Knowledge Utilization: The Classical Approach

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Knowledge UtilizationThe Classical Approach

• Marita G. Titler, PhD, RN, FAAN
• Director of Research, Quality and Outcomes
  Management
• Department of Nursing Services and Patient
• University of Iowa Hospitals and Clinics
• and
• Clinical Professor
• University of Iowa College of Nursing

Linda Q. Everett, PhD, RN Associate Director,
University of Iowa Hospitals and
Clinics Director, Department of Nursing Services
and Patient Care/Chief Nursing Officer University
of Iowa Hospitals and Clinics
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Purpose

• To discuss the classical approach to knowledge
  transfer - experts generate knowledge and
  help organizations with implementation
  strategies

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Overview

• Definitions and assumptions
• View of individual and organizational
  perspectives
• Overview of science of TRIP
• Example TRIP study - issues
• Issues in knowledge transfer

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Knowledge Utilization

• Application of evidence from randomized clinical
  trials as well as other types of scientific
  investigations and other types of knowledge (e.g.
  case reports, expert opinion)

(Cook, 1998 Feinstein Horwitz, 1997 Guyatt,
Sackett, Sinclair et al , 1995 Stetler, Morsi,
Rucki et al, 1998 Titler, Kleiber, Steelman et
al, 2001)
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Evidence-Based Practice

• Conscientious and judicious use of current best
  evidence to guide health care decisions

(Dickersin Manheimer, 1998 Rochon, Dikinson,
Gordon, 1997 Sackett, et al, 1996)
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Research Utilization

• A process of using research findings as a basis
  for practice. It encompasses dissemination of
  scientific knowledge, critique of studies
  synthesis of findings, determining applicability
  of findings, application/implementation of
  scientific findings in practice, and evaluating
  the practice change.

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Research Utilization
Evidence-Based Practice
Figure 1
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Translational Research

• Testing the effect of interventions for promoting
  adoption of evidence-based practices
• Outcomes-rate and extent of healthcare providers
  use of these practices

(Titler Everett, 2001)
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Individual and Organizational Perspective

• Individual perspective
• Variation in practice
• Governed by organizational SOC
• Organizational perspective
• Change in SOC - change in practices by
  individuals
• System changes
• Access to evidence
• Organizational infrastructure
• Combination of both

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Models of Evidence-Based Practice

• Several models for promoting use of
  evidence-based practice
• Individual practitioner perspective
• Organizational perspective
• Nursing
• Interdisciplinary

(Cronenwett, 1995 Demakis et al, 2000 Dufault,
2001 Foxcroft et al, 2002 Goode Piedalue,
1999 Horsley et al, 1978 Logan et al, 1999
Rosswurm, 1999 Rubenstein et al, 2000 Rutledge
Donaldson, 1995 Stetler, 2001)
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Diffusion of Innovation Model (Rogers, 1995)

• Social science
• Framework for knowledge utilization studies
• Empirical testing by various disciplines

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Adoption of Innovation (Rogers, 1995)
Figure 2
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Issues in TRIP

• Access and synthesis
• Isolation from colleagues - knowledgeable of
  research findings
• Little known about the science of TRIP

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Issues in TRIP

• Single Site
• Non-experimental designs
• Test one or two strategies
• Sustainability of change
• Multi-site experimental design

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Model to Guide Research
Titler Everett (2001). Critical Care Nursing
Clinics of North America
Figure 3
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From Book to Bedside Acute Pain Management in
the Elderly
Funded by AHRQ RO1 HS10482
University of Iowa Iowa City, Iowa
Principal Investigator Marita G. Titler, PhD, RN,
FAAN Co-Principal Investigator Keela Herr, PhD,
RN Project Director Gail Ardery, PhD,
RN Investigators John Brooks, PhD Kathleen C.
Buckwalter, PhD, RN, FAAN William Clarke,
PhD Stacey Cyphert, PhD
Investigators Linda Everett, PhD, RN R. Edward
Howell, MS Meridean Maas, PhD, RN, FAAN J.
Lawrence Marsh, MD Janet C. Mentes, PhD, RN
Linda Rubenstein, PhD Margo Schilling,
MD Bernard Sorofman, PhD Toni Tripp-Reimer, PhD,
RN, FAAN Xianjin Xie, MS
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Experimental Design
RO1 HS10482
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Characteristics of the EBP

• Localization of the guideline
  (Burns et al, 1997 Newton, et al 1996 Shortell
  et al, 1995 Soumerai et al, 1998)
• Practice prompts
  (Bakersville et al, 2001 Chamber et al, 1989
  Cook et al, 1997 Hunt et al, 1998 OConnor et
  al, 1996 Oxman et al, 1995 Schulte et al, 2001)
• Clinical systems
• Computerized decision-support
• Practice prompts (algorithms)

RO1 HS10482
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Opinion Leader

• Practitioner within a specific discipline (nurse,
  physician, administrator)
• Viewed as an important and respected source of
  influence amongst peer group
• Role expectations
• Organizational leadership
• Experts in practice
• Promote needed changes in organizational
  infrastructure (e.g., documentation systems) to
  support evidence-based practice

(Bero et al, 1998 Elliott et al 1997 OBrien et
al, 2002 Oxman et al, 1995 Soumerai, 1998
Valante Davis, 1999)
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Change Champions

• Organizational change
• Expert clinician
• Perceived as informal leader
• Passionate about topic
• Positive working relationship with other health
  care professionals

(Backer et al, 1986 Backer, 1987 Backer, 1995
Greer, 1988 Rogers, 1995 Titler, Moss et al,
1994 Titler, 1998 Titler Mentes, 1999)
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• A change champion believes in an idea will NOT
  take no for an answer
• is undaunted by insults and rebuff and above
  all, persists.

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Outreach/Academic Detailing

• One-on-one meeting with practitioners in their
  setting
• Convey information on
• New practice/innovation
• Provider performance
• Issues encountered

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Four Building Blocks
Leadership
Recognition and Rewards
Resources and Governance
Performance Expectations
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Route - IM Use
January 1, 1999 - December 31, 1999 Baseline Data
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PCA Orders
26.1
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Percent () with Pain Reassessed Within 60
Minutes Following Administration of
Analgesic(NAnalgesic Administrations)Note
Does not include PCA administrations.
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Model to Guide Research
Figure 4
Rogers, 1995
RO1 HS10482
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Design and Measurement Issues

• Definition/terms
• Unit of analysis
• Determining practice patterns
• Sensitivity of measures to detect change
• Subjects
• Frequency of data collection
• Data sources

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Selection of Dependent Measures

• Directly related to research question/specific
  aim
• Dependent construct(s)
• Adherence of nurses to the evidence-based
  guideline will occur more rapidly in experimental
  group versus control group
• Rate of adoption

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Dependent Variables Adherence to Guideline

• Pain assessment practices
• Pharmacological administration practices
• Nonpharmacological pain treatments
• Assessment of pain treatment side effects

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Data Sources

• Direct observation
• Patients
• Nurses, physician self-report
• Nurse, physician behavior - medical record
  abstraction

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Selection of Records

• Records of patients admitted (January 1, 1999 to
  December 31, 1999) to one of 12 Midwest hospitals
  for hip fracture (ICD-9 820.)
• 65 years of age or older
• Not in an ICU during first 72 hours following
  admission
• Random selection of eligible subjects

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Preliminary AnalysisPain Assessed Every 4
Hours(N709 Medical Records)
January 1, 1999 - December 31, 1999 Baseline Data
RO1 HS10482
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Pain AssessmentMean Percent of Four-Hour Time
Blocks(N709 Medical Records)
January 1, 1999 - December 31, 1999 Baseline Data
RO1 HS10482
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Demerol and Propoxyphene Administration(N709
Medical Records)
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Profile of Opioid AdministrationsOver 72
Hours(N5721 Opioid Administrations)
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Extent of Adoption Scores by Stage of
DiffusionNurse and Physician Self-Report
(Baseline)
RO1 HS10482
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Dependent Variable Barriers

• Barriers to Optimal Pain Management Questionnaire
  (baseline, 12, 24 months)
• Barriers to optimal pain management
• Physician and nurse version
• Internal consistency - .79

RO1 HS10482
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Barriers to Managing Acute Pain in Elders
Baseline Data
RO1 HS10482
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Organizational Variables

• Organization Assessment Instrument - CNE
• Case mix index
• Skill mix
• ADC
• Bed capacity
• Use of nursing research in practice (Stiefel,
  1996)
• 9 elements systems perspective
• Test-retest (r.84)
• CNE
• Organizations stage of adoption of pain
  management practices
• Staff nurses

RO1 HS10482
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Adoption/Implementation Stage
p lt .001
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Characteristics of Nurses and PhysiciansQuestion
naires (Baseline, 12, 24)

• Attitudes toward guidelines
• Likelihood (1-4) of CPGs to result in certain
  actions
• Innovativeness instrument
• Willingness to change/adopt new ideas
• Demographics

RO1 HS10482
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Innovativeness Scores
RO1 HS10482
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Summary