Sharon E. Straus, MD, MSc, FRCPC
Eman Leung, PhD

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The Action Cycle

  • The action cycle is the process by which knowledge is implemented
  • The “Action Cycle” represents phases of activities that, according to planned-action theories, are needed for knowledge applications to achieve a deliberately engineered change in groups that vary in size and setting

The 7 Phases of the Action Cycle

1. Identifying the Knowledge-To-Action Gaps

  • Identification of the knowledge-to-action gaps (knowledge needs) is the starting point of knowledge implementation
  • This process should involve rigorous methods and engage relevant stakeholders
  • Strategies for needs assessments depend on the

    • purpose of the assessment
    • the type of data
    • available resources
    • whether the needs are subjectively or objectively measured
  • Needs assessments can occur from the perspective of the

    • population
    • organization
    • health care provider
  • Examples:

    • Reducing antibiotic prescription in the community by the prudent use of antibiotics is seen as one way to slow the rise in antibiotic resistance and appears safe
    • However, our understanding of HOW best to achieve this is limited

2. Adapting Knowledge to Local Context

  • Any knowledge must be adapted to local settings to ensure it is relevant and feasible
  • For example, although guidelines provide evidence in a more usable form for practitioners and health settings than a plethora of primary studies, the adaptation of the guideline to the context of use is a necessary step

    • Customizing a clinical practice guideline for a particular organization may help improve acceptance and adherence
  • Example:

    • In the contemporary West (where absolute rates of complications are lower) the number needed to treat to benefit will rise above a rate at which it might be regarded as worthwhile to treat, and thus the guideline suggests that antibiotic should not be prescribed to healthy adults
    • However, in low-income countries where the absolute rate of complications may be much higher, the lower number needed to treat to benefit will mean antibiotics are more likely to be effective
    • Hence the previous guideline of prescribing antibiotic will need to be adapted to the low-income community

3. Assessing Barriers/Facilitators to Knowledge Use

  • Methods to access barriers and facilitators to knowledge use include:

    • The Delphi procedure (to achieve consensus among a panel of experts)
    • Qualitative approaches such as focus groups, interviews, and questionnaires
    • Statistical analysis on observational dataset by regressing potential determinants of variation in health care delivery
    • Statistical analysis of multiple studies concerning guideline implementation to determine factors that account for the heterogeneity of effects across studies
  • Examples:

    • Lack of awareness
    • Current (habitual) practices

4. Selecting, Tailoring, Implementing Interventions

  • Knowledge translation interventions need to be tailored to specific barriers for change, similar to a clinical treatment that is tailored to a diagnosed health problem
  • Knowledge translation interventions can target different stakeholders:

    • Health Care Professionals: e.g. interventions that bring information close to the point of decision making (such as reminders and decision support)
    • Patients: e.g. interventions that target health literacy or self-care
    • Organizations: e.g. interventions such as quality management, organizational evidence-based practice guidelines
  • KT interventions should be tailored to the barrier to knowledge use on a theory-driven basis.

    • For example,

      • Barriers for change: difficulty in acquiring the information
      • Theory: Cognitive theory on learning
  • Examples:

    • Barrier to knowledge use: Lack of awareness
    • Evidence-based intervention: Printed educational material and reminders are not effective in capturing care-providers’ attention in their busy daily routine

      • Interactive educational meetings that invite physicians to actively participate in their learning in an educational setting are effective (Arnold & Straus, 2005)
    • Barrier to knowledge use: Prescribing habit
    • Evidence-based intervention: Make small changes, DELAY, not abolish antibiotic prescriptions (Arnold & Straus, 2005)

5. Monitoring Knowledge Use

  • Knowledge use can be:

    • Conceptual: to change the levels of knowledge, understanding and attitudes
    • Instrumental: to change behavior or practice
    • Persuasive: to use knowledge as ammunition in the attainment of power or profit
  • Knowledge can be translated in a usable form, such as care pathway, and used in making specific decisions
  • Knowledge use could be monitored by observing the frequency of how often such a decision is made
  • Example

    • Changes in antibiotic prescription practices could be monitored through electronic/sticker tracking

6. Evaluating Outcomes

  • Strategies for evaluating knowledge implementation should use explicit, rigorous methods and should consider both qualitative and quantitative methodologies:

    • Examples of qualitative evaluation methodology:

      • interviews, surveys, focus groups
    • Examples of quantitative evaluation methodology:

      • Randomised trials, interrupted time series
  • Because the evaluation of outcome is a lengthy and resource-consuming task, attention is also paid to the resource under which knowledge is being implemented and the activities that bring about knowledge use
  • Examples:

    • Structural measures: Resource available for interactive educational meeting on optimal practice of prescription
    • Process measures: Antibiotic prescription
    • Outcome measures: Complications, reduced antibiotic-resistant pathogen in local testing hospital

7. Sustaining Knowledge Use

  • The sustenance of knowledge use refers to the continued implementation of evidence over time
  • The consideration of sustainability should occur early in the process and include the discussion of:

    • Budgetary Resources
    • Human Resources
    • Health Care System
  • Example:

    • To develop a sustainability action plan for changing the prescription practices of antibiotics, needs to consider the following:

      • How relevant is the issue of antibiotic over-prescription?
      • What is the benefit of implementing strategies that change practice in antibiotic prescription?
      • What are the attitudes of physicians, patients and other relevant stakeholders toward the issue of antibiotic over-prescription?
      • What is the nature of the team/group which can be engaged to facilitate the sustainability of strategies that may lead to optimal prescription practices?
      • Are there champions of change among the senior management?
      • How will the new prescription practice fit with the existing policy?
      • What funding is required, and can cost-effective strategy be used?