Knowledge in Clinical Practice Guidelines

To Use or Not to Use?
by Tazim Virani, Irmajean Bajnok

In this first of three articles addressing knowledge management and knowledge use, the focus will be on clinical best practice guideline development and implementation. Implementation in this context refers to knowledge translation, transfer and uptake of knowledge. Over the three articles, we will describe a multifaceted approach to facilitating evidence-based practice and policy development used by the Registered Nurses Association of Ontario (RNAO). The approach includes development, pilot-testing, evaluation and dissemination of nursing best practice guidelines for the older adult population; programs to assist long-term care and other sectors in implementing these guidelines; a focus on healthy work environments; development of a long-term care orientation program; leadership in elder care policy development and dissemination of service and policy initiatives through annual conferences on elder care.

Information is doubling every twelve to eighteen months. In the biomedical publishing alone, we have seen an increase from 20,000 journal publications to upwards of 2 million in the last 50 years. Data is more easily accessible and in greater volume than ever before. In the busy day-to-day work situation, time to “keep up” with new information and new knowledge is inadequate. Additionally, new information needs to be critically appraised, interpreted and reconciled with other experiential knowledge, clinical context and patient preferences. Identifying valid and reliable information from the plethora of documents, research reports and anecdotal evidence requires both time and skill. More importantly, once we gather reliable and valid information, how do we turn it into knowledge that can readily be used at the point of care delivery! Will the paradox of having maximum access to extensive information but minimal time or tools to translate it into meaningful knowledge create at best a mediocre health care system?

In order to address the overwhelming amount of information in health care within a paradigm of evidence-based practice, several responses have emerged over the past decade. This includes conducting rigorous systematic reviews, meta-analysis, health technology assessments, clinical practice guidelines as well as databases or clearing houses to disseminate these forms of “packaged knowledge”. Such strategies have been widely recognized around the world and in recent times also supported through the standards set by the Canadian Council on Health Services Accreditation (www.cchsa.ca) as well as the Romanow Report (2002).

In addition to accessing “knowledge for direct use”, there is also the growing realization that we know very little about how to “put such knowledge to use”. This question of course is not new, as reflected in the considerable study, debate and activity since the early 1930’s when Kurt Lewin and Paul Lazarsfeld imported the field of knowledge and research utilization from Europe to the United States (Huberman, 1994). The subject of knowledge translation and transfer has become an important field of study and indeed an industry in and of itself. Knowledge networks related to health care are springing up all across the country through such groups as the Canadian Research Transfer Network, Atlantic Telehealth Knowledge Exchange, and the Alberta Heritage Foundation for Medical Research. Training on knowledge translation and transfer is now available through courses, workshops and the Internet, and new knowledge broker roles are rapidly being established (CHSRF, 2003).

The issue of how information gets used, however, may be getting more rather than less complicated, resulting in an increasing distance between knowledge and the end user. Figure 1 is one way of viewing the current state of knowledge utilization in health care. Information generation is ever increasing. There are, at the same time, increasing forms of access being developed and different forms of knowledge translation being established. However, there are significant barriers that prevent this information from reaching point of care. These barriers encompass the key areas of time, and workload in particular for nurses and other health care providers (Edwards, Davies, Dobbins, Griffin, Ploeg, Skelly, et al. 2003). Other barriers however exist such as a rigid culture of skepticism to anything new or different. These and other barriers to knowledge use require tremendous attention to address, with no guarantees that point of care knowledge transfer will be the result. In other words there do not seem to be any “magic bullets” in this area (Oxman, Thomson, Davis, & Haynes, 1995).

Figure 1 is included in the print edition of STRIDE.

Best Practice Clinical Guideline Development

The RNAO is a provincial nursing professional association with the mandate of speaking out for health care and speaking out for nursing. In keeping with its mandate, RNAO undertook a project of addressing the need to make the best clinical knowledge available at the point of care delivery. The Ontario Ministry of Health and Long-Term Care funded this project for the development, implementation and evaluation of clinical best practice guidelines on a multi-year basis. The cornerstone of the project is to ensure that appropriate knowledge is appropriately utilized in patient care, through the development, testing and dissemination of clinical best practice guidelines. To do this, the RNAO established an operational structure and methodology as follows:

To date there have been twenty-one topic areas where guidelines have been developed. Details on the topics can be found on the RNAO website at www.rnao.org/bestpractices. Topic areas pertinent to the long-term care sector including screening and management of delirium, dementia and depression; falls risk assessment and prevention; promoting continence; reducing constipation; pressure ulcer prevention, assessment and management; pain management, etc. The guidelines are developed by scanning and critically appraising existing clinical practice guidelines, reviewing systematic reviews, and meta-analysis. Other primary research, existing health technology assessment reports, as well as gray literature are also reviewed. Evidence is reviewed and consensus reached on recommendations. Panel members’ experiential expertise and knowledge of clinical areas is utilized to address issues of feasibility and pragmatic considerations.

The challenges identified in guideline development are many; three key ones will be discussed here.

First, there are numerous challenges in gathering, critically appraising and identifying evidence that addresses the clinical issues of concern to practitioners. Not only is this activity a time-consuming one, but also one that requires well thought through search terms, and skills in critical appraisal. Such an activity requires information specialists, dedicated staff support and panel members with critical appraisal skills. The panel members of clinical experts consistently comment on the learning that they personally acquire through the process. Some existing systems for research and guideline appraisal have been found to be useful [for example, research appraisal courses particularly those available through online learning, and the use of guideline appraisal instruments such as the AGREE instrument (www.agreecollaboration.org)]. These tools have been helpful in ensuring a systematic and rigorous process to evidence appraisal.

Secondly, the patient care questions of importance to clinicians are often not addressed conclusively nor answered precisely by research. Research inherently has limitations. Therefore, many of the recommendations are reduced to consensus statements, albeit informed by research and experience.

Thirdly, panel members often find evidence disconnected from reality; that is, recommendations are difficult to implement because of environmental constraints such as skill requirement, lack of structures and systems, etc. Panel members often spend enormous time debating on making evidence-based recommendations versus better practice recommendations. With this in mind, the RNAO project expert panels provide three types of recommendation: clinical, educational and organization/policy recommendations. Clinical recommendations focus on the clinical questions. Educational recommendations address the requirement for knowledge, skills and attitudinal shifts requiring for practice change. Organizational and policy recommendations address the systems and structures that enable clinical and education recommendations to be implementable.

Guideline Implementation

While information is being turned into accessible knowledge and at the same time attention is being paid to how to use knowledge, there is mounting evidence that end users are still not adequately incorporating the available knowledge into their daily practices, (Cabana, Rand, Powe, Wu, Wilson, Abboud, et al., 1999). The public at large is becoming more confused with this disconnect. Guideline implementation and evaluation, along with related research in identifying the barriers to knowledge use, point to some interesting themes. The organizational context or the nature of organizational factors play a much larger role in knowledge use than has been given credit in the past (Argote, 1999).

Past and current knowledge utilization has an overemphasis on education of the practitioner, without adequate attention to organizational factors, such as processes, structures, stakeholder buy-in, need for resources and whether or not the knowledge is going to be readily accepted. A number of theories and much research conducted in fields outside of the health care sector can be examined for their application to health care settings. Roger’s theory of diffusion is now heavily used in health care.

However, other theories and related research such as organizational learning, stakeholder theory, and concepts such as “organizational slack”(Bowan, 2002) and “absorptive capacity” (Cohen & Levinthal, 1990) may provide the health care sector with other effective ways of thinking about organizational barriers. Organizational slack can be thought of as an organization’s availability of resources (people, time, money, expertise), opportunities for learning and experimenting (pet projects, innovations) and workload buffers such as extra staff, or dedicated time to a project. Absorptive capacity according to Cohen and Levinthal (1990) is an organization’s prior knowledge and the value it places on bringing and assimilating new information towards meeting its objectives. Both these concepts can be used in planning strategies that incorporate environmental readiness assessments when introducing clinical best practices.

In the work RNAO has carried out, some obvious and some not so obvious barriers have been identified. Some of the obvious ones are the need for financial resources, time for staff to attend educational sessions, and readily available supplies and equipment to enable application of the new knowledge. Some other barriers have been less obvious. Organizations often do not dedicate specific individuals to lead clinical innovations projects, and if they do, the project lead individual does not have the appropriate and necessary project management skills. Another not so obvious barrier is that much of what is acquired as knowledge is not embedded into structures and processes, and therefore relies on individuals to remember and assimilate the new knowledge into their work. This is not only unrealistic but also impractical. Another barrier of importance is not spending enough attention to getting all appropriate stakeholders identified and engaged in the change process.

In response to many of these barriers, RNAO has developed a toolkit for clinical practice guideline implementation. The toolkit is currently being evaluated and has been used by many organizations. The toolkit offers a model of clinical practice guidelines implementation based on a six-phase process. First, critically appraise guidelines and clearly identify what it is that will be introduced as a change in a practice setting. Second, identify, assess and engage your stakeholders well. Third, conduct an environmental assessment. Find out what are the showstoppers and what are the facilitators. Fourth, select implementation strategies that work. There is a growing knowledge base on what strategies are effective, what has been found to work sometimes and what has been found to be ineffective. (Table 1 outlines the these three category of implementation strategies in health care.) Fifth, decide how you are going to evaluate the clinical change outlined in phase 1. It is the demonstration of what works and what does not work that will win over the skeptics and ensure a greater commitment to the change.

Table 1 is included in the print edition of STRIDE.

Lastly, think through what resources will be needed and ensure engagement of stakeholders who can enable access to necessary resources. Although, these steps are based on a planned change model, it is our experience that organizations are often too much in a hurry to implement a guideline and short cut very valuable steps, in planning, determining environmental readiness and engaging stakeholders. The toolkit is a practical resource with various worksheets that can be used by a group or individually.

Concluding Remarks

Although many organizations are successfully putting forth efforts in breaking the barriers to knowledge use, there is much that is not known. What facilitates uptake and ready use of one type of knowledge while another takes dozens of years? Why do some settings adopt an innovation readily while others struggle? Continued attention, research and attempts to try different approaches will provide answers to some of these questions. In health care, in particular, where the latest research is integral to quality of care, it is imperative that there be concerted efforts devoted to enhancing the interface between new knowledge and point of care delivery.

As part of the new paradigm of knowledge-based economies, the health care sector must learn to harness and transfer the infinitely growing resource of knowledge to enhance the work of its knowledge professionals.