Using knowledge brokers to facilitate the uptake of pediatric measurement tools into clinical practice: a before-after intervention study

'Best practice' is defined as the integration of research evidence, client preferences, and clinical experience [1]. In pediatric physical therapy, clinical practice includes examination and evaluation of the client, diagnosis, prognosis, intervention, and evaluation of outcomes [2]. All of these components of practice require documentation and measurement. Standardized measures assist physiotherapists (PTs) to assess children's abilities, limitations and potential objectively. Clinical use of reliable and valid outcome measures also facilitates collaborative clinical and administrative decision-making, and evaluation of change of children's abilities. For research purposes, aggregation of data from standardized measures allows for evaluation of intervention outcomes.

Investigators at CanChild Centre for Childhood Disability Research at McMaster University, Ontario, Canada have developed and validated a set of measurement tools to assist in the measurement and understanding of gross motor function of children with cerebral palsy (CP). These tools include the Gross Motor Function Classification System (GMFCS) [3, 4], the Gross Motor Function Measure (GMFM-88 [5] and GMFM-66 [6‐8]), and the Motor Growth Curves (MGCs) [9]. When used together, this collection of tools provides an integrated, evidence-based approach to clinical practice and can help service providers set and evaluate intervention goals and answer parents' questions about prognosis (Figure 1). These measurement tools are recognized internationally in the research/academic community as the gold standard measures of motor function for children with CP. Our group has extensive experience training clinicians to use these tools [10, 11] and continues to research the development and application of the tools in research and clinical practice [12‐19].

Although PTs recognize the importance of using standardized measures as part of evidence-based practice, they face many challenges in selecting, using and interpreting the information from measures [20]. The challenges to moving outcome measures into clinical practice in children's rehabilitation settings [20, 21] are similar to those reported in a systematic review of barriers to moving evidence to practice more broadly [22]. Specifically, Cochrane et al. [22] identified seven categories of barriers: supports/resources (e.g., time, funding, resources), cognitive/behavioural (e.g., knowledge, awareness, skills), healthcare professional (e.g., characteristics, age/maturity of practice, peer influence), system/process (e.g., workload, team structure, referral process), attitudinal/rational-emotive (e.g., perceived competence, perceived outcome expectancy, authority), clinical practice guidelines/evidence (e.g., utility, access, local applicability), and patient factors (e.g., patient characteristics, adherence).

A survey of pediatric PTs and occupational therapists (OTs) [23] revealed wide variation in the practices of therapists treating young children with CP in relation to best practice guidelines. One solution suggested by the authors was the promotion of knowledge translation (KT) strategies to encourage evidence-based practice among practicing clinicians. The Canadian Institutes of Health Research defines KT as a 'dynamic and iterative process that includes synthesis, dissemination, exchange and ethically sound application of knowledge to improve health, provide more effective health services and products and strengthen the healthcare system' [24].

Researchers are now beginning to investigate KT strategies within clinical contexts.

In a study examining the use of outcome measures by pediatric PTs in the Netherlands, passive KT strategies such as peer-reviewed journal articles and web-based summaries were found to be effective in increasing awareness of outcome measures, but did not increase their use [25]. Although interactive workshops were somewhat successful in increasing use of the measures, a significant gap still remained between knowledge and use. It was proposed that ongoing support and opportunities to share experiences with peers may be necessary for the clinical use of evidence-based measures to be maintained long term.

In a clinical trial, mental health practitioners randomized to a 'community of practice' group demonstrated more frequent clinical use of an accepted standardized measure compared to those who had access only to their organizations' regular supports [26]. Communities of practice may be an effective KT strategy to support use of research evidence in clinical practice. In addition to the interactive aspect, this approach also involves individuals from within the clinical practice setting. Because barriers to using evidence in practice will vary by practice setting, having someone from within the clinical practice setting available to help identify both barriers and supports would be important to influence effective KT strategies.

A recent systematic review of strategies used by rehabilitation professionals to move evidence into practice suggested that active, multi-component interventions improve evidence-based knowledge and behaviours by PTs [27]. One strategy for knowledge transfer that is gaining interest is a KT program built around the roles and activities of a knowledge broker (KB). A KB has been defined as someone who is capable of 'bringing researchers and decision makers together, facilitating their interaction so that they are able to better understand each others' goals and professional culture, influence each others' work, forge new partnerships, and use research-based evidence. Brokering is ultimately about supporting evidence-based decision making in the organization, management and delivery of health services' [28]. Pediatric PTs in children's rehabilitation settings share common values, interests, and uncertainties about their work, and within these communities of practice the role of the KB may be particularly useful.

Despite the increasing interest in knowledge brokering, little research evidence exists regarding the use of a KB. A common feature among different types of brokering models is the concept of interactive engagement; however, the specific brokering activities of the KB are difficult to define or standardize because the role should be flexible and responsive to the needs of the stakeholders [29, 30]. Most brokering studies to date have been in policy decision-making environments [31‐33]. Although there is evidence that KBs help decision makers gain knowledge and skills in the evidence-based process [32], Dobbins et al. [29] found that the use of a KB in addition to tailored messages linking relevant research evidence to specific decision makers was not as effective as tailored messages alone in influencing policy decision making for public health organizations with a high research culture. These findings are useful; however, the environments in which policy makers and front-line clinicians practice are very different, as are the issues that they must address. Thus, investigation of a KB model in a clinical environment was warranted.

The primary purpose of this study was to evaluate the short-term (six-month) and long-term (12-month) impact of a multi-faceted KT intervention using KBs to facilitate the use of four evidence-based measurement tools by PTs in children's rehabilitation facilities in Ontario (the 'East'), and Alberta and British Columbia (the 'West'). A secondary purpose of the study was to explore factors such as organizational support that might modify or mediate the intervention.

We hypothesized that in both regions (East and West), PTs would increase their knowledge and use of the measurement tools, but that there would be regional differences because of baseline differences in familiarity with the tools between the regions. Therapists in the East have a longstanding partnership with CanChild and their involvement in previous research related to the development and validation of the measurement tools may provide them with more familiarity with the tools. The natural variation between the regions enhances the generalizability of the intervention approach across settings, level of baseline knowledge, and use. We also hypothesized that organizational culture would influence the uptake of evidence based on previous work [31, 34].

We developed a KT model of a KB embedded within the clinical context and supported by the network of knowledge brokers and the research team (including a broker to the knowledge brokers). We refer to this as a 'broker to the knowledge brokers' model (Figure 2). This model focused on the 'action' or implementation phase of the knowledge to action (KTA) framework [35], with an emphasis on knowledge uptake rather than on providing a synthesis of the evidence or on teaching clinicians to be experts in critical appraisal.

This is the first study we are aware of which evaluates the impact of a multi-faceted KB intervention to help bridge the evidence to practice gap within children's rehabilitation organizations. Following a six-month (two hours/week) KB intervention, changes were reported in practicing PTs' self-reported familiarity with and use of four specific evidence-based measurement tools in two regions of Canada. The changes were maintained one year later. These results are in line with those of a recent systematic review of KT interventions for rehabilitation professionals (OT and PTs) that found moderate level evidence that active multi-component KT interventions (i.e., combination of opinion leaders, outreach visits, working groups, printed materials) improved knowledge and practice behaviours compared with passive dissemination strategies for PTs [27].

How our results fit with those of Dobbins et al. [31] is less clear. Their randomized control trial involved three KT intervention groups moving from the most passive (access to on-line systematic reviews through healthevidence.ca, or HE), to a moderately interactive KT strategy (access to HE plus receiving tailored, targeted messages, or TM), and the most interactive (HE plus TM plus KBs). There was no significant effect of the intervention for any of the groups on the primary outcome of using evidence in program decisions; however, there was an effect on public health policies and programs for decision makers receiving the moderately interactive approach of HE plus TM. The addition of the KB seemed to wash out the effect of the HE plus TM strategy. Support for the HE plus TM plus KB was found only in those departments where the organizational culture for research was low. Our results showed that a strong research culture and supervisor expectations were the significant factors in predicting familiarity and use of only one of our measurement tools, the GMFCS. The GMFCS is used not only by PTs but by other clinicians as well, and therefore PTs might have had greater expectations to use this tool, especially when communicating with other service providers. Availability of organizational resources were not observed to have a significant impact on familiarity or use of the measurement tools, perhaps because the study team provided educational resources (manuals, CD-ROM training) and financial remuneration for the KBs. The target in the Dobbins study [31] was on individual decision makers in public health departments to increase their capacity to be evidence-based and to impact on health policies and programs. An important detail is that the KB was not situated in the public health departments, and 30% of the health departments never received any of the brokering intervention. In contrast, our study was focused primarily on the implementation of specific evidence-based measurement tools by KBs embedded in the clinical sites on knowledge and on use by practicing clinicians, rather than capacity building which would take longer to show an impact. A large component of our study was the multiple supports offered to KBs throughout the intervention, including facilitation of a KB community of practice, which is thought to be an important component of KT interventions [25, 26, 31].

The KB model employed in this study was designed to address many of the barriers to knowledge transfer identified in the literature, and was primarily focused on the 'action' phase of moving evidence into practice. An attempt was made to minimize potential barriers by: obtaining support from organizations prior to implementing the KB model; engaging KBs who were enthusiastic about the role; providing financial support to each of the rehabilitation organizations to allow for dedicated time for the KB role; limiting the content to four measurement tools relevant to clinical practice; providing tailored, synthesized materials and training resources in a variety of formats; and providing a social network of support to the KBs comprised of other KBs and the research study team. To implement this KB model in practice without having the evidence synthesized in user-friendly formats would require significantly more time and resources than were provided in this study. This underscores the need for researchers to devote more time to describing and highlighting implications for practice, and to packaging their research materials in ways that make them accessible to front-line practitioners. In addition, academic institutions need to acknowledge the importance of KT activities and to value them in decisions of academic promotion and tenure.

Throughout the study KBs identified the significance of the PT research coordinator or 'broker to the KBs' as being an important facilitator of the process. The research coordinator readily understood the therapists' needs, responded in a timely fashion to KBs requests for help or information and was in contact on a regular basis throughout the intervention with KBs and the study team [36].

Ketelaar et al. [25] have demonstrated the knowledge/use gap with a subset of these measurement tools with PTs in the Netherlands. In our study, therapists from the West tended to have a wider gap between familiarity and use of measurement tools at baseline than those in the East, and this KB strategy helped to narrow the gap considerably. Changes reported in rehabilitation organizations across the three provinces imply that the model can be generalized across different practice settings because clinicians provided service to children of all ages, practiced in urban and rural settings, and had varying levels of baseline knowledge. It is encouraging that the changes reported immediately post-intervention were maintained one year later.

A success of this intervention was the high retention rate of 24 out of 25 KBs (96%) and 114 of 122 (93%) participating therapists through the six-month intervention. This is an indication of the interest and enthusiasm that was generated for this KB process.

A before-after research design does not provide a concurrent control group for comparison. However, the tools we evaluated have been published and available to service providers for several years through traditional dissemination methods (journal articles, books, workshops, and the internet), and they are still not routinely being used in clinical practice. We therefore felt that we had a stable baseline from which to make a comparison over time with each site acting as its own control.

The sample size for this study was estimated based on change on the 10-point Likert scale of the survey questionnaire. To facilitate clinical interpretation of the scale and because the data were not normally distributed, the 10-point scale was collapsed into three categories. The lack of precision in some of our odds ratio estimates may have been limited by our sample size.

There is a need for reliable and valid outcome measures to evaluate the impact of KT interventions and to identify and document supports and barriers to implementation. The primary outcome measure in this study was a survey questionnaire used to evaluate PTs' self-reported knowledge of and use of four specific measurement tools. Self-report measures can lead to an over-reporting bias [39]. It would have been useful to validate the reported use in our study through a chart audit. Barwick et al. [26] found no difference in reported use of measures between a community of practice group and a control group, but did find a difference in actual use in the community of practice group as measured through chart audit.

Ideally it would also be important to determine whether the observed changes in knowledge and use of the measurement tools impacted child and family outcomes. Through this study KBs and PTs identified an additional barrier that would be important to address prior to looking at the impact on child and family outcomes. They sometimes found it challenging to communicate the results from these measurement tools with families, particularly 'classifying children,' sharing prognostic information with families at a time when families were 'ready' to hear the information, and presenting results in a sensitive manner while supporting families to maintain hope. This information will be useful for developing further resources for therapists and families to help address this important barrier.

This multi-centre study showed that by providing modest financial remuneration (two hours/week for six months), ongoing resource materials, and personal and intranet support, a KB embedded within a clinical site was effective in increasing self-reported knowledge and use of specific evidence-based measurement tools. These reported changes were sustained at 12 months. Because the study provided many supports to the organizations, further research is warranted into understanding feasible, cost effective models for implementing a KB strategy to move other measures and evidence based information into clinical practice.

DJR is partially supported by research scholar awards from the Ontario Federation for Cerebral Palsy and the McMaster Child Health Research Institute, McMaster University.