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Knowledge Broker Capabilities: Translating Knowledge into Action for Healthcare Quality.

Narrative Review and Analysis of Literature

Contents

1. Background and Purpose ......................................................................... 3 2. Scope ....................................................................................................... 3 3. Methods.................................................................................................... 4 4. Results ..................................................................................................... 4

4.1 Knowledge translation models ............................................................ 5 4.3 Integration with healthcare teams ....................................................... 6 4.4 Operating as a collaborative network .................................................. 7 4.5 Bridging the worlds of research and practice ...................................... 7 4.6 Identifying and solving problems ......................................................... 7 4.7 Accessing and identifying knowledge ................................................. 8 4.8 Describing and organising knowledge ................................................ 8 4.9 Analysing, appraising and interpreting knowledge. ............................. 8 4.10 Combining and presenting knowledge .............................................. 9 4.11 Contextualising and customising knowledge .................................... 9 4.12 Building relationships and networks ................................................ 10 4.13 Facilitating organisational change ................................................... 10 4.14 Sustaining knowledge in action ....................................................... 11

4.14.2 Building workforce capabilities in knowledge into action. ......... 11 4.14.3 Embedding knowledge in education ......................................... 11 4.14.4 Disseminating and spreading knowledge ................................. 12 4.14.5 Monitoring knowledge implementation and outcomes ............. 12

4.15 Knowledge broker attributes ........................................................... 13 5. Discussion .............................................................................................. 13 6. Conclusion .............................................................................................. 15 7. References ............................................................................................. 18

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Summary This narrative review of published literature on the knowledge broker role identifies key knowledge, skills, attitudes and behaviours which enable knowledge brokers to bridge the domains of research and practice. Knowledge brokers apply these capabilities through close collaboration with healthcare teams to help them apply knowledge in frontline practice, planning and policy, and embed knowledge in healthcare improvement. The review highlights that knowledge brokering involves a diverse range of capabilities which combine the strengths of established evidence-based practice (based on “know-what”) and more emergent quality improvement approaches (drawing upon “know-how” and “know-who”). In combination, these capabilities can provide a powerful knowledge system to underpin healthcare improvement, implementation support and innovation. This literature describes the broad range of clinical and non-clinical disciplines that can participate in knowledge brokering. It emphasises the importance of collaboration within knowledge broker teams or networks, to combine complementary areas of expertise. As identified through this analysis, knowledge broker capabilities fall broadly into three categories: 1. Applying inquiry and knowledge management techniques to define and

solve problems. This is supported by use of technology and other tools to access, identify, describe and organise knowledge. This provides a foundation for combining and presenting knowledge in a format that is relevant to context and audience, embedding knowledge in routine practice wherever possible.

2. Facilitating relationships and networks, among people and across

organisations, based on sharing tacit knowledge – e.g. expertise and experience. Fostering connections, dialogue and interaction In this way helps to generate innovation as well as to expedite uptake of knowledge into practice.

3. Building organisational capacity and capability for translation of knowledge

into practice and policy. This includes development of organisational culture and values for use of knowledge, as well as approaches that help to sustain widespread application of knowledge in practice. This includes building workforce skills in using knowledge; embedding use of knowledge in education; targeted dissemination and spread of knowledge; promoting use of practice data and quality measures; monitoring and measuring impact of use of knowledge.

Taken together, the findings from this review provide a strong foundation for development of a knowledge broker capability framework which aligns application of knowledge with the skills, behaviours and values of quality improvement.

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Knowledge Broker Capabilities: Translating Knowledge into Action for Healthcare Quality.

Narrative Review and Analysis of Literature

1. Background and Purpose 1.1 The NHSScotland strategic review “Getting Knowledge into Action for Healthcare Quality” (1) defines a vision of a national network of knowledge brokers, integrated with clinical and improvement teams. This collaborative network will draw participants from a variety of backgrounds, including librarians, clinical effectiveness, public health, research, informatics, and clinical practice. Collectively, members of this network will provide a portfolio of services which support practitioners to apply knowledge in frontline practice, and embed knowledge in healthcare improvement activities. 1.2 This literature review aims to identify knowledge, skills, behaviours, attitudes and values associated with the knowledge broker role. This analysis will continue to inform development of the capability framework for the NHSScotland knowledge broker network.

2. Scope 2.1 The Canadian Institute for Health Research definition of knowledge translation was used as the basis for identifying knowledge broker roles which facilitate the translation of knowledge into healthcare practice: “a dynamic and iterative 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.” (2) 2.2 The scope of this overview included roles formally described as “knowledge brokers” as well as other terms used for knowledge support roles involving integrated working with healthcare teams to support translation of knowledge into practice – notably, clinical librarians, informationists, and, in some instances, healthcare practitioner roles. Knowledge broker roles associated with public health or clinical practice, originating from any professional background, both clinical and non-clinical, and working in research, education or practice, were all within scope. This literature review is primarily concerned with the capabilities required by individual healthcare workers in knowledge broker roles, though aspects may also be pertinent to teams, organisations and even whole countries operating as knowledge brokers. 2.3 While the primary focus of this review is on knowledge broker capabilities in the health setting, the original literature search identified knowledge broker functions in settings broader than healthcare, and reference is made to learning from wider contexts where appropriate.

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3. Methods 3.1 The following databases were searched via The Knowledge Network:

Cochrane Library including CRD Medline EMBASE CINAHL PsycInfo ASSIA HMIC ERIC EMERALD LISTA Campbell Collaboration Biomed Central Web of Science Social Science Citation Index Google search World Health Organisation website Some sources were identified via citation searches or from articles identified in the original K2A review. Search terms used knowledge translation knowledge broker* knowledge exchange knowledge gap evidence gap knowledge role* capabilit* framework* competenc* framework health librarian clinical librarian informationist clinical information specialis* outreach librarian clinical teams outreach librarian knowledge manage* 3.2 Abstracts were reviewed and fulltext obtained for articles which described knowledge broker roles. Given the practical focus of this literature overview, where available, systematic reviews were used as the main source of information for the primary research articles they covered. References to knowledge, skills, behaviours, values and attitudes were extracted, and common themes identified across articles. These themes are described below where they occurred across more than one primary article.

4. Results

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4.1 Knowledge translation models

4.1.1 Reports of the knowledge broker role primarily referred to two models of knowledge translation: The Knowledge to Action model (3): This describes a knowledge creation process linked to a planned action cycle, with fluid boundaries between the two. While this model stresses the iterative and fluid nature of knowledge translation, it is underpinned by the positivist principle of driving towards, and determining, action as the overall goal. Ward’s Knowledge Exchange Framework (4). Ward’s framework emphasises building of understanding and reflection rather than determining action. It comprises five broad, fluid components which are continuously interrelated and influence each other throughout the knowledge exchange process:

1. Problem identification and communication 2. Analysis of context 3. Knowledge development and selection 4. Knowledge exchange activities/interventions 5. Knowledge use

4.1.2 Although not explicitly mentioned in the articles identified on the knowledge broker roles, the Institute for Healthcare Improvement (IHI) definition of eight types of knowledge relevant to healthcare improvement is also a useful reference point in considering capabilities required to support the translation of knowledge into healthcare improvement activities and frontline practice (5): 1. Customer/beneficiary knowledge: Identifying people or groups using

healthcare and assessing their needs and preferences. 2. Healthcare as process/system: Acknowledging the interdependence of service

users, procedures, activities and technologies that come together to meet the needs of individuals and communities.

3. Variation and measurement: Using measurement to understand variation in performance in order to improve the design of healthcare.

4. Leading and making change in healthcare: Methods and skills for making change in complex organisations, including the strategic management of people and their work.

5. Collaboration: Knowledge and skills needed to work effectively in groups and understand the perspectives and responsibilities of others.

6. Developing new, locally useful knowledge: Recognising and being able to develop new knowledge, including through empirical testing.

7. Social context and accountability: Understanding the social context of healthcare, including financing.

8. Professional subject matter: Having relevant professional knowledge and an ability to apply and connect the other seven domains. This includes core competencies published by professional boards and accrediting organisations.

4.2 Who can be a knowledge broker, and where do they work? Professional backgrounds and working contexts.

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4.2.1 The literature describes knowledge brokers from a variety of professional backgrounds. In the healthcare context this includes library (6) and information technology (7), research (8), rehabilitation (9), public health (10,11), health promotion (12) and healthcare policy (13), as well as clinicians in multiple disciplines in acute, primary care and community settings - medical, nursing, long term care staff, physiotherapy, pharmacy (14-18). Managers with a clinical background or clinicians and managers working in close partnership to combine their complementary knowledge, have been highlighted as a powerful knowledge brokerage role (19,20). Scottish Government has particularly noted the value of knowledge brokerage, in terms of data and information analysis, combined with sourcing and synthesis of research evidence, in developing health policy and promoting evidence-based management (21,22). Users of the knowledge mediated by brokers in the healthcare environment range from clinicians to policymakers to service users and patients (23). 4.2.2 Outside health, knowledge brokers operate in the pharmaceutical industry, where they have a critical role in linking research and development to new product development and then facilitating uptake of new products in healthcare settings (24,25). The benefits of embedding knowledge broker approaches in education, particularly work-based and social learning, have been noted by several authors (26,27). The importance of knowledge brokering in Higher Education is well-established, in ensuring that research is aligned with practice needs (28,29). In the business world, sales managers have been described as adopting a knowledge broker role in communicating and disseminating knowledge to target audiences and persuading them of the relevance to their working practice or personal lives (30,31). Tourist information likewise has been described in terms of knowledge brokerage (32). 4.3 Capabilities identified from articles describing the knowledge broker role are summarised below.

4.4 Integration with healthcare teams

4.4.1 A defining characteristic of knowledge brokers, cutting across the range of specific functions, is their close collaboration with healthcare teams. Knowledge brokers are often regarded as “embedded” in the working context of the practitioners or policy makers they support. Lomas (33) describes knowledge brokers as an extension of the healthcare team, while Rankin (34) recommends that informationists should work as clinical team members or expert consultants. Brettle (35), outlining four types of clinical librarian role, emphasises that both outreach and clinical query-answering services, require the clinical librarian to tailor services to particular user groups and to align with the clinician’s perspective and working context, going beyond the constraints of the traditional library role. Considering the future role of healthcare librarians in knowledge brokering, Muir Gray (36) calls for them to: “Close the library for half the hours it is open, allowing the librarian to become free to roam on the ward and in the boardroom. “

Booth (37) reaffirms this essential need for integration with healthcare teams in his essay on opportunities for healthcare librarians to become proactive facilitators of translation of knowledge into frontline practice. 4.4.2.The Collaborative Leadership in Applied Research in Care (CLAHRC) initiatives in NHS England provide current examples of knowledge broker roles as an integral

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part of teams combining Higher Education research and healthcare practitioner leadership to support improvement in healthcare priority areas. Rowley (38) describes clinical “Diffusion Fellows” within one CLAHRC adopting knowledge broker roles to help embed research in clinical practice, while Sinfield (39) highlights the important role of knowledge brokers in facilitating interprofessional team working and commissioning.

4.5 Operating as a collaborative network

4.5.1 Several key articles recognise that providing the full portfolio of knowledge brokering support requires a team or network approach. While there are logical links between different types of knowledge broker activity, the range and level of expertise involved call for a combination of complementary strengths rather than a single new type of role. Booth (37) and Ward (40) both describe knowledge broker teams with a combination of expertise encompassing technology, information management, knowledge selection and development and facilitation. Gerrish (41) and Rankin (34) both note the need to combine clinical, educational, knowledge management and technology expertise within knowledge brokering roles. Lomas (33) describes an early knowledge broker network established in Canada, uniting individuals with a wide range of specialisms and backgrounds, clinical, educational, research, knowledge and informatics, with a common commitment to supporting the translation of research into healthcare practice.

4.6 Bridging the worlds of research and practice

4.6.1 Closely allied with the principle of integrated working with healthcare teams is the generic knowledge broker role of linking research and practice. This knowledge broker role has been acknowledged within Higher Education for some time (28,29,42) as essential to strengthening the focus on applied research (43). Lomas (33) and Dobbins (44) both highlight that the knowledge broker should have a mutual understanding of the goals and cultures of research and end-user decision-making, with Lomas describing knowledge brokering as the “in-between world” in the middle-ground between research and practice. Ward (4,40) likewise notes that a key function of the knowledge broker is to facilitate interaction between researchers and practitioners.

4.7 Identifying and solving problems

4.7.1 In providing a bridge between research and practice, knowledge brokers are well-positioned to help define practical issues and problems, and then to investigate how research or other forms of knowledge can help to provide solutions. Booth (37) notes that the established librarian role in defining questions using the PICO (Population-Intervention-Comparison-Outcome) and SPICE (Setting-Population-Intervention-Comparison-Evaluation) formulas represent one important aspect of problem definition. Dobbins (44) extends the role in problem definition to in-depth assessment of knowledge needs of particular user groups. Brettle (35), Rankin (34) and Davidoff (45) focus on the knowledge broker role in defining clinical questions at point of care, and matching these to appropriate types of evidence. Ward (4) notes the iterative nature of inquiry and that the knowledge broker will work with end-users to identify, refine and reframe issues throughout the course of an improvement initiative. Straus (3) distinguishes between two types of knowledge inquiry – “know-what” questions about clinical interventions; and “know-how” questions about

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implementation approaches. “Know-what” questions feature more strongly in the knowledge creation stage of the Knowledge to Action model and “know-how” questions more in the planned action cycle.

4.8 Accessing and identifying knowledge

4.8.1 Following problem definition, the next step in problem-solving will often be locating relevant information and knowledge (46). Dobbins (44) and Davis (47) particularly emphasise the knowledge broker’s skills in sourcing research evidence, while Lomas (33), Gerrish (41), Booth (37) and Ward (4.40). recognise that knowledge brokers will also source knowledge in a variety of other formats, as appropriate to the question in hand. These formats may include practice data, and practitioner and patient experience. This capability, of identifying knowledge from practice and experience as well as from research, is intrinsic to Glasziou’s description of the different types of knowledge which underpin evidence-based practice and quality improvement.

4.9 Describing and organising knowledge

4.9.1 The skills of describing, classifying and organising knowledge for easy retrieval, and highlighting relationships between resources, are well-established within librarian and broader informatics roles. Gerrish (41), Booth (37), and Rankin (34) all underline the importance of these skills. Rankin (34), drawing upon the earlier work of Davidoff (45) and others, draws attention to the way in which technology provides new contexts for applying traditional classification and cataloguing skills. Management of electronic knowledge repositories such as websites and portals is an increasingly common responsibility of knowledge brokers. Rankin’s systematic review (34) describes how the informationist role focuses particularly on coding and mapping techniques to create links between electronic health record systems and knowledge sources.

4.10 Designing knowledge management technology and facilitating its use

4.10.1 Several authors draw attention to the importance of knowledge broker skills in user-centred design of online systems, and in facilitating effective use of technology to find, share and disseminate knowledge (48,49, 50). Verona (51) points to the emergence of a new breed of “virtual knowledge brokers” providing knowledge support remotely in a technology environment. Reznick-Zelley (52) highlights the increasingly important role of knowledge brokers in facilitating virtual communities and in managing repositories of online knowledge – including research, practice data and policy.

4.11 Analysing, appraising and interpreting knowledge.

4.11.1 Describing, classifying and organising knowledge can be regarded as first steps towards extracting meaningful use from it. Several studies highlight the knowledge broker role in more in-depth evaluative review, analysis and interpretation of knowledge (53-55). Most authors emphasise the standard critical appraisal tools used to evaluate research evidence and guidelines (56,57), but Lomas (33) notes the

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need to assess knowledge in a range of formats, both published and experiential. Rankin (34) adopts a stronger informatics perspective, extending this analytical and interpretive role to data from practice and performance.

4.12 Combining and presenting knowledge

4.12.1 Straus’s Knowledge to Action model (3) centres on the creation of new knowledge by combining original knowledge from a range of pre-existing sources. The resulting new knowledge can be presented in a range of formats - from simple annotated lists of references, to evidence digests highlighting key points from original papers (58). Tools such as decision aids, pathways and guidelines are example of “actionable knowledge” formats, integrating knowledge into clinical workflow. 4.12.2 Accounts of knowledge broker roles describe this synthesis and distilling of different forms of knowledge to differing degrees. Gerrish (41) describes how advanced practice nurses in knowledge broker roles combine and summarise knowledge from research as well as practice and experience to inform frontline improvement. Booth (37) and Ward (4,40) both note that selecting knowledge from explicit and tacit sources supports generation of new knowledge to feed back to practitioner teams. Rankin (34) highlights the importance of combining knowledge from research literature with knowledge from clinical and statistical data. 4.12.3 Lomas (33) was one of the first to highlight the knowledge broker role in presenting and communicating knowledge derived from search and synthesis in a format tailored to the needs of the audience. Several authors subsequently explored the characteristics of clinical knowledge summaries. They underline the importance of accessible, concise outputs in plain English to support quick and easy use of knowledge in clinical practice (59,60). Ward (4) highlighted the fact that knowledge brokers need to present knowledge verbally as well as in written format, helping their practitioner teams to understand the material they feed back following search and synthesis. She also emphasises that knowledge may be presented to support business cases and service improvement as well as clinical decision-making. Rankin (34) recognises that presentation of knowledge drawn from different sources may take many other forms - including, for example, current awareness, authoring of posters, presentations and reports. He also emphasises the role of the informationist in providing actionable knowledge – for example, in the form of point of care knowledge services, decision support, prompts and reminders within clinical systems.

4.13 Contextualising and customising knowledge

4.13.1 Adapting knowledge to the context in which it will be used, by aligning with local systems, processes, policy, and work culture, without losing the integrity of the underlying evidence base, is a consistent theme for researchers of the knowledge broker role. The knowledge broker can be regarded as a two-way intermediary, translating international research evidence into locally relevant knowledge, and facilitating wider spread of knowledge generated in local settings (61). For example, contextualisation may involve incorporating evidence-based recommendations into local handbooks or pathways, or incorporating checklists and prompts into clinical routines. This customising of knowledge to local context and working practices depends on integrating the knowledge broker within the healthcare team. It is one aspect of tailoring knowledge support specifically to the needs of a defined group of end-users.

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4.14 Building relationships and networks

4.14.1 The “knowledge transfer and exchange” (62) or “linkage and exchange” (63) functions of the knowledge broker offer a contrast to the technical focus of sourcing and organising knowledge. These functions depend on human interaction as a key enabler of embedding knowledge in practice. This component of the knowledge broker role reflects the conclusions of Greenhalgh (63,64) and Gabbay and Le May (65). These researchers conclude that knowledge translation is primarily a dynamic and fluid process which depends on developing formal and informal relationships among the people involved in implementation. Approaches which foster this social and relational use of knowledge include communities of practice, educational/academic detailing, use of champions and opinion leaders. Lomas (33) ascribes primary importance to the knowledge broker role in facilitating, mediating and negotiating understanding, and commitment to change, among researchers and practitioners. Dobbins (44) likewise emphasises the importance of the knowledge broker as the critical link between healthcare and research teams. Ward (4,40) regards the facilitating role of the knowledge broker as pivotal, in mediating dialogue and interaction among practitioners in the team aiming to change practice, and in creating new connections – for example, between the healthcare team and relevant experts. Brettle’s focus (35) on knowledge brokers with a librarian background also recognises the importance of educational outreach, enabling clinical librarians to engage with practitioners and to facilitate sharing of knowledge within practitioner teams. 4.14.2 The knowledge broker role in building relationships and networks is not limited to people networks but can also include building connections between knowledge and information services which support the service user moving across settings, health and social care services in NHS, local authority and third sectors. The “community navigator” function described by Henderson (66) , and the cross-sectoral knowledge brokering approach advocated by McAneney (67). illustrate the potential of knowledge broker networks to provide continuous knowledge support for the service user throughout their journey of care.

4.15 Facilitating organisational change

4.15 .1 Mobilising knowledge within networks and communities can be regarded as one stage in “unfreezing” embedded organisational practices in order to achieve change in culture, policy and processes. Davis (47) echoes Straus’s and Graham’s focus on a logical, “planned action” cycle of change (3). This is based on assessing the organisational and practitioner enablers of, and barriers to, knowledge use, as a basis for selecting and tailoring interventions. While not explicitly referencing the knowledge broker role, Glasziou’s description (68) of a knowledge system combining evidence-based practice and improvement knowledge confirms the benefits of a dual approach, which supports individual practitioners to source and apply knowledge, and at the same time addresses the systems-level determinants of change. Dobbins (44) underlines that successful knowledge brokering in the public health context is equally dependent on organisational leadership and support as on any technical aspects of knowledge management. At the level of clinical teams, Gerrish (41) points to approaches such as role modelling as means for local leaders to facilitate change in systems and culture. Rankin (34) acknowledges the importance of organisational knowledge as a feature of the knowledge broker role, and highlights the project management aspects of implementing change. Booth (37) stresses the need for

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political astuteness in order for knowledge brokers to contribute effectively to change in practice. He also quotes Henderson’s recommendation (66) that librarians of the future, in a modernised, knowledge broker role, will need insight and practical skills in behavioural and organisational change models and techniques. Booth and Henderson envisage knowledge brokers having at their disposal a “change toolbox” which they can select from as appropriate to need. 4.15.2 The role of the knowledge broker in facilitating communication and collaboration across traditional boundaries of organisation and discipline is integral to their support for communities of practice and interprofessional team working (63,65, 69, 70) – both key enablers of healthcare improvement. In mediating communication and creation of a common knowledge base across structural boundaries they play an important role as change agents (71), particularly in the complex healthcare environment where integration across boundaries of health and social care and wider public services is a policy priority.

4.16 Fostering innovation

Hargadon (72) and Ekaterina (73) both emphasise that knowledge brokering is critical to innovation. Hargadon attempts to remove some of the mystification surrounding innovation by describing it as a knowledge brokering process by which existing knowledge (“old ideas”) serves as the raw material for generation of new ideas through creative dialogue and interaction to identifying new uses and new perspectives.

4.17 Sustaining knowledge in action

4.17.1 Like other improvement and implementation approaches, knowledge brokering needs to design and deploy strategies to sustain the integration of knowledge in practice. The literature highlights the importance of ongoing knowledge brokering support, and suggests a number of key approaches designed for sustainability:

4.17.2 Building workforce capabilities in knowledge into action.

A core role of the knowledge broker, reported in several contexts, is the building of healthcare worker capability and self-sufficiency in evidence-informed decision-making, knowledge management and research skills. Lomas (33) recommends that knowledge brokers should have a grounding in the principles of adult learning for this reason. He sees that a whole-system approach to building capacity for knowledge into action involves supporting researchers to develop skills in applied research, while at the same time facilitating decision-makers to build the capabilities involved in using research and other forms of knowledge effectively. Rankin (34) and Gerrish (41), approaching the subject from quite different perspectives, both describe knowledge brokers teaching practitioners alongside clinical experts, so that the skills of finding, evaluating and disseminating knowledge are closely associated with clinical skills and knowledge.

4.17.3 Embedding knowledge in education

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Davis (47) argues that knowledge translation builds on and subsumes continuing education and continuing professional development, as a process for improving healthcare outcomes using validated knowledge. Graham (3) similarly acknowledges that continuing education needs to incorporate best available knowledge and to deploy effective approaches to translate that knowledge into practice. Gerrish notes the importance of practice-based education as a means to sustain use of new knowledge within clinical environments. Dietinger (74) and Psarras (75) both note the value of integrating knowledge brokerage in education and training. Evans (76) highlights that key elements of knowledge brokerage – facilitating sharing of knowledge from experience – and applying knowledge in day to day practice – align closely with situated and work-based learning. In short, embedding knowledge into action approaches – whether in the form of new knowledge products, or facilitating exchange and dissemination of knowledge - in training and continuing professional development is an important knowledge broker role in promoting sustained knowledge use. As the potential of learning technology gains increasing recognition, so is the relevance of knowledge broker skills in creating elearning environments that link individual and collective experiential learning with established research-based knowledge (77).

4.17.4 Disseminating and spreading knowledge

Presentation of knowledge assets, facilitation of knowledge exchange through communities and networks, and embedding knowledge in clinical workflow, organisational systems, and education, as outlined above, are all means which the knowledge broker can deploy to facilitate dissemination and spread of knowledge. Straus and Graham’s planned action model (3), and Gerrish’s practical study of clinical knowledge broker roles (41), recommend a systematic approach to dissemination and spread, including traditional knowledge dissemination methods such as publication, presentation at conferences, etc. Gagnon (78) describes the role of the knowledge broker both in communicating knowledge within small teams and in targeted dissemination to large audiences. Dobbins (44) highlights the importance of the knowledge broker role in horizon-scanning to ensure that knowledge is continuously updated and fit for purpose for contemporary healthcare practice.

4.17.5 Promoting use of quality measures.

Knowledge brokers can have a specific role in promoting awareness and use of clinical quality measures, as an integral component of their role in embedding application of knowledge in practice in a sustainable manner (79, 80). This role helps to align knowledge brokerage firmly with quality improvement and implementation support, with their strong emphasis on data and measurement as a driving force for improvement.

4.17.6 Monitoring knowledge implementation and outcomes

“Closing the loop” on the knowledge into action process and demonstrating sustained impact involves the knowledge broker monitoring knowledge into action interventions and evaluating outcomes of use of knowledge. Outcome measurement needs to take

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account of the different forms of knowledge utilisation, as highlighted by Ward (4,40), Greenhalgh (63,64) and Nutley (81) – including instrumental use – i.e., direct application in healthcare practice; conceptual use – i.e. changing ways of thinking about healthcare issues; and political use – i.e. to change policy or political approach. Outcome measurement also needs to recognise that translating knowledge into action involves a multi-factorial, interrelated series of interventions, taking place in a complex healthcare system. Both direct and indirect impact measures therefore need to be considered. In line with the measurement framework defined for the Knowledge into Action review (1) , and the related Kirkpatrick model (82) for evaluating educational interventions, direct measures may include, for example:

• Reach – i.e. improved stakeholder awareness and engagement.

• Reaction – i.e. stakeholder satisfaction.

• Knowledge and skills – i.e. evidence that stakeholders improve their understanding and technical capabilities.

Indirect measures may include:

• Practice and behaviour – evidence of actual implementation of new knowledge and skills - through change in practice or decisions.

• Service outcomes – ultimately, measurable improvement in outcomes for service users, practitioners and services as a whole.

4.18 Knowledge broker attributes

4.18.1 The literature is in accord that knowledge brokering requires a distributed, collaborative leadership approach (83,84) to build on complementary strengths in different aspects of knowledge brokering. This requires confidence and competence in leadership, while recognising the need for teamworking with knowledge broker partners. 4.18.2 A number of researchers highlight further specific attributes and attitudes, which go beyond knowledge and skills (33, 34, 37, 85). These include: Entrepreneurial approach Solution-focused mind-set Innovating, open to new ideas Proactive approach Professionalism Customer- / User-centred approach Commitment to continuous learning.

5. Discussion 5.1 Based on these findings, Figure 1 below summarises key knowledge, skills and attitudes required of the knowledge broker role. The analysis presented in this overview lends support to several aspects of the NHSScotland Knowledge into Action model and change package. It confirms the fundamental importance of a collaborative, networked approach to knowledge brokering, combining strengths from a variety of specialisms and backgrounds. As shown in table 1, the knowledge broker capabilities identified in this analysis can be readily aligned with the elements of the Knowledge into Action change package, and with the IHI domains of healthcare knowledge. This mapping of capabilities to areas identified for service development provides a useful basis for developing a knowledge broker capability

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framework, planning configuration of the NHSScotland-wide knowledge broker network, and associated support for learning and workforce development. 5.2 This overview provides a foundation for individual and team self-assessment, to identify key gaps and challenges in developing knowledge broker roles within the knowledge broker network in local contexts. For example, librarians’ strengths in problem definition, sourcing, describing and organising knowledge, while researchers’ strengths may tend more towards knowledge synthesis and interpretation. 5.3 Overall, this analysis highligts the need for a flexible approach, open to complementary perspectives on knowledge brokering as best suited to the improvement needs in hand. Some studies and descriptions align primarily with the structured and logical flow of knowledge into action described by Straus and Graham (3), while others better reflect Ward’s more fluid and socially adaptive model (4). The importance of organisational context and its readiness for translating knowledge into action – “absorptive capacity for knowledge” (63) – as an enabler of knowledge brokering - is a recurring theme throughout the literature, and presents both challenges and opportunities for exertion of the leadership role of knowledge brokers. 5.4 This overview lends support to Paul Glasziou’s description (68) of the interdependencies between evidence-based practice and quality improvement, with knowledge translation connecting the two. Evidence-based practice and quality improvement both depend on problem definition, sourcing and combining knowledge about interventions and about implementation approaches. The knowledge broker carries out the translation activities of packaging knowledge to embed in clinical workflow, facilitating interpersonal exchange and dissemination of knowledge, building organisational capacity for use of knowledge, and measuring impact, can all contribute actively to quality improvement and implementation support. 5.5 The synergies between knowledge brokering and healthcare improvement, and the potential for knowledge broker networks to make a substantial contribution to improvement, implementation and innovation in health settings, is further substantiated by Batalden and Davidoff’s analysis of the knowledge systems underpinning quality improvement (86). Their account of the integral importance to improvement of knowledge sourcing and synthesis, relational and actionable use of knowledge, and knowledge of local context and systems, aligns well with the description of knowledge broker capabilities emerging from this overview. Indeed, some authors have already specifically noted the role of knowledge brokers in guideline implementation, healthcare innovation and improvement (87,88). 5.6 While a sound evidence base has been identified for each type of intervention within the Knowledge into Action change package, the overall evidence for how to implement these services, individually or collectively, through knowledge brokers, is still emergent. This is not surprising, given the complex nature of knowledge brokering as a dynamic combination of interventions, rather than a single approach, and the varied interpretations of knowledge brokering currently in play. Moreover, given that evidence exists for individual elements of the knowledge broker role, the key research question is arguably more one of implementation – “How to maximise effectiveness of the knowledge broker role?” rather than of efficacy of knowledge brokerage as an intervention – “Is knowledge brokerage effective?” As NHSScotland progresses to develop and implement the knowledge broker role, this presents the opportunity to research and evaluate practice to build the evidence base to answer some key research questions about knowledge broker effectiveness. For example:

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1. Which combination of knowledge broker activities are associated with optimal decision-making and healthcare outcomes? Does the combination vary according to setting (e.g. primary, community or secondary care), and among different healthcare workers?

2. What types of knowledge contribute to priority healthcare outcomes, e.g. avoiding

errors, shortening length of stay, greater efficiency, improving patient experience? 3. Can knowledge brokers contribute to priority healthcare outcomes, e.g. avoiding

errors, shortening length of stay, greater efficiency, improving patient experience? 4. Which knowledge broker tasks can be performed more effectively by technology? 5. How does the knowledge broker role compare with other methods to improve

translation of knowledge into practice? 6. What factors or approaches promote knowledge inquiry (questioning) and use of

the most appropriate knowledge to support delivery of care? 7. What contextual factors promote embedding of knowledge in frontline practice

and systems improvement? 8. How can the knowledge broker role support application of knowledge to

individualised, person-centred patient care?

6. Conclusion This overview describes the range of capabilities which research to date has indicated make up the full extent of the knowledge broker role. By bringing together this research in one place for the first time, it reveals the major contribution which knowledge brokers can make to improving the quality of healthcare. It underlines the range of complementary skills and knowledge, grounded in both social and medical models of care, required to embed knowledge in healthcare policy and practice. It underlines the necessity for a networked approach to knowledge brokerage, collaborating to combine knowledge and skills from a range of professional backgrounds. Establishing this networked knowledge broker infrastructure calls for a confident commitment across disciplines and organisations to collaborative leadership, to create synergies and maximise benefits across disciplines and contexts. Overall, the review uncovers the potential of knowledge brokering to embed use of knowledge in healthcare improvement. It invites leaders at all levels in improvement and knowledge management to work together to realise this potential in their healthcare settings.

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• Collaborative leadership

• Entrepreneurial approach

• Solution-focused mind-set

• Innovating

• Proactive approach

• Demonstrating professionalism

• Customer / User-centred approach

• Commitment to continuous learning

• User / Customer knowledge

needs and preferences

• Healthcare as process/system

• Knowledge sources – research,

experience, practice.

• Data analysis - variation and

measurement.

• Leading change

• Social, political and

organisational context

• Informatics and knowledge

management technology

• Research design and analysis

• Adult learning principles

• Communication

• Collaboration

• Problem-definition and problem-solving

• Sourcing and capturing knowledge from research, practice and experience.

• Describing and organising knowledge.

• Analysing, evaluating, interpreting knowledge.

• Combining and presenting knowledge.

• Tailoring and packaging knowledge to embed in clinical and other systems.

• Facilitating relationships and networks

• Supporting organisational change

• Education

• Innovation processes

• Measuring improvement in use of knowledge and associated outcomes.

Attitudes Figure 1: Summary of Knowledge, Skills and Attitudes within Knowledge Broker Role.

Skills “Know-How”

Knowledge “Know-What”

Knowledge Broker

Network “Know-Who”

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Table 1: Mapping Elements of Knowledge Broker Role to Knowledge into Action Change Package.

NHSScotland Knowledge into Action Change Package Elements of Knowledge Broker Role Identified from Literature

Developing knowledge broker network

Knowledge search and synthesis

Delivering actionable knowledge.

Social and relational use of knowledge

Building organisational capacity and capability

Transforming physical library resource.

1. Integration with healthcare teams

2. Operating as a collaborative network

3. Bridging the worlds of research and practice

4. Identifying and solving problems

5. Accessing and identifying knowledge

6. Describing and organising knowledge

7. Designing knowledge management technology, facilitating its use.

8. Analysing, appraising and interpreting knowledge.

9. Combining and presenting knowledge

10. Contextualising and customising knowledge

11. Building relationships and networks

12. Facilitating organisational change

13. Fostering innovation

Sustaining knowledge in action- see below:

14. Building workforce capabilities in knowledge into action.

15. Embedding knowledge in education

16. Knowledge dissemination and spread

17. Promoting use of quality measures

18. Monitoring knowledge implementation and outcomes

18

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Dr Ann Wales NHS Education for Scotland August 2012