 2010 interview: “The reason why I say don’t ask “why”, ask “how”, is very practical. If I say to you “why did you become a sociologist”, you have to give me a good answer. Most of us didn’t know what we were doing when we chose this profession. I never had the intention to be a sociologist, I wanted to be a terrific piano player. Sociology was a sort of hobby. But after some years, I realized I could be a good piano player, but never a terrific piano player. I had to acknowledge the truth: I was a sociologist, not a professional musician. I still could not tell you why I became a sociologist, but I can tell you how. If I ask why, I get a defensive response, the person I question wants to give me a “good” reason, a defensible reason. But if I ask: How did it happen? You can give me practical answers.” (http://www.booksandideas.net/Social-Life-as-Improvisation.html) He said the impetus for this approach came from an essay by C Wright Mills (1940) and expounded it at more length in his book Tricks of the Trade.

Where does this leave us in relation to understanding KM processes? I’d say that non-participant observation can yield valuable insights but you have to be prepared to be in for the long haul or else to have a prior deep understanding of the context in which you’re working. If you don’t want to do that, or you want to complement that approach with another one, by all means ask questions but be reflective about what you’re asking and what answers you will get; and ask how rather than why.

 

References
Becker HS. Tricks of the Trade: How to Think about Your Research While You’re Doing It. 1998. Chicago: University of Chicago Press

Gabbay J, le May A. Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care. BMJ 2004; 329

Grimshaw JM, Eccles MP, Lavis JN, Hill SJ, Squires JE. Knowledge translation of research findings. Implementation Science. 2012 31;7:50.

Mills CW. Situated Actions and Vocabularies of Motive. American Sociological Review 1940. 5(6): 904-913.

Fear not, management is here

Yes, you do detect a note of sarcasm in the title, for I have a long-standing animosity towards impenetrable management gobbledygook. But more fool me – there are pearls within this literature, not least of which is Van de Ven & Johnson’s ‘Knowledge for theory and practice’. The term ‘knowledge co-creation’ is often bandied around now in health services research, but Van de Ven & Johnson got there first and articulated it in a way that demands close inspection. Here’s a start…

So what do Van de Ven & Johnson say about different ways of ‘using knowledge’? First, we’ve all long got over the idea that knowledge can simply be transferred lock, stock and barrel (they don’t actually say this as such, but I’ll say it for them). Second, in some areas of practice, an incommensurability exists between different forms of situated and generalised knowledge – that way lies ‘debate’ that generates more heat than light. But Van de Ven & Johnson articulate a third, dialectical form of knowledge co-creation in which the different perspectives, competencies and knowledge of stakeholders are brought together. Not so much parallel streams that add up to a whole, as a fusion that produces something greater than its constituent parts. They refer to this as ‘engaged scholarship’, a wonderful term that encapsulates the need for all stakeholders to be both engaged with one another and with the knowledge that they employ in the dialogue in which they work towards a decision (sorry, explaining engaged scholarship doesn’t always lend itself to pithy sentences).

I’d like to think that this is what I do in my own research, but I’d also like to know how to do it a whole lot better. I’d also like to know whether or not ‘engaged scholarship’ really does make a difference, or whether it’s just a plausible set of ideas that appeal to researchers like me. I think I’ll also have many more questions to ask of ‘engaged scholarship’ over the coming months. Feel free to add your own here and contribute to the conversation.

Van de Ven, A.H & Johnson, P.E (2006) Knowledge for theory and practice. Academy of Management Review 31 (4) 802-821

On implementing non-evidence-based interventions

Kitson, Harvey and McCormack put together a conceptual framework and published it in a 1998 paper entitled Enabling the implementation of evidence based practice. Within that paper, almost as a throwaway line near the end, they remark, “Of particular interest, and something which was not discussed in this paper at all, is to explore the mechanisms by which new interventions which have very limited or no research evidence, are successfully implemented into practice.” The authors don’t say anything more on this topic and it isn’t mentioned, as far as I know, in any of their subsequent papers on related topics.

The line has stuck with me because in health and social care new interventions are introduced and changes are made all the time, and a lot of them are introduced on the basis of partial or no evidence. I recently saw the question asked “Why is it so difficult to change things in the NHS?” and I thought it was the wrong question for a couple of reasons: first, because it’s not just the NHS. From a certain perspective it’s hard to change things in any domain, which is why much interesting writing on implementation and knowledge mobilisation comes appears in management journals. Second, and more relevant here, it’s not actually hard to change things in the NHS, or elsewhere: change is happening all the time, and unless we imagine that those changes are just occurring spontaneously then we have to suppose that people are making them happen (though it is conceivable that they do so unintentionally.

How and why do these changes happen? That’s obviously what Kitson and colleagues are suggesting requires further investigation, and I think we could learn from that. Most related work tends to focus on how people make decisions based on incomplete information, or on no information at all – for example, in formal decision-making game theory and decision-analytic modelling might be used.

But I think we need to consider from a different angle how people – or, more likely in the contexts I have in mind, groups – make decisions. When, for instance, a healthcare decision-making group has money to allocate (say, on dementia care in the community) they are not in the sort of situation that a game-theoretical approach would favour, i.e. one in which they have to make the best move considering the potential moves an opponent may make. Rather, they have to use the information to which they collectively have access in order to reach agreement about how to use the money but without there necessarily being a discrete set of options from which to select.

I would argue that they are likely to do so in a rational way but in a way that is affected by what they have heard is happening elsewhere, what they have done in the past, what they think they ought to do, and so on. They will often not have a clear need that they seek to address but may have a desire to act in a way that will fit with the explicit or implicit goals of the group: in the case of a group concerned with community dementia care this might involve improving quality of life for people with dementia, reducing health problems in carers, and reducing institionalisation rates.

One way to think about these processes of decision and change is through the lens of new instutionalism, as presented by the sociologists and organisational scholars DiMaggio and Powell (1993). They propose that, rather than being formed in a purely rational way, organisations take on forms, and thus act in ways, that come to resemble the forms and actions of similar organisations in similar contexts. They call this process institutional isomorphism; isomorphism here means a “constraining process that forces one unit in a population to resemble other units that face the same set of enviornmental conditions”. They describe three mechanisms that lead to institional isomorphic change: coercive isomorphism (rules or laws that must be followed: “it’s a legal requirement for us to do this”); mimetic processes (imitation when faced with uncertainty; “we’re not sure what to do but this is what they did over there – let’s do the same”; and normative pressures, primarily through professions; “we’d better do this because all those guys are doing it”).

Rather than regard chance as impossible to bring about we might benefit from considering the changes that do take place and looking at the processes and dynamics that lead to them. In doing so we might learn a lot about how to bring about the positive changes that we would like to see as well as how to reduce the frequency of the negative changes we would rather avoid.

 

 

References

Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based practice: a conceptual framework. Qual Health Care 1998;7:149-158 doi:10.1136/qshc.7.3.149

DiMaggio PJ, Powell W. “The iron cage revisited” Institutional isomorphism and collective rationality in organizational fields, American Sociological Review 1983;48:147-60.

Transferring, Translating, and Transforming

Among the Knowledge Mobilisation papers I’ve found useful is one by Paul R Carlile called “Transferring, Translating, and Transforming: An Integrative Framework for Managing Knowledge Across Boundaries”. Carlile is a management scholar and this paper was published in Organization Science but although it is focused on product development on a fictional car manufacturing company, its broader theme of managing knowledge across boundaries is relevant to health and other sectors.

As the title indicates, in this paper Carlile discusses the differences between, and challenges posed by, three ways of managing knowledge across boundaries: transferring, translating, and transforming. These relate to three levels of complexity in communication – syntactic (transfer), sementic (translation), and pragmatic (transformation) – and to the increasing level of novelty implicated as we move from transfer towards transformation.

Carlile identifies crossing syntactic boundaries as common when the idea of knowledge transfer is prominent. He says that when there is a common lexicon on each side of a boundary that can adequately deal with the “differences and dependencies of consequence” present then transferring knowledge across that boundary should be relatively unproblematic. He notes that a common lexicon is necessary, though not always sufficient, to share and assess knowledge across a boundary.

When a semantic boundary is involved, creating common meanings to share and assess knowledge may require knowledge translation and the creation of new agreements. This can occur when differences or dependencies are unclear or when meanings are ambiguous. Shared meanings can emerge when communities of practice develop or when knowledge brokers or translators are involved – the challenge is typically one of making tacit knowledge explicit.

Finally, when pragmatic boundaries are present it means that the knowledge to be changed is “at stake” and the interests of individuals or groups are challenged by it or face costs in resolving the differences uncovered. To achieve chance in such circumstances knowledge transformation is often necessary; Carlile suggests the use of boundary objects like drawings and prototypes (which makes sense in terms of car manufacturing) to assist in such negotiations.

 

I don’t find it too hard to think of examples of each of these boundaries. A colleague recently described to me the efforts of a patient who was keen to get to grips with the evidence behind treatments for her condition. She starting asking health professionals where they found the evidence they used to inform their practice but her repeated question “So what magazines do you read?” brought her bemused looks. Of course it wasn’t a major step for her to realise that she should be asking about journals rather than magazines (“Did you see the results of that RCT reported in Marie Claire?”) and so to come closer to having a common lexicon with those to whom she was speaking – this would be a (very simple) example of something enabling knowledge transfer across a syntactic boundary.

Knowledge translation was necessary for me when I, as a public health practitioner, started working with social-care colleagues. I realised after a while that what I meant when I spoke about prevention (roughly speaking, stopping people from developing health problems) was not the same thing that they meant when they said prevention (making sure people didn’t reach a position where they need to receive statutory services). Our conversations on this topic became easier when I had realised this difference in meanings. This is a simple example of knowledge translation and the situation will be more difficult when it’s not just a single word that is involved.

Finally, I had experience of (unsuccessful) knowledge transformation when I was asked to review a service provided by a partner organisation. To make life easy for me, or so I thought, someone had just completed a PhD that was partly based on an evaluation of the service in question. They had found that the service was ineffective – in fact, that some of the people enrolled in the service seemed to have poorer outcomes than people who were not enrolled. I reviewed the published literature and found little evidence anywhere to support services of this type. I wrote a brief report and sat back, waiting for the service to be closed and savings to be made; but it wasn’t, and they weren’t. The matter was less clear-cut than that and it took me a while to realise what had happened. In effect, the knowledge that I had put together – negative evaluation outcomes, no evidence of effectiveness – presented a challenge to the knowledge of those commissioning and running the service – that people liked the service, that they were personally and politically invested in the service, that they didn’t like the way the evaluation had been conducted. They had knowledge that was put at stake by my knowledge (which was also challenged by their knowledge). I failed in my attempt at knowledge transformation and in this instance the practical boundary was not crossed.

 

Carlile puts these elements together in an integrative framework as part of a much longer and richer paper in which he considers ways of tackling the problems identified. Considering even these simple elements, though, helps me think about some of the challenges central to knowledge mobilization in healthcare: the need to take knowledge across boundaries of different kinds, the importance of thinking of the differences involved, and the political and practical challenges involved in successful knowledge sharing.

 

 

References

Carlile, PR. Transferring, Translating, and Transforming: An Integrative Framework for Managing Knowledge Across Boundaries. Organization Science. Vol. 15, No. 5, September–October 2004, pp. 555–568. Non-final version available from institutional repository: http://dspace.mit.edu/bitstream/handle/1721.1/3959/EEL_3T.pdf or at http://pubsonline.informs.org/doi/pdf/10.1287/orsc.1040.0094

You say potato, I say knowledge mobilisation … or implementation science, or knowledge transfer, or translational research … etc. etc.

Yes, we know – unhelpful isn’t it?

Being interested in how research and other forms of knowledge can better influence policy and practice is hard work.  It is at times, quite literally, like trying to learn a new language –  but without the audio-cassettes and exotic foreign trips; a language that has different tribal dialects and shifting terms for things which, to a great extent, seem to be the same thing.  And every tribe has its current favourite.

Four or five years ago, following hot on the heels of some MRC strategic plan, the research strategy for our medical school was all about Translational everything.  More recently the NIHR (National Institute for Health Research) has committed itself to Knowledge Mobilisation, a term imported from Canada.  Meanwhile, in academic publishing, the journal Implementation Science has established itself as the main journal in which to publish articles about how research influences policy, management and practice, or the effectiveness of specific strategies for promoting the use of particular knowledge to particular organisations or problems.  Finally, post-REF, enabling Research Impact (or Knowledge Transfer) is now an issue for everyone working in universities.

This causes bemusement and fatigue.  Even trying to name this blog became a parody of the terminological jelly-wrestling that is knowledge mobilisation/implementation science/translational research.

This blog aims to share experiences among the growing group of people in the Medical School, the wider University of Exeter and health and care services who are interested in understanding how to better apply (use, adapt, generate, create space for – you get the idea) knowledge in different service organisations and professions etc.  Above all, we want to avoid the classic academic pitfall of endlessly defining and redefining terms  (… I think it should be potato by the way –  my colleagues will probably disagree).

Instead, collectively we want to help each other make sense of this stuff, share tips, send links, and reflect upon all things knowledge mobilisation-ish in ways which are engaging, informative and hopefully amusing too.

Please join us, post comments and queries, or just eavesdrop on our ruminations.

Rob, Iain, Mark and Becky

Gollum asks the important question.