Applications of social constructivist learning theories in knowledge translation for healthcare professionals: a scoping review

Several authors conceptualize KT as a process that occurs through social and environmental interactions, and emphasize that knowledge exchange between researchers and healthcare professionals must happen in a mutually created social context [21, 31‐33]. Indeed, knowledge use within KT can be regarded as an active learning process, because knowledge is not an inert object to be ‘sent’ and ‘received’, but a fluid set of understandings shaped by those who produce it and those who use it. Clinicians act upon new knowledge by transforming the information based on pre-existing experiences and understandings, by relating it to existing knowledge, imposing meaning to it and, in many cases, monitoring their understanding throughout the process. Hence, the meaning of research is constructed by the user and casts the clinician as an active problem solver and a constructor of his or her own knowledge, rather than a passive receptacle of information [22]. This has led us to propose that social constructivist theory may be useful for understanding why and how individuals integrate and apply new knowledge in evidence-based clinical decision making and how practice behaviors may change as a result of KT interventions grounded in the core tenets of this theory. We wish to emphasize that in this paper, we are focusing on constructivism, not constructionism. Though the two terms tend to be used interchangeably and often unapologetically [84], p.30, they are not synonyms. Social constructionism emphasizes purposeful creation of knowledge. The focus is on revealing the ways in which individuals and groups participate in the creation of their perceived social reality. It involves looking at the ways social phenomena are created, institutionalized and made into tradition by humans. Socially constructed reality is seen as an ongoing, dynamic process, and reality is reproduced by individuals acting on their interpretation and their knowledge. According to Burr (2003) there is no one feature which could be said to identify a social constructionist position, but there are assumptions among individuals who identify as such namely, ‘a critical stance towards taken-for granted knowledge, historical and cultural specificity, knowledge is sustained by social processes and knowledge and social action go together’ [85]. The social context is at the center of ‘meaning making’ in social constructionism and the attention is on the ‘knowing’ that is created through shared production. Constructionism also ‘emphasizes the hold our culture has on us: it shapes the way in which we see things and gives us a quite definitive view of the world’ [86] (p.58). In contrast, within a social constructivist paradigm, the individual is at the center of the meaning making experience. The focus of constructivism is on the individual’s learning that takes place because of their interactions within a particular social context. According to Crotty (1998), ‘it would appear useful, then, to reserve the term constructivism for epistemological considerations focusing exclusively on ‘the meaning making activity of the individual mind’ and to use constructionism where the focus include the collective generation [and transmission] of meaning’ [86] (p.58). We privileged social constructivism as the focus of this review, for its emphasis on the individual and how/she he creates knowledge in socially medicated contexts.

Social constructivism is a sociological theory of knowledge that focuses on how individuals come to construct and apply knowledge in socially mediated contexts [21, 22]. The fundamental premise of this theory is that knowledge is a human construction and that the learner is an active participant in the learning process [23]. Constructivism is based on three assumptions about learning [24‐28]. First, learning is a result of the individual’s interaction with the environment. Knowledge is constructed as the learner makes sense of their experiences in the world. The content of learning is not independent of how the learning is acquired; what a learner comes to understand is a function of the context of learning, the goals of the learner, and the activity the learner is involved in. Second, cognitive dissonance, or the uncomfortable tension that comes from holding two conflicting thoughts at the same time, is the stimulus for learning. It serves as a driving force that compels the mind to acquire new thoughts or to modify existing beliefs in order to reduce the amount of dissonance (conflict). Cognitive dissonance ultimately determines the organization and nature of what is learned [29]. Third, the social environment plays a critical role in the development of knowledge. Other individuals in the environment may attempt to test the learner’s understanding and provide alternative views against which the learner questions the viability of his knowledge. Constructivism supports the acquisition of cognitive processing strategies, self-regulation, and problem solving through socially constructed learning opportunities [25, 26, 28, 30], all of which are critical skills for evidence-based knowledge uptake and implementation in clinical practice [31].

The Knowledge to Action (KTA) framework [32] adopted by the Canadian Institutes for Health Research, is a widely used framework that focuses on knowledge creation and exchange. The KTA framework contains two principal components, a knowledge creation funnel and an action cycle. The knowledge creation funnel consists of three phases: knowledge inquiry, knowledge synthesis, and knowledge tools and products. The action cycle consists of seven stages involved in moving knowledge into practice: identifying a problem in practice or a gap in knowledge and identifying, reviewing, and selecting the knowledge to be implemented to address the gap; adapting or customizing the knowledge to the local context; evaluating the determinants of the knowledge use (barriers and facilitators); selecting, tailoring and implementing interventions to address the knowledge or practice gap; monitoring the knowledge use in practice; evaluating the outcomes or impact of using the new knowledge; and determining strategies for ensuring that the new knowledge is sustained [32]. The KTA framework is grounded in the social constructivist paradigm which privileges social interaction and adaptation of research evidence by taking the local context and culture into account [34]. To our knowledge, this is the only KT framework developed with social constructivist underpinnings. Despite the growing recognition that the KTA framework can facilitate knowledge use and exchange in practice, its association with social constructivist theory has yet to be explicitly explored.

Social constructivist approaches to the science of KT have the potential to support researchers interested in examining how learning in the clinical context occurs and how new knowledge is created, disseminated, exchanged and used to inform practice. While social constructivist theory may be useful for informing the design and evaluation of KT interventions, we have yet to understand the extent to which social constructivist theory has been applied in the KT literature for healthcare professionals. Thus, this paper presents the results of a scoping review on the application of social constructivist theory in KT for healthcare professionals.

The research question that guided the review was ‘What are the applications of social constructivism and/or social constructivist theories in KT to promote EBP among healthcare professionals’? We used the PICOS format as a structure for our research question and to design our search strategy. The population is ‘healthcare professionals’; intervention is ‘application of social constructivism in KT’; the outcome is ‘promote EBP’; and the study design refers to all the study designs eligible for inclusion in the review. Eligible study designs included: all qualitative methodologies and quantitative designs (observations studies, randomized controlled trials, cohort studies, cross sectional studies, longitudinal studies and case studies).

All members of the research team were involved in decisions about inclusion and exclusion criteria. The team worked with a rehabilitation sciences librarian (JB) who suggested that, given our research question, we take a broad approach to the concept of KT when selecting search terms. The terms captured both the theory and application of KT as discussed by McKibbon [36], and took into account the terms used by a previous systematic review on KT in rehabilitation [37]. A first pilot search was constructed to include articles where any variation of the word ‘constructivism’ or ‘constructivist’ appeared in the title or abstract of articles discussing health professionals. A research assistant under the supervision of one member of the research team (AT) was responsible for reading the abstracts of all the articles identified in this first search and applying the original inclusion/exclusion criteria in an abstract screening tool. Two members of the research team (AT and AM) piloted the inclusion/exclusion criteria with a subset of abstracts retrieved from MEDLINE. The same two members of the research team (AT and AM) reviewed the search terms, the redesigned strategy and approved the abstract screening tool. This process resulted in modifications to the inclusion/exclusion criteria and the search was redesigned to include: publications from all health professions; all research methodologies (quantitative and qualitative); conceptual and theoretical papers related to KT; and, papers written in English. Excluded from the review were papers that had no evidence of the concept of knowledge translation in the abstract; were unrelated to any health profession or health field; discussed new curricula designed to promote higher level learning in health sciences students; and described new pedagogical methods (i.e., virtual, simulating techniques, etc.) for teaching in schools.

The pilot search developed for MEDLINE was conducted again with the new inclusion criteria, and then adapted for other databases. The Ovid MEDLINE search strategy is presented as ‘Additional file 1’. Searches were conducted in six databases: Ovid MEDLINE (1948 – May 16, 2011), Ovid EMBASE (1980 – May 16, 2011), CINAHL (searched entire database to May 16, 2011), ERIC (1966 – May 16, 2011), PsycInfo (1967 – May 16, 2011), and AMED (1985 – May 16, 2011). The librarian used GoPubMed to analyze the subject headings of the full-text articles that were assessed and considered for eligibility (see PRISMA flow chart) and then again of the final articles to determine whether any important terms had been missed. The iterative nature of scoping reviews allowed the research team to consider the addition of articles that best reflected new ideas gained from the review process. The GoPubMed analysis added seven other medical subject headings to the search (line 21 in Additional file 1). An expanded search including these new subject headings was conducted six months later.

The authors developed a data charting form that included the following categories: author, year of publication, purpose of the study/research question, practice setting, nature of theory use, links with the KTA framework, methodology, population characteristics, outcome evaluation (evaluation setting, evaluation responses, effectiveness of implementation, variables of evaluation, outcomes), implications for practice, and directions for future research. The data charting form was piloted on the first 10 articles and reviewed by the research team to ensure that it was comprehensive. A research assistant extracted the data for the remaining articles. The two senior authors (AT and SA) reviewed and discussed the completed extraction tables. Categories such as ‘population characteristics’, ‘outcome evaluation’, ‘effectiveness of implementation’, and ‘evaluation variables’ were not appropriate for several conceptual papers and were adapted to be more inclusive. This was an iterative process that ensured that the tables included all the salient information for generating the themes as per step four described below.

An analytical framework of quantitative (numerical) and thematic analysis was used to examine and combine study findings [35]. The numerical analysis highlighted: the nature and distribution of the studies; the nature of the social constructivist assumptions used in each study; and the KTA stage/component targeted.

The nature of the application or use of social constructivism across all papers served as the major unit of analysis. We also aimed to identify which of the three social constructivist assumptions were used in the selected studies. Two members of the research team (AT and SA) independently reviewed the data charting tables and identified a number of preliminary emerging themes. All other members of the research team were consulted to discuss the themes and ensure agreement. This process resulted in the generation of five themes. With the assistance of a doctoral student (AMR), we revisited all the charting tables to confirm that these corresponded with the themes that were generated. A summary of the major findings organized under each theme was produced following several iterations and meetings with the research team.

A total of 855 results were retrieved from all sources. Duplicates were removed (n = 341), yielding 514 records for eligibility screening. We screened the 514 abstracts and excluded 437 papers on the basis of our four exclusion criteria. Seventy-seven articles were read in full and assessed for eligibility. Fourty-two additional papers were excluded for the following reasons: no evidence of the concept of knowledge translation in the abstract (n = 8); study was unrelated to any health profession or health field (n = 8); study findings were related to new online curriculum designs in higher level learning for health sciences students (n = 10); study was based on new pedagogical methods (i.e., virtual, simulating techniques, etc.) for teaching in schools or was conducted in an educational setting with undergraduate students in health sciences (n = 16). The number of eligible article at this stage was 35. The expanded search resulted in an additional 55 additional articles plus seven MEDLINE articles for screening for a total of 62 additional articles for screening. In the end however, none of these new articles from the expanded search were eligible for the final review. The numbers of articles at each stage selection process are shown in the PRISMA flow chart (Figure 1).

Thirty-five papers published between 1992 and 2011 met the inclusion criteria. Table 1 shows the charting categories and associated content for the 35 studies. Tables 2, 3, 4 represent the study designs, practice setting, and professional groups respectively. Twenty-seven studies used a qualitative study design. These ranged from various types of literature reviews, conceptual and reflective papers to studies using interviews and questionnaires, focus groups and observations. Six papers described the results of KT interventions that for the most part, consisted of a workshop or a didactic course [38‐43]. Two studies used a mixed method design [44, 45] (Table 2). The most common practice settings identified were primary healthcare (n = 10) [42, 44, 53, 59‐62, 64, 65, 82], followed by post-graduate educational settings (n = 7) [39‐41, 43, 45, 65, 81], and mental health clinical environments (n = 5) [50, 52, 58, 78, 80] (Table 3). Nursing was the professional group most frequently targeted in the papers (20 of 35 included studies), alone [42, 43, 47, 53, 55, 60‐62, 77], or along with physicians [64, 82], patients [44], or interdisciplinary teams [38, 39, 48, 51, 57, 65, 76, 79]. Psychologists/psychiatrists was another identified group (n = 5) [50, 52, 58, 78, 80]. Four papers [40, 41, 45, 80] presented results of studies conducted with postgraduate (e.g., residents and other trainees not considered undergraduate learners) health care professionals (Table 4).

Table 5 illustrates that 15 papers discussed research grounded in the social constructivist assumption ‘learning is a result of the individual’s interaction with the environment’. Eight studies corresponded to the assumption that ‘the social environment plays a critical role in the development of knowledge’ and four studies were about ‘cognitive dissonance as the stimulus for learning’. Eight studies explored all three assumptions.

As shown in Table 5, 13 studies involved knowledge creation (n = 7 knowledge synthesis, n = 5 knowledge inquiry and n = 1 knowledge tools). Twenty-two studies addressed one of the four specific steps of the action cycle: four studies addressed step one, ‘identify the problem or knowledge gap’, two studies addressed ‘adapting knowledge to local context’ (step two), and the remaining were equally divided between step three ‘assessing barriers and facilitators’ (n = 8) and step four ‘select, tailor and implement intervention’ (n = 8). No study mapped onto more than one step of the action cycle.

We identified five themes related to the applications of social constructivist theory in KT with several nested concepts within each theme (Table 6).

The papers [46‐52, 76, 79] in this theme reported findings from literature reviews exploring the meaning of evidence and the epistemology of research and practice. Papers in this theme recognized that there may be various definitions of ‘knowledge’ and ‘knowledge creation’ which may vary depending upon the theoretical lens used to explore the applications of knowledge in clinical practice. Adler’s [46] review of the history of science literature suggested that different types of evidence can and should be used in health research. Appleton [47] discussed the relevance of constructivism to researchers in health services while Labonte’s [48] literature review on the social constructivist paradigm in health promotion research, suggested that this paradigm has the potential to resolve some of the philosophical tensions between research and practice in health promotion. Plack [49] suggested that physical therapists should shift their focus from mainly positivist approaches to care to more constructivist ones in order that they may make better use of evidence. In another literature review, Miller [50] found that the social constructivist paradigm could serve as a bridge between researchers and practitioners by suggesting that research efforts be directed towards identifying the needs of those who will be offering and receiving health care services. Wilson [51] discussed the biomedical model of care and introduced a debate on the effectiveness of objectivism in health care. The authors suggested that a more subjectivist model to healthcare, and one that embraces social constructivist theories, would include recent evidence on doctor-patient relationship as a major contributor to patient outcomes in addition to incorporating ‘objective’ clinical findings. Hoshmand’s [52] literature review emphasized a broader choice of research methods, the development of reflective skills in practice and better linkages between researchers and practitioners.

Social constructivism was used as a lens through which to gain a greater understanding of how knowledge is acquired, manifested and used to inform practice as well as to explain the individual and contextual factors that have an impact on skill development and/or behavior [39, 53‐60, 77, 78, 80‐82]. Nine of the 14 papers corresponding to this theme were literature reviews, conceptual papers and reflective pieces [54‐58, 77, 78, 80, 81]. Topics were varied and ranged from how factors such as loyalty to the profession has an impact on practice [53], to how tailoring information to practice needs influences learning and learner satisfaction [39].

Major findings from the review papers included the notion that the social constructivist paradigm provides a means for professionals to voice their knowledge [54], the importance of context in learning and the difficulty in transferring knowledge to different contexts in physical therapy practice [55]. Higgs [56] explored the nature of knowledge and discussed knowledge as ‘underpinning clinical practice’. He suggested that knowledge is an active and dynamic phenomenon constantly undergoing changes and being tested in practice. In addition, Higgs’ paper emphasized that knowledge is the basis for evidence-based practice, as clinicians draw from experiential and declarative sources of knowledge in their daily practice. Kinsella [57] discussed the philosophical underpinnings of reflective practice and how these can be used to advance our knowledge and interpretation of practice. McGuckin’s [58] literature review focused on the most effective methods for teaching modern psychiatric practice knowledge, attitudes, and skills. The author found that constructivist learning is an eclectic approach with great potential as learners are actively engaged in the learning process and they bring their unique perspectives to the learning situation. Moreover, relevant and meaningful learning activities are used to promote the desired knowledge and skills. A qualitative study of physician researchers found that implementing research evidence is more complex than suggested in current models of evidence-based medicine and that clinical decision-making is strongly influenced by factors other than just research evidence [59]. Schluter [60] used a critical incident technique grounded in a constructivist methodology to understand how nurses conceive their scope of practice. Findings suggested that different nursing areas of expertise have diverse scopes of practice, that require varied methods for applying knowledge, with the optimal method relying on nurses’ grade and skill mix.

Fairweather [61] used focus groups with primary healthcare nurse specialists in order to identify the characteristics and attributes of competency that specialist nurses ascribe to their practice; describe how specialist nurses delineate specialist boundaries from generalist practice; and generate evidence based knowledge for the development of regulatory procedures for nurses. Results indicated that knowledge is a synthesis of propositional and practice knowledge and that expertise was gained through exposure and reflection. Assumptions from social constructivist theory were used to help novices move towards expertise in practice. Differences in knowledge acquisition and application were believed to be associated with level of experience and expertise.

This theme focused on the use of constructivist approaches for examining the ‘centrality’ of the patient. The two studies in this theme found that health care professionals keep the patient at the ‘center’ of their clinical decisions and treatment interventions when acquiring and applying knowledge. Fagan [62] used a constructivist inquiry approach to examine accident and emergency nurses’ perceptions of their roles in identifying child abuse in primary healthcare. The ability of nurses to identify children in potentially abusive situations required nurses to evaluate the child’s safety as accurately as possible, to ensure that he/she received the appropriate treatment and attention. The author concluded that although all nurses in the study had sufficient knowledge to identify child abuse, this knowledge base increased with experience. The author also suggested that additional training and education is needed for multidisciplinary decision making about the role of nurses in this context. A qualitative study by Greenslade and Mandville-Ansey [63] used in-depth interviews within a constructivist approach to understand the experiences of women having same-day breast cancer surgery. Women’s subjective experiences were used to make client-centered recommendations to assist healthcare professionals in effecting change to enhance quality of care.

Nine studies examined the effects of various interventions aimed at increasing knowledge and skills in order to improve practice. One study used a mixed methods design [44], one used a qualitative design [64] and the remaining seven used surveys [38, 42, 43, 45] and workshop evaluations [40, 41, 65]. The intervention studies assessed workshops that were related to specific clinical training skills such as cultural competence [40] and alcohol dependence screening [38], while some focused on social constructivism approaches as strategies for experiential learning and reflective practice [45]. In this theme, social constructivist theory was used to inform the design of KT interventions intended to promote core skills, knowledge, and competencies needed for evidence based practice, and support behavior change (increased use of best practices).

Scoping reviews offer a unique opportunity to retrieve and scan a broad range of literature to answer a research question. A potential limitation is that by searching the titles, abstracts, and subject headings only, we may have missed relevant papers. We could have also used citation chaining in Web of Science or Scopus to find other articles that cited the key articles we had already found.

We recommend that future research in this area clearly cite the theories used to design KT interventions to ensure that they are identified in reviews similar to this one, as well as in systematic reviews of theory.

The articles included in this review were not appraised for their scientific rigor, as scoping reviews do not typically include critical appraisals of the evidence. In deciding to summarize and report the overall findings without the scrutiny of a formal appraisal process, we recognize that our results speak to the extent of the research activity, major conclusions and research gaps, rather than provide the reader with support for the effectiveness of interventions or for evidence-informed recommendations that were grounded in the social constructivist paradigm. However, this represents the evolution of research that explicitly incorporates social constructivist theory in the development and application of KT. As a larger number of studies rigorously test KT interventions guided by theory, systematic review and quality appraisal will be necessary.