Understanding the uptake of a clinical innovation for osteoarthritis in primary care: a qualitative study of knowledge mobilisation using the i-PARIHS framework

Swaithes, L., Dziedzic, K., Finney, A. et al. (2020) Understanding the uptake of a clinical innovation for osteoarthritis in primary care: a qualitative study of knowledge mobilisation using the i-PARIHS framework. Implementation Sci 15, 95. https://doi.org/10.1186/s13012-020-01055-2

Abstract

Background: Osteoarthritis is a leading cause of pain and disability worldwide. Despite research supporting best practice, evidence-based guidelines are often not followed. Little is known about the implementation of non-surgical models of care in routine primary care practice. From a knowledge mobilisation perspective, the aim of this study was to understand the uptake of a clinical innovation for osteoarthritis and explore the journey from a clinical trial to implementation.

Methods: This study used two methods: secondary analysis of focus groups undertaken with general practice staff from the Managing OSteoArthritis in ConsultationS research trial, which investigated the effectiveness of an enhanced osteoarthritis consultation, and interviews with stakeholders from an implementation project which started post-trial following demand from general practices. Data from three focus groups with 21 multi-disciplinary clinical professionals (5–8 participants per group), and 13 interviews with clinical and non-clinical stakeholders, were thematically analysed utilising the Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, in a theoretically informative approach. Public contributors were involved in topic guide design and interpretation of results.

Results: In operationalising implementation of an innovation for osteoarthritis following a trial, the importance of a whole practice approach, including the opportunity for reflection and planning, were identified. The end of a clinical trial provided opportune timing for facilitating implementation planning. In the context of osteoarthritis in primary care, facilitation by an inter-disciplinary knowledge brokering service, nested within an academic institution, was instrumental in supporting ongoing implementation by providing facilitation, infrastructure and resource to support the workload burden. ‘Instinctive facilitation’ may involve individuals who do not adopt formal brokering roles or fully recognise their role in mobilising knowledge for implementation. Public contributors and lay communities were not only recipients of healthcare innovations but also potential powerful facilitators of implementation.

Conclusion: This theoretically informed knowledge mobilisation study into the uptake of a clinical innovation for osteoarthritis in primary care has enabled further characterisation of the facilitation and recipient constructs of i-PARIHS by describing optimum timing for facilitation and roles and characteristics of facilitators

This study comes out of clinical research in osteoporosis but there is a lot that links into the broader literature and practice on knowledge mobilization and implementation science so while I don’t think many readers will take away osteoporosis knowledge we will be able to take away some considerations for our practices.

The group held a stakeholder workshop to discuss what KMb theories and frameworks would work for this research. They landed on PARIHS framework. I have written about PARIHS a couple of times (The Role of Evidence, Context, and Facilitation in an Implementation Trial: Implications for the Development of the PARIHS Framework and The PARiHS Framework (Promoting Action on Research Implementation in Health Services) in this journal club. While it has evolved over time it is a conceptually sensible framework that says if you want your research evidence to be used you pay attention to three things: the evidence, context of the evidence use and facilitation of the evidence in the context of its use. What I would like to know is what other frameworks and theories did they debate at their stakeholder workshop. It would be nice to know what competition PARIHS was up against.

There is a lot of connections to “unintentional” mobilizers…people who mobilizing knowledge without it being a role for them, often patients and the public who have received the evidence/intervention and can speak about it with the authority of lived experience. But there is an interesting comment that might explain the lack of dedicated knowledge mobilization/implementation expertise on project teams. “Lay interviewees assumed that clinicians knew and understood KM as part of their role and had a more advanced status in KM than patients. However, non-lay interviewees reported patients and the public as pivotal mobilisers of knowledge.” My take away is that everyone thinks it is someone else’s job/expertise.

Because these authors aren’t from the classic knowledge mobilization space they present a different list of barriers to effective knowledge mobilization including: restricted resource and capacity; policy and regulatory environment; service and system design; staffing models, practice culture; role of the patient. That’s a new list and something that can be reviewed in your own contexts.

But the thing that caught my eye in the abstract is the thing that is left under developed in the paper. “In the context of osteoarthritis in primary care, facilitation by an inter-disciplinary knowledge brokering service, nested within an academic institution, was instrumental in supporting ongoing implementation by providing facilitation, infrastructure and resource to support the workload burden.” I really wanted to know more about this service, referred to in the paper as the “Impact Accelerator Unit (IAU) evolved within the academic institution that conducted MOSAICS, to support these activities.” The paper doesn’t describe the functions, institutional affiliation, funding, remit etc of this unit. As someone who set up a knowledge brokering service within an institution, I was hoping for more on the IAU.

And finally, here’s an interesting observation, possibly the knowledge mobilization equivalent of the Hawthorne Effect (example of observer affect). “The focus groups themselves facilitated implementation by enabling recipients to consider the application of knowledge from the training relevant within their practice circumstances and to develop strategies to overcome potential barriers.” Basically, the research methods in this study acted as implementation facilitators presumably because they reminded participants of the intervention. How is it possible to study implementation if the act of studying it actually affects what you are trying to study?

Questions for brokers:

  1. If you were in the workshop on theories and frameworks which others would you have suggested? Which one would you fight for over PARIHS?
  2. Is knowledge mobilization someone else’s job or is it the job (at least in part) of everyone involved in the project?
  3. What needs to happen to minimize the impact of the Hawthorne effect?

Research Impact Canada is producing this journal club series to make evidence on KMb more accessible to knowledge brokers and to create online discussion about research on knowledge mobilization. It is designed for knowledge brokers and other knowledge mobilization stakeholders. Read this open access article. Then come back to this post and join the journal club by posting your comments.

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