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2 Theory

2.2 The Knowledge to Action framework

The KTA framework was developed by Graham and colleagues (2006).

It is a theoretical approach to knowledge translation (Fig. 2). The Canadian Institutes for Research defines knowledge translation as

‘dynamic and interactive process that includes the synthesis, dissemination, exchange and ethically sound application of knowledge to improve health, provide more effective health services and products and strengthen the healthcare system’ (Straus et al., 2013, p. 4). There are several frameworks for achieving knowledge translation (Rycroft-Malone et al., 2010) with the goal of linking research findings to practice (McDonald, 2013). The KTA framework is grounded in planned action theories. Planned action theories focus implementation efforts and present guiding concepts (Straus et al., 2013).

Figure 2 – The knowledge-to-action cycle (Straus et al., 2013, p. 10).

The knowledge to action framework consists of knowledge creation and action cycle. Figure 2 shows that knowledge to action starts with knowledge creation (centre) which then feeds into the action cycle. The cycle is an iterative and dynamic process (Graham et al., 2006; Straus et al., 2013).

Knowledge creation consists of knowledge inquiry (primary studies such as randomised trials), knowledge synthesis (systematic reviews) and creation of knowledge tools or products (decisions aids, guides, or clinical practical guidelines to present knowledge in implementable format). Knowledge is filtered through each stage of the knowledge creation process and generates knowledge that becomes more useful for end-users (e.g., researchers, healthcare professionals, managers, policy makers). In each phase of the process, the knowledge is tailored to end-users’ activities and needs (Straus et al., 2013). In this thesis, the leadership guide was based on reviews of the literature and major fieldwork in the QUASER project and then integrated in the QUASER guide (QUASER, 2013). In addition, the SAFE-LEAD project team collaborated on knowledge translation and adapting the QUASER guide for the nursing home and homecare setting before it was ready for the action cycle.

Knowledge synthesis is used to interpret the results of individual studies to link research with decision making. The synthesis provides the evidence base for knowledge translation tools (Tricco et al., 2013). The development and evaluation of these tools can be an effective integrated knowledge translation strategy because it requires active collaboration between researchers and knowledge users. A completely integrated approach begins with end-users determining the needs for the tool and participatory processes that involve end-users in the development to ensure relevance, usability and implementability. Clinical practical guidelines, for example, are developed to maximise quality and safety and improve care (Tricco et al., 2013).

The action cycle is a structured process for effecting change and translating knowledge into practice. The action cycle consists of seven action phases: identification of the problem and selecting the knowledge to implement; adapting the knowledge to local context; assessing barriers and facilitators; implementing the intervention; monitoring the use of knowledge; evaluating outcomes; and sustaining knowledge (Straus et al., 2013).

The boundaries between knowledge creation and action phases are fluid.

The phases of knowledge can influence the action phases at several points in the action cycle (Straus et al., 2013). Bowen and Graham et al.

(2013) focus on ‘doing’ in the translation of knowledge, because doing requires a special understanding of the healthcare context in order to effect change, and the ability to develop relationships with stakeholders in the implementation. In this thesis, this means involving co-researchers from the municipalities, patient and next of kin representatives. The end-users (managers in nursing homes and homecare services) of the knowledge are included to ensure the relevance of knowledge and implementation to their needs. Straus et al. (2013) note that the integration of research with contextual knowledge can be accomplished only with the genuine participation of knowledge users from the beginning of the research process. For this thesis and in the research project, this means involvement from planning to publication. Bowen and Graham (2013) observe that the knowledge to action gap is often interpreted as a knowledge transfer problem, where knowledge is not used because it is difficult to transfer to its intended users. The production of knowledge is an alternate interpretation, one that considers the problem not as research dissemination, but as the failure of the research itself to consider the most urgent problems facing managers, clinicians and decision makers (Bowen & Graham, 2013).

The knowledge to action cycle is a participatory approach to research, one that engages knowledge users and where stakeholders are invited to suggest ways of adapting the intervention to local practice (Straus et al.,

2013). Theoretical frameworks are a way of preparing for the multiple and dynamic factors that influence the implementation of knowledge in practice and it can contribute to a more systematic translation of knowledge (Legare et al., 2009). In this thesis, the KTA framework is applied as a guide to our knowledge translation activities. The KTA framework also ensured the involvement of end-users to adapt the intervention to the nursing home and homecare context. In addition, it guided the identification of barriers to implementation. Figure 3 depicts the logic model of the SAFE-LEAD intervention program and processes (Johannessen et al., 2019a) based on the KTA framework to translate knowledge (leadership guide) into practice.

Figure 3. Logic model of the SAFE-LEAD intervention program based on Straus et al., (2013) in (Johannessen et al., 2019a, p. 10).

2.3 Rationale for choice of theory in the thesis