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National Center for the Dissemination of Disability Research

Knowledge Translation: Introduction to Models, Strategies, and Measures

Knowledge Translation Models

Knowledge Translation Models

Table of Contents
Knowledge Translation: Introduction to Models, Strategies, and Measures

CIHR Model of Knowledge Translation

CIHR (2005) proposed a global KT model, based on a research cycle, that could be used as a conceptual guide for the overall KT process. CIHR identified six opportunities within the research cycle at which the interactions, communications, and partnerships that will help facilitate KT could occur. Those opportunities are the following:

Figure 1 shows a graphical model in which the six opportunities listed here were superimposed on CIHR's depiction of the knowledge cycle.

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Figure 1. CIHR research cycle superimposed by the six opportunities to facilitate KT

[Large image of Figure 1]

Figure 1. CIHR research cycle superimposed by the six opportunities to facilitate KT

(Source: Canadian Institutes of Health Research Knowledge Translation [KT] within the Research Cycle Chart. Ottawa: Canadian Institutes of Health Research, 2007. Reproduced with the permission of the Minister of Public Works and Government Services Canada, 2007).

Other Models and Frameworks Applicable to Knowledge Translation

The CIHR's KT model offers a global picture of the overall KT process as integrated within the research knowledge production and application cycle. However, the use of other models and/or frameworks with more working details may be necessary to implement each part of the CIHR conceptual model successfully. Such details could be used to augment an understanding of the specific components, chronological stages, and contextual factors that must be taken into consideration to facilitate successful communications, interactions, partnerships, and desired outcomes during each of the KT opportunities. Selected comprehensive models that could be used to augment the CIHR's KT model are described in this section. An effective KT framework requires not only the environmental organizational view, but also the microperspective of an individual (Davis, 2005). Therefore, models and frameworks that represent an individual user's perspective, as well as those that address contextual factors, are included.

Interaction-Focused Framework

Understanding-User-Context Framework: This framework for knowledge translation (Jacobson et al., 2003) was derived from a review of literature and the authors' experience. It provides practical guidelines that can be used by researchers and others to engage in the knowledge translation process by increasing their familiarity with and understanding of the intended user groups. Specifically, this framework can be used as a guide for establishing interactions required by the KT process illustrated in the CIHR's model.

The framework contains five domains that should be taken into consideration when establishing interactions with users:

  1. The user group
  2. The issue
  3. The research
  4. The researcher–user relationship
  5. The dissemination strategies

Each domain includes a series of questions. The purpose of these questions is to provide a way to organize what the researcher already knows about the user group and knowledge translation, identify what is still unknown, and flag what is important to know. The following paragraphs and lists describe the foci and sample questions for each domain.

The user group domain focuses on understanding several aspects of the user group, such as the group's operational context, morphology, decision-making practices, access to information sources, attitudes towards research and researchers, and experiences with knowledge translation.

Sample questions for the user group domain are as follows:

The issue domain focuses on the characteristics and context of the issue intended to be resolved through the knowledge translation effort.

Sample questions for the issue domain are as follows:

The research domain focuses on the research characteristics, the user group's orientations toward research, and the relevance, congruence, and compatibility of the research (at hand) to the user group.

Sample questions for the research domain are as follows:

The research–user relationship domain focuses on the description of relationships between the researcher and the user group.

Sample questions for the research–user relationship domain are as follows:

The dissemination strategies domain focuses on practical strategies for disseminating the research knowledge.

Sample questions for the dissemination strategies domain are as follows:

As suggested by Jacobson et al. (2003), these questions may help raise awareness of the type of information about the user group that may be useful for the knowledge translation process. The scope in obtaining this information will depend on each knowledge translation circumstance. This framework offers a comprehensive approach to guide the interaction of knowledge creators and knowledge users. However, the focus of these interactions was on the implementation of existing knowledge (K4 and K5 in the CIHR's KT model). Additional frameworks that illuminate the mechanisms, considerations, and influencing factors of the interaction between the knowledge creators and the knowledge users through all steps in the process of knowledge translation are certainly needed.

Context-Focused Models and Frameworks

These selected models and frameworks can be used to understand the contextual factors that could play important roles in the success or failure of the knowledge translation effort and should be taken into consideration in all stages of the KT process.

The Ottawa Model of Research Use: The Ottawa Model of Research Use (OMRU) is an interactive model developed by Logan and Graham (1998). The feasibility and effectiveness of using the OMRU in actual practice contexts was supported by findings from a number of studies (Hogan & Logan, 2004; Logan, Harrison, Graham, Dunn, & Bissonnette, 1999; Stacey, Pomey, O'Conner, & Graham, 2006). The OMRU views research use as a dynamic process of interconnected decisions and actions by different individuals relating to each of the model elements (Logan & Graham, 1998). This model addresses the implementation of existing research knowledge (KT4 and KT5 in the CIHR's KT model).

The model has gone through some revisions since its inception. The most recent version of the OMRU (Graham & Logan, 2004) includes six key elements:

  1. Evidence-based innovation
  2. Potential adopters
  3. The practice environment
  4. Implementation of interventions
  5. Adoption of the innovation
  6. Outcomes resulting from implementation of the innovation

The relationships among the six elements are illustrated in Figure 2.
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Figure 2 The Ottawa Model of Research Use

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Figure 2. The Ottawa Model of Research Use

(Reprinted with permission from Canadian Journal of Nursing Research, Vol. 36, Graham, I. D. & Logan, J., Innovations in knowledge transfer and continuity of care, pp. 89–103, copyright © 2004)

According to Graham and Logan (2004), the OMRU relies on the process of assessing, monitoring, and evaluating each element before, during, and after the decision to implement an innovation. Barrier assessments must be conducted on the innovation, the potential adopters, and the practice environment to identify factors that could hinder or support the uptake of the innovation. The implementation plan is then selected and tailored to overcome the barriers and enhance the supports identified. Introduction of the implementation plan is monitored to ensure that the potential adopters learn about the innovation and what is expected of them. The monitoring is ongoing to help determine whether any change in the current implementation or a new implementation plan is required. Finally, the implementation outcomes are evaluated to determine whether the innovation is producing the intended effect or any unintended consequences.

The Knowledge-to-Action Process Framework: Graham et al. (2006) proposed the knowledge-to-action (KTA) process conceptual framework that could be useful for facilitating the use of research knowledge by several stakeholders, such as practitioners, policymakers, patients, and the public. The KTA process has two components: (1) knowledge creation and (2) action. Each component contains several phases. The authors conceptualized the KTA process to be complex and dynamic, with no definite boundaries between the two components and among their phases. The phases of the action component may occur sequentially or simultaneously, and the knowledge-creation-component phases may also influence the action phases.

In the KTA process, knowledge is mainly conceptualized as empirically derived (research-based) knowledge; however, it encompasses other forms of knowing, such as experiential knowledge. The KTA framework also emphasizes the collaboration between the knowledge producers and knowledge users throughout the KTA process. The visual presentation of the KTA process is shown in Figure 3.
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Figure 3. The Knowledge-to-Action Process

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Figure 3. The Knowledge-to-Action Process

(Reprinted from the Journal of Continuing Education in the Health Professions, Vol. 26, No. 1, Graham, I. D. et al., Lost in knowledge translation: Time for a map, pp. 13–24, copyright © 2006, with permission from John Wiley & Sons, Inc.)

Knowledge creation consists of three phases: (1) knowledge inquiry, (2) knowledge synthesis, and (3) knowledge tools/products. Knowledge creation was conceptualized as an inverted funnel, with a vast number of knowledge pieces present in the knowledge inquiry process in the beginning. Those pieces are then reduced in number through knowledge syntheses and, finally, to an even a smaller number of tools or products to facilitate implementation of the knowledge. The authors stated that as knowledge moves through the funnel, it becomes more distilled and refined, and presumably becomes more useful to the stakeholders. The needs of potential knowledge users can be incorporated into each phase of knowledge creation, such as tailoring the research questions to address the problems identified by the users, customizing the message for different intended users, and customizing the method of dissemination to better reach them.

The action cycle represents the activities needed for knowledge application. Graham et al. (2006) conceptualized the action cycle as a dynamic process in which all phases in the cycle can influence one another and can also be influenced by the knowledge creation process. The action cycle often starts with an individual or group identifying the problem or issue, as well as the knowledge relevant to solving it. Included in this phase is the appraisal of the knowledge itself in terms of its validity and usefulness for the problem or issue at hand. The knowledge then is adapted to fit the local context. The next step is to assess the barriers and facilitators related to the knowledge to be adopted, the potential adopters, and the context or setting in which the knowledge is to be used. This information is then used to develop and execute the plan and strategies to facilitate and promote awareness and implementation of the knowledge. Once the plan is developed and executed, the next stage is to monitor knowledge use or application according to types of knowledge use identified (conceptual use, involving changes in levels of knowledge, understanding, or attitudes; instrumental use, involving changes in behavior or practice; or strategic use, involving the manipulation of knowledge to attain specific power or profit goals). This step is necessary to determine the effectiveness of the strategies and plan so they can be adjusted or modified accordingly. During the KTA process, it is also necessary to evaluate the impact of using the knowledge to determine if such use has made a difference on desired outcomes for patients, practitioners, or the system. A plan also needs to be in place to sustain the use of the knowledge in changing environments as time passes.

As stated by Graham and colleagues (2006), the relationships between the action phases within the cycle are not unidirectional. Rather, each action phase can be influenced by the phase that precedes it and vice versa. For example, knowledge not being adopted and used as intended could indicate the need to review the plans and strategies again to improve the uptake of knowledge. The phases in the action process of the KTA are those also presented in the OMRU, as delineated in the previous section.

The KTA process framework presents a more comprehensive picture of KT than the OMRU because it incorporates the knowledge creation process. The framework also incorporates the need to adapt the knowledge to fit with the local context (which has also been indicated in the CIHR's KT model) and the need to sustain knowledge use by anticipating changes and adapting accordingly. However, the KTA process framework does not provide additional details in the knowledge action process aside from what has already been outlined by the OMRU. Nevertheless, it is a comprehensive framework that begins to incorporate the full cycle of knowledge translation from knowledge creation through implementation and impact.

The Promoting Action on Research Implementation in Health Services Framework: The Promoting Action on Research Implementation in Health Services (PARIHS) (Kitson, Harvey, & McCormack, 1998; Rycroft-Malone, 2004; Rycroft-Malone et al., 2002) is a conceptual model describing the implementation of research in practice. According to the model, a successful implementation of research into practice is a function of the interplay of three core elements: (1) the level and nature of the evidence to be used, (2) the context or environment in which the research is to be placed, and (3) the method by which the research implementation process is to be facilitated. These three elements have equal importance in determining the success of the research use. Each of the elements is positioned on a low-to-high continuum, and the model predicts that the most successful implementation occurs when all elements are on the high end of the continuum.

Evidence is defined as a combination of research, clinical experience, patient experience, and local data or information. For each type of evidence, there is a range of conditions from "low evidence" to "high evidence." An example of high evidence would be that the research is valued as evidence, well conceived, and well conducted; the clinical experience is seen as a part of the decision; the patient experience is relevant; and the local data or information is evaluated and reflected on.

Context refers to the environment or setting in which people receive health-care services or the environment or setting in which the proposed change is to be implemented. Context can include physical environment in which the practice occurs; characteristics that are conducive to research utilization, such as operational boundaries, decision-making processes, patterns of power and authority, and resources; organizational culture; and evaluation for the purpose of monitoring and feedback. The PARIHS specifies three key themes under context as (1) culture, (2) leadership, and (3) evaluation. The low-to-high continuum was specified for each theme. A low context would be predictive of unsuccessful research utilization, and a high context would be predictive of successful utilization. An example of a high context would be a culture that values individual staff and clients, the leadership within effective teamwork, and the use of multiple methods of evaluation.

Facilitation is defined as a technique by which one person makes things easier for others. The framework authors believe that facilitators have a key role in helping individuals and teams understand what and how they need to change to apply evidence to practice. The role of a facilitator is an appointed one (rather than one arising from personal influence) that could be internal or external to the organization. The function of this role is about helping and enabling, as opposed to telling or persuading. It can encompass a broad spectrum of purposes, ranging from helping achieve a specific task to helping individuals and groups better understand themselves in terms of attributes that are important to achieve those tasks, such as attitudes, habits, skills, ways of thinking, and ways of working. According to the framework, there are three themes of facilitation: (1) purpose, (2) roles, and (3) skills and attributes. Same as the previous elements, each theme has dimensions of low and high. In PARIHS, high facilitation relates to the presence of appropriate facilitation depending on the needs of the situation.

The PARIHS framework is unique in that it identifies facilitation as one of the main elements in the research utilization process and provides much detail in determining the potential of success based on the prediction structure of the model. However, similar to most models reviewed so far, the emphasis is on the implementation component within the knowledge translation process. PARIHS does not discuss elements or factors related to the knowledge creation process, although creation is also an important part of knowledge translation.

Although the PARIHS model is highly complex and likely to be comprehensive in explaining factors and elements related to the use of research and practice, more demonstration of how the model could be applied in an actual practice environment is needed. The most updated version (Rycroft-Malone, 2004) is substantially more complex than the original (Kitson et al., 1998). All elements were revised based on concept analysis of each element (evidence, context, facilitation) through extracting various dimensions of the elements from extensive literature to form a comprehensive definition and scope. Although doing so has undoubtedly increased the level of complexity of the model, it is not certain how that would affect the actual use of the model as a general framework to guide research utilization in everyday practice settings.

The Coordinated Implementation Model: Lomas (1993) proposed a model of research implementation that outlines the overall practice environment to capture schematically the competing factors of influence to the implementation process. According to the author, this model demonstrates some of the additional and largely unexploited routes through which research information could influence clinical practice. The factors of influence to the implementation process were illustrated in the model diagram in Figure 4.

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Figure 4. The Coordinated Implementation Model

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Figure 4. The Coordinated Implementation Model

(Reprinted from The Milbank Quarterly, Vol. 71, Lomas, J., Retailing research: Increasing the role of evidence in clinical services for childbirth, pg. 439–475, copyright © 1993, with permission from Blackwell Publishing)

As discussed by Lomas (1993), the approaches used to transfer research knowledge into practice must take into account the views, activities, and available implementation instruments of at least four potential groups. Those include community interest groups, administrators, public policymakers, and clinical policymakers. Although the influences on the use of research from these groups (public pressure, regulation, economic incentives, education, and social influence) are exerted through different venues, they form a system in which, when they work together, the sum of their effects is greater than their parts. This model holds that patients, either as individuals or groups, can also strongly influence practitioners' decisions.

This model helps increase awareness of factors that should be taken into consideration in the implementation effort within the knowledge translation process. Having similar models that outline the contextual factors that could influence the knowledge translation process in other steps would also be extremely helpful and add more to the understanding of the process.

Individual-Focused Models

The Stetler Model of Research Utilization: The Stetler Model of Research Utilization is the practitioner-oriented model, expected to be used by individual practitioners as a procedural and conceptual guide for the application of research in practice. The model was first developed as the Stetler/Marram Model of Research Utilization (Stetler & Marram, 1976) and later revised and renamed the Stetler Model of Research Utilization (Stetler, 1994, 2001). The latest version of this model consists of two parts. The first part is the graphic model containing five phases of research utilization. The second part contains clarifying information and options for each phase. The graphic model is illustrated in Figure 5.
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Figure 5. The Stetler Model of Research Utilization

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Figure 5. The Stetler Model of Research Utilization

(Reprinted from Nursing Outlook, Vol. 49, Stetler, C. B., Updating the Stetler model of research utilization to facilitate evidence-based practice, pg. 272–279, copyright © 2001, with permission from Elsevier)

The Stetler model was developed as a prescriptive approach designed to facilitate safe and effective use of research findings (Stetler, 2001). The model is based on six basic assumptions:

  1. The formal organization may or may not be involved in an individual's utilization of research.
  2. Utilization may be instrumental, conceptual, and/or symbolic.
  3. Other types of evidence and/or non-research-related information are likely to be combined with research findings to facilitate decision making or problem solving.
  4. Internal and external factors can influence an individual's or group's view and use of evidence.
  5. Research and evaluation provide us with probabilistic information, not absolutes.
  6. Lack of knowledge and skills pertaining to research utilization and evidence-based practice can inhibit appropriate and effective use.

The updated model directs users to be conscious of the types of research evidence and suggests that users seek already published systematic reviews whenever possible instead of using primary studies. The following paragraphs provide descriptions of activities within each of the five phases in the graphic model shown in Figure 5 (Stetler, 1994, 2001).

Phase I focuses on the purpose, context, and sources of research evidence. The practitioner identifies potential issues or problems and verifies their priority; decides whether to involve others; considers other influential internal and external factors, such as beliefs, resources, or time lines; seeks evidence in the form of systematic reviews; and selects research sources with conceptual fit.

Phase II focuses on the validation of findings and includes activities such as critiquing a systematic review, rating the quality of each evidence source, and determining the clinical significance of the evidence. The evaluation is utilization-focused, and the decision is made whether to accept or reject the evidence (rather than using the traditional critique to determine simply whether the evidence is weak or strong). If there is no evidence or the evidence is insufficient, the process will be terminated when the evidence is rejected. Otherwise, the evidence is accepted and the practitioner progresses to Phase III.

Phase III focuses on the four criteria used together as a gestalt to determine whether it is desirable to use the validated evidence in the practice setting. Substantiating evidence is meant to recognize the potential value of both research and additional non-research-based information as a supplement. Fit of setting refers to how similar the characteristics of the sample and study environment are to the population and setting of the practitioner. Feasibility entails the evaluation of risk factors, need for resources, and readiness of others involved ("r, r, r," as stated in the graphic model shown in Figure 5). Current practice entails a comparison between the current practice and the new practice (that may be introduced) to determine whether it will be worthwhile to change the practice. A decision is then made whether to "use," "consider use," or "not use" the evidence considered.

Phase IV focuses on the evidence implementation process, beginning with the confirmation of type of use (conceptual, instrumental, symbolic), method of use (informal/formal, direct/indirect), and level of use (individual, group, organization). Next, the operational details are specified as to who should do what, when, and how. In this phase, a decision is made regarding whether to use or to consider the use of the evidence.

Phase V focuses on the evaluation of the use, with two separate processes to evaluate the case of "use" and the case of "consider use" as decided in Phase IV. The evaluation of the "consider use" option requires pilot testing to enable further evaluation of the feasibility of the change in practice. Pilot data are then used to decide whether the evidence will be formally used. In the case of a "use" decision, the implementation process will be formally evaluated.

This model was originally developed for use with nurses. However, the same principles could conceivably apply readily to other practitioners, including in those in rehabilitation. The Stetler model is highly comprehensive and provides procedures to help guide practitioners through all steps in the research use process while taking into consideration the practical (utilization-focused) aspects of clinical decisions.

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