Assisting nurses with evidence-based practice: A case for the Knowledge-to-Action Framework

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Health SA Gesondheid

ISSN: (Online) 2071-9736, (Print) 1025-9848

Page 1 of 3 Editorial

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Author:

Wilma ten Ham-Baloyi¹ Affiliation:

1Faculty of Health Sciences, Nelson Mandela University, Gqeberha, South Africa Corresponding author:

Wilma ten Ham-Baloyi, wilma.tenham-baloyi@

mandela.ac.za Dates:

Received: 29 July 2022 Accepted: 05 Aug. 2022 Published: 02 Nov. 2022 How to cite this article:

Ten Ham-Baloyi, W., 2022,

‘Assisting nurses with evidence-based practice: A case for the Knowledge-to- Action Framework’, Health SA Gesondheid 27(0), a2118.

https://doi.org/10.4102/

hsag.v27i0.2118 Copyright:

Licensee: AOSIS. This work is licensed under the Creative Commons Attribution License.

Globally, nurses are expected to base their practices on rigorous evidence to improve individual patients’ health outcomes and the overall quality of health care. Therefore, the use, uptake and implementation of best practices, such as evidence-based health practices, methods, interventions, procedures or techniques are increasingly encouraged in an attempt to provide the best care possible in an environment that has become progressively more complex (Lehane et al 2019).

Evidence-based practice (EBP) requires nurses to incorporate the best research with clinical proficiency and patient values to achieve optimal health outcomes (Lehane et al. 2019; Winters &

Echeverri 2012). However, it takes on average 17 years for best practices to be implemented in clinical practice (Greenet al. 2009), which can be referred to as the so-called ‘knowledge-practice gap’.

Although nursing students are introduced to the concept of EBP at an early stage during their nursing education, and there is an expectation for nurses to use, uptake and implement best practices, this often does not happen because of various reported barriers, including lack of time, staff shortages, heavy patient caseloads, limited knowledge of EBP and negative beliefs towards EBP as well as limited academic skills, which seems especially to be the case for novice nurses (Ferguson & Day 2007; Mallion & Brooke 2016).

Knowledge translation is used to close the knowledge-practice gap and can be defined as translating clinical science, knowledge or evidence, which aims to enhance health outcomes (Grimshaw et al. 2012; Steinskog et al. 2021). The Knowledge-to-Action (KTA) Framework was developed based on consensus of 31 planned-action theories (the action cycle) as well as the knowledge creation component to offer a holistic view of knowledge translation (Graham &

Tetroe 2010). The KTA framework consists of two main components: Knowledge Creation and the Action Cycle. The Knowledge Creation process is divided into three phases: (1) knowledge inquiry, (2) knowledge synthesis and (3) knowledge tools and products, whereas the Action Cycle focuses on application of knowledge in the practice setting, using seven phases, namely:

(1) identifying problem or gap that needs attention and identify, review and select the knowledge

Assisting nurses with evidence-based practice: A case for the Knowledge-to-Action Framework

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Source: Graham, I.D. & Tetroe, J.M., 2010, ‘The knowledge to action framework’, in Models and frameworks for implementing evidence- based practice: Linking evidence to action, vol. 207, p. 222.

FIGURE 1: The Knowledge-to-Action framework.

Select, Tailor implement interventions

Monitor knowledge

use

Sustain knowledge

use Evaluate outcomes Assess

barriers/

facilitators to knowledge use

Knowledge inquiry Knowledge synthesis

Knowledge tools/

products Tailoring knowledg

e Tailoring knowledg

e

Adapt knowledge

to local context

Identify problem Determine the Identify, review select knowledge

know/Do gap

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(evidence) that can solve that problem or gap; (2) adapting or tailoring the knowledge obtained to the local context;

(3) assessing barriers and facilitators to knowledge use; (4) selecting, tailoring and implementing the tailored interventions; (5) monitoring the knowledge use after implementation of the interventions; (6) evaluating outcomes on the interventions’ target group and (7) sustaining the knowledge use (Graham & Tetroe 2010) (see Figure 1).

Figure 2 illustrates how the KTA framework can be used by (novice) nurses for the uptake, use and implementation of EBPs in clinical practice.

Some side notes need to be made to the proposed activities in relation to the KTA framework in Figure 2. The proposed activities are not fully comprehensive and may be adapted, depending on the knowledge translation context.

• Conduct a gap-analysis:

• What should be happening (best practice) versus what is happening (current practice) = what is the difference between best and current practice?

• What contributes to the difference between best and current practice (part of the solution)?

• Search:

• Research findings/evidence:

▪ Patient care audits/quality improvement data

▪ Current literature

▪ Institutional/National/International clinical guidelines

• Expert feedback: e.g. nurse manager, nursing, and non-nursing colleagues

• Regulatory requirements: nursing act, occupational health and safety

Select: based on the assessment of the barriers and drivers, make a final selection on the intervention for adaptation:

• Consider: consistency of the intervention after tailoring and adapting it, partnerships and capacity required, evaluating and sustaining the intervention.

Tailor:

• Consider: The barriers and drivers obtained from stage 3 and tailor the intervention to accommodate the barriers and drivers, if needed

• Expert review: distribute the intervention to experts in the nursing, management or EBP fields and obtain their input (using a feedback tool)

Implement: Can be done via workshops, educational tools, summaries of guidelines, demonstrations, in-service training, simulation

• Consider: a multifaceted approach, piloting the intervention with a small group of potential target users, duration of the implementation (usually weeks to months - busy units may need less time)

Monitor knowledge: site/visits, follow-up discussions with target users:

• Consider: the feasibility of the intervention, any barriers to the intervention, additional training or knowledge required to use the intervention

Evaluate: the short-term and long-term effectiveness of the intervention in terms of:

• Patient outcomes – audit on infection rates, length of stay, morbidity, mortality • Nurse outcomes – questionnaire/interviews on enhanced knowledge, attitudes practices • Organisational outcomes – cost-effectiveness analysis/audit

Sustain knowledge use through:

• Ongoing orientation and education of (new) nursing staff/patients/clients on the intervention and updated versions of the intervention

• Evaluating long-term effectiveness of intervention e.g. annually (see stage 6)

Select: a potentially suitable and feasible intervention (e.g. clinical practice guideline, policy, poster, presentation, educational toolkit or programme)

• Consider: target population of the intervention, objectives/outcomes of the intervention, appropriateness, relevance, proven effectiveness in other contexts, robustness, cost-effectiveness and available resources, capacity maintaining the intervention, monitoring the effect of the intervention Assess: barriers and drivers to the implementation of the intervention, using:

• Questionnaires or interviews with the target users of the intervention (e.g. nursing, and non-nursing colleagues, patient/client) and/or those you need buy-in from (e.g. nursing, management) Phase of knowledge

creation and translation Activities

(1a) Identify a problem or gap (1b) Search for the knowledge or research evidence that can solve the problem

(2) Adapt the knowledge or research evidence to the local context and

(3) Assess the barriers and drivers to the implementation of the knowledge or research evidence

(4) Select, tailor, implement the knowledge or research evidence

(5) Monitor knowledge use (6) Evaluate the outcomes

(7) Sustain knowledge use

EBP, Evidence based practice.

FIGURE 2: Utilisation of the knowledge-translation-action framework.

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Further, the distinction between adaptation of the knowledge (stage 2) and selecting the knowledge (stage 4) is not always clear or may seem repetitive; however, considering adaptability from the earliest stages of knowledge translation could help ensure that interventions are more resilient to changes in the context. Additionally, stakeholder involvement to create a sense of ownership, leadership, a feasible and contextually appropriate plan or strategy on how to implement the intervention, as well as buy-in as overarching principles should be central to all stages of knowledge translation (Moore et al. 2021). It is further recommended that novice nurses should be mentored and trained by, for example, senior nurses or academics on EBP, and active partnership and collaboration between (novice) nurses and academics must be promoted, especially as limited knowledge of EBP and limited academic skills were reported barriers towards the uptake, use and implementation of EBPs (Mallion & Brooke 2016). Nonetheless, it is expected that the various proposed activities to create and translate knowledge according to the KTA framework could be used by (novice) nurses to promote the uptake, use and implementation of EBPs in clinical settings, thereby reducing the knowledge-practice gap.

References

Ferguson, L.M. & Day, R.A., 2007, ‘Challenges for new nurses in evidence-based practice’, Journal of Nursing Management 15(1), 107–113.

Graham, I.D. & Tetroe, J.M., 2010, ‘The knowledge to action framework’, in J. Rycroft-Malone & T. Bucknall (eds.), Models and frameworks for implementing evidence-based practice: Linking evidence to action, vol. 207, p. 222, Wiley- Blackwell, New York.

Green, L.W., Ottoson, J., Garcia, C. & Robert, H., 2009, ‘Diffusion theory and knowledge dissemination, utilization, and integration in public health’, Annual Review of Public Health 30(1), 151–174.

Grimshaw, J.M., Eccles, M.P., Lavis, J.N., Hill, S.J. & Squires, J.E., 2012, ‘Knowledge translation of research findings’, Implementation Science 7(1), 1–17.

Lehane, E., Leahy-Warren, P., O’Riordan, C., Savage, E., Drennan, J., O’Tuathaigh, C.

et al., 2019, ‘Evidence-based practice education for healthcare professions: An expert view’, BMJ Evidence-Based Medicine 24(3), 103–108.

Mallion, J. & Brooke, J., 2016, ‘Community-and hospital-based nurses’ implementation of evidence-based practice: Are there any differences?’, British Journal of Community Nursing 21(3), Moore, G., Campbell, M., Copeland, L., Craig, P., Movsisyan, A., Hoddinott, P. et al.,

2021, ‘Adapting interventions to new contexts – The ADAPT guidance’, British Medical Journal

Steinskog, T.L.D., Tranvåg, O., Nortvedt, M.W., Ciliska, D. & Graverholt, B., 2021,

‘Optimizing a knowledge translation intervention: A qualitative formative study to capture knowledge translation needs in nursing homes’, BMC Nursing 20(1), 1–11.

Winters, C.A. & Echeverri, R., 2012, ‘Teaching strategies to support evidence-based practice’, Critical Care Nurse