They also use a measure of strength of recommendation based on these three categories:

• directly based on category I evidence;
  
• directly based on category II evidence;
  
• directly based on category III evidence OR extrapolated recommendations from category I and II evidence;
  
• based on clinical opinion from a group.

But, in practice, do we use evidence to make our decisions, whether it is about the management of dementia, or our view of the world? Our contention is that, while evidence and innovative knowledge should inform practice, it must first be created and then transferred within health care and education systems. This is the state of current work in interprofessional education (IPE).

Challenges of knowledge translation: Applying evidence to practice

Aristotle, in the 4th century BC, determined that the sun moved around the earth (an earth-centric view). It made sense, fitted the observed movements of the star, and the weight of his opinion meant that an early heliocentric (‘sun-centred’) system, proposed by Aristarchus of Greece (Heath, 2013; Zellik, 2002), did not last long. In the 15th century, Copernicus developed a model with the earth moving around the sun rather than the other way around and later Galileo, using a simple telescope, provided evidence of a sun-centred model, but the evidence did not outweigh dogma and was disbelieved or ignored. Copernicus did not publish his works until near death, thus avoiding the issue (Somervill, 2005). Galileo published Dialogue, in which he compared the Aristotelian (earth-centric) and Copernican (sun-centred) views. As a result he faced the Inquisition, was placed under house arrest and refused the rights to have visitors or publish his works (Finocchiaro, 2010). It was not until 1744, 102 years after his death, that the Church lifted its ban on the publication of Galileo’s Dialogue. Challenging accepted dogma can be very difficult.

In health, Semmelweis, a Hungarian physician, in the 1840s, clearly showed that hand washing greatly reduced post-delivery mortality in the Vienna General Hospital. However, despite showing clear evidence in support of his approach, and convincing some junior doctors of its value, he failed to convince senior staff, who had a different view that improved ventilation had reduced mortality, and did not publish his findings. He was hounded from his post, later suffered a mental breakdown and died in an asylum (Best & Neuhauser, 2004).

The resistance to the introduction of better ways of practice continues, although perhaps without the drastic consequences experienced by Semmelweis. Why does resistance continue in the face of evidence to the contrary? Why do we continue to believe something and act on it when we have good evidence about a better way? To change and counter a prevailing view takes courage when the view is held by powerful forces. Why was Semmelweis ignored? He was ignored because his ideas did not fit into existing views of how the known world was structured, or about the causation of disease before the germ theory (Best & Neuhauser, 2004). The paradigm shift, or scientific revolution, that was needed to accept Semmelweis’ view, including the crisis where serious anomalies cannot be reconciled within the existing world view, had not yet occurred (Kuhn, 2012).

Both Galileo and Semmelweis were unable to change the culture of the Church or hospital despite convincing some of the value of their ideas. Those in authority maintained the orthodoxy and protected their professional reputations and positions. Neither was able to develop an environment that was willing to accept new ideas (Best & Neuhauser, 2004). The balance between healthy scepticism of the new and rigid acceptance of the status quo can be difficult to find.

There is currently no lack of evidence or guidelines to inform practice in caring for those with dementia. Guidelines for diagnosis, for treatment and for psychosocial approaches to care and treatment are clear in the literature. Eccles and colleagues (1998) developed evidence-based guidelines for the treatment of dementia using categories of evidence and evaluating strength of recommendations. They had GPs in mind when they developed guidelines, both to help manage patients with dementia and also to help their carers. Throughout the guidelines, published in the British Medical Journal, they identify the level of evidence for their statements and recommendations. They identify physical and cognitive screening, risk factors for other conditions, such as falls and depression, and the need for residential care as well as drug therapies available at the time. By 2013, the article had been cited 44 times, indicating that it has had an impact on other researchers; but have they changed practice? The literature also raises concerns about these guidelines not being used (Drake et al., 2001) and it is unknown whether they have resulted in a corresponding change in practice.

The Cochrane Collaboration (2014) provided reviews that helped doctors, patients, policy makers and others make decisions about health care. By April 2014, the Dementia and Cognitive Improvement Group had published 270 reviews on dementia, including 19 on diagnosis and 194 on dementia and chronic cognitive impairment. The Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2013) has synthesised evidence and recommendations, and this has resulted in a much revised set of recommendations. However, while evidence is there, it may be inconclusive in some cases (Lyketsos et al., 2006; Köpke & McCleery, 2015) and thus go unrecognised or ignored. (Zipoli & Kennedy, 2005) found that, amongst speech pathologists, clinical experience and colleague opinion was used more than clinical practice guidelines or research studies even when there was a positive response to EBP.

Why don’t health care teams evidence their practice?

Changing practice and implementing new ways of doing things is not easy. Even when a change promises to make service faster and more efficient with better outcomes, making the change requires an investment of time and resources in order to overcome institutional/organisational inertia. Both institutional and personal factors can build barriers (McKenna, Ashton & Keeney, 2004; Solomons & Spross, 2011). Workloads are such that few health care teams have the time or energy to invest in improving practice during their employment hours. While most health professional qualifications require evidence of critical thinking, deductive reasoning, knowledge of research methodologies and engagement with current research literature, once in the workforce these skills may not be well used and may be forgotten. In addition new graduates in particular may not see promoting and leading change as part of their role and developing professional identity.

Institutional barriers to EBP occur within strategic, cultural, technical and structural contexts. At a strategic level, leaders and managers within an organisation may consider EBP as a lower priority and invest resources into other aspects of service. Short-term cost constraints and poor staff retention and recruitment practices can increase workloads, limit access to resources and inhibit changes in practice.

At a cultural level, working in a multidisciplinary team, and convincing other professions of the benefits of change, especially if it requires a change in practice as well, can be a barrier. There may also be a lack of respect for, and suspicion of, research and organisational change. Research is not usually a part of everyday clinical practice and to the uninvolved is seen as an activity far removed from the practicalities of the workplace. Interpreting and determining transferability of research findings requires a cultural environment – including managers, professionals and care staff – conducive to questioning current practice and an appreciation of research as a means of answering such questions.

At a technical level, inadequate information systems and poor training in IT can make accessing available resources difficult. For example, information may not be compiled and/or stored in one place, making it difficult, and requiring advanced IT skills, to find and collate relevant information. Making a change in practice will most likely require different resources that may be difficult to attain.

In organisations with several service sites, consistency of practice is prized highly. At this structural level, implementing change requires a whole organisational approach. Taking a proposal from the long and complicated committee process through to the resource-intensive training and implementation phases is daunting.

How can health workers be supported to use evidence in their practice?

How do we most effectively translate new advancements in knowledge and technology into the everyday practices of health workers? While the transfer of quality research into clinical settings is the foundation of EBP, a significant research–practice gap exists. This affects the ease, speed and effectiveness with which new findings are adopted in the care of people with dementia (Davis et al., 2003; Draper et al., 2009). In the past, this process has been viewed as being pushed by researchers as a one-way communication from researcher or educator to practitioners. However, more recently, there has been a growing emphasis on knowledge translation (KT), with the benefits of promoting knowledge exchange between researchers, educators and practitioners, and an emerging view that this can be interactive and mutually advantageous (Mitton et al., 2007). Such principles appear consistent with many of those within the literature on IPE – sharing an emphasis on facilitating the collaboration of health care teams (professionals and care workers) and educators from different backgrounds for the purposes of improving quality of care (Centre for the Advancement of Interprofessional Education, 2002).

KT is the term often used to describe integration of research into practice where the intent is clear from the beginning of the research. Johnson (2005) has conceptualised knowledge translation as:

an active, multi directional flow of information which begins at project inception … with interactions that occur before, during and after a project with the goals of developing research questions, setting a research agenda and then determining actions.

Other definitions also acknowledge the complex interaction and exchange that contributes to KT (Davis et al., 2003; Draper et al., 2009). Action research methodology responds to this complexity with its focus on collaboration between researcher and the people in the situation, involving critical enquiry and reflective learning (Checkland & Holwell, 1998). Within this framework, it is clear that the research is intended to change the organisation or system in which the research takes place by empowering and educating workers. However, this ideal and complex interaction between researcher and the situation or organisation does not always take place, and there can be a disconnection between research and practice; this is the research–practice gap that can reduce the effectiveness of KT.

Can education support knowledge translation and reduce this research–practice gap?

Education can be a key with KT seen as an essential ‘third stream’, linking researchers (universities) and practitioners (industry), and providing continued education for professionals, and thereby reducing the research–practice gap (Phillips, 2006). The conceptualisation of this educational dimension can link research, education and practice with mutual benefit. For example, during 2011–13, the Australian Dementia Training and Study Centre (DTSC) developed and adopted a conceptual framework for ‘knowledge transfer and translation’ for use within the DTSC education and training programs nationally (Phillipson, Reis & Fleming, 2013) (known as the DTSC KT National Framework). This conceptual framework adapted the work of Phillips (2006) and defined ‘knowledge’ broadly to be inclusive of information, attitudes (mindsets/cultures), skill, work practices, technologies and other capabilities, relevant to the practices of health care teams in the care of people with dementia. In this context, Phillipson, Reis & Fleming (2013) defined knowledge transfer and KT in this framework to comprise:

The process of engaging with [undergraduate and graduate] health professionals (and/or their representative employers, professional associations, or tertiary institutions involved in their training) to generate, produce, acquire, apply or make accessible the ‘knowledge’ (information, skills, capabilities, technologies or other) required to improve the ‘the quality of care and support provided to people with dementia and their caregivers’.

They also suggested that, within this framework, effective educational practice to promote KT requires activities to support health care teams in the following domains:

• the identification of knowledge or evidence (knowledge generation);
  
• the use of high quality educational products, resources and tools (knowledge products);
  
• the provision of timely access to, and effective dissemination of, evidence (knowledge access);
  
• support to build, and practise, skills and capacity (knowledge capacity);
  
• support to build professional relationships to achieve KT outcomes (knowledge relationships).

How knowledge translation affects day-to-day practices of health care teams and educators

As pointed out by Mitton et al. (2007), there is limited evidence evaluating KT and the strategies that actually work in practice. In this light, the DTSC KT National Framework has also adapted the four stage ‘Awareness to Adherence’ KT Evaluation Model (known as ‘the Pathman Model) (Pathman et al., 1996; Phillipson, Reis & Fleming, 2013). The DTSC KT National Framework defines domains of educational activity that can move students and practitioners from personal awareness through to agreement and adoption, but also extends the Pathman Model to consider the strategies that may be needed to support adherence (sustained practice change) at both a personal and organisational level. In a clinical context, this process of change may be measured by assessing awareness using statements such as ‘this educational activity (e.g. workshop or lecture) increased my awareness of new knowledge in the area’ to agreement, such as ‘I feel my capacity to address this issue in my workplace has been enhanced by … the workshop’ and ‘I agree it is important to change my practice’ and ‘I intend to try and make a change’ then to adoption ‘I have tried to change my own practice/practice in my workplace as a result of this workshop.’ Adherence is the final stage, where the DTSC KT National Framework suggests that EBP has been achieved when the new practice becomes ‘the way we do things around here’.

These stages of KT evaluation relate to many others within the behaviour-change literature, such as those outlined by Procheska and Velicer (1997) in the transtheoretical model of health behaviour change. They proposed that the process of behaviour change involves five stages: pre-contemplation, contemplation, preparation for action, action and maintenance. During this process, initially a person may be aware of a problem or indeed may not, and has no thought of changing their behaviour. When they move to contemplation, they do want to change their behaviour. However, they may not actually do so until they prepare for it and then begin to undertake the new behaviour in the action phase. Once the behaviour has become habitual and undertaken for at least six months, the person enters the maintenance phase. While not specifically aligned with the DTSC KT National Framework, there are clear links between contemplation and awareness, preparation and agreement, action and adoption, and maintenance and adherence. Likewise, there is a motivational aspect to behaviour change that is identified in the health action process approach (Schwarzer, 1992). This approach brings motivation for change into the Pathman Model between awareness and action or adoption. At an organisational level, there are parallels, with resistance to change, especially where innovation is a factor, being an important issue. Lewin (1951) developed the Force Field Analysis Model, where those forces driving changes are resisted by restraining forces. Individuals resist change for many reasons, including a lack of perceived benefit, fear of failure, sense of threat to existing status and power, and dependence (Martin, 2005). Kotter and Schlesinger (2008) identified a number of strategies to help deal with resistance, including education and communication, participation and involvement, and facilitation and support. These strategies respond to individuals and their processof behaviour change.

Evaluation

Appraisal or value of something.

Power

Power, it has been argued, is the ability or capacity to act or to exercise influence. As such, it has many dimensions (gender, race, class, knowledge, etc.) that can impact on interprofessional relations (Baker et al., 2011).

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