Managing KnowledgeKinta Beaver

Professor of Cancer NursingSchool of Health

University of Central Lancashirekbeaver@uclan.ac.uk

How do we manage knowledge?

Health CareGenerate (research), share, disseminate, apply

Evidence based practice = effective and efficient health care

• Generate Knowledge

• Knowledge Transfer• Exchange, interaction, dissemination

• Knowledge Implementation• Move evidence into practice

Where do we get our evidence?

• Historical approach – go to library

Books and Journals Write a letter !!

Where do we get our evidence in 2013?

British Medical Journal

• Weekly journal !• A million ‘visitors’ a month• 30 associated journals• BMJ’s website has articles going back to 1840

Dr Eager on Fever

Influence of Climate on Consumption

Dr Fife on a Case of Jaundice

Death from Brandy and Salt

Information Overload

Knowledge Implementation

• Does change happen as a result of having knowledge/evidence?

• Is it about more than just the evidence?

Promoting Action on Research Implementation in Health Services (PARIHS) Framework

• The level and nature of the evidence

• The environment in which research is to be placed

• The way in which the process is facilitated

Kitson A et al. (1998). Enabling the implementation of evidence based practice: a conceptual framework. Quality in Health Care. 7:149-158

Rycroft-Malone J et al (2002). Ingredients for change: revisiting a conceptual framework. Quality and Safety in Health Care. 11:174-180

Mindlines

• Ethnographic study of GP practices

• GP’s used mindlines rather than guidelines to inform decision making

Mindlines• Tacit knowledge (difficult to relay)• Based on experience and beliefs • Habits and rituals • Emotional content• E.g. Riding a bicycle (you know how to do it

but what if you had to write down how to do it?)

Knowledge Change

Research EvidenceEnvironment/context

Facilitating factorsMindlines

1991 - 1995

• Breast cancer• Women had specific information needs • Outpatient appointments with drs after

treatment not meeting needs• Need new approaches to follow-up • Should fully inform women• Specialist nurses should provide information

Was this evidence well received ?

• Off to a slow start• ‘Tip them over the edge’• Mindlines – paternalistic attitude prevailed,

something will be missed if not seen by dr in OPD

• Environment not ready?

Environment

• Fewer specialist nurses• Nurse-led clinics were a novelty• No policy focus on information provision• No change in practice• Historical practice continued

Time to pause for thought What do we know?• OPD not meeting needs• Breast care nurses were an excellent source of

specialist information • Local recurrences rarely detected in asymptomatic

women at outpatient visits by clinical examination

The Plan in 1997

• Specialist nurses provide follow-up care• Telephone people at home• No need for clinical examination• Routine mammograms to proceed • Aim to meet information needs not search for

recurrence• RCT (Hospital vs Telephone) to show this was

effective

Was the environment ready now?

RUN !

Why?

• Mostly a lack of interest (no body of evidence)• Something would be missed (mindline)• Specialist nurse roles still under-developed

(but there was progress) • Found one hospital and 2 breast care nurses

prepared to ADD ON telephone follow-up• No RCT (yet)

Pilot Study (1997 – 2000)

• Telephone follow up by specialist nurses –was it acceptable and feasible?

• Involve clinicians in development of intervention (knowledge exchange, knowledge sharing, understand environment and mindlines)

• Demonstrated that it could work in practice• Still some scepticism• Was telephoning people ‘real work’?• Credibility (mindline)

2002• More people surviving cancer – OPD busy & not economically

sustainable• More nurse specialist posts• More nurse-led clinics• Surgeons and oncologists prepared to randomise women to

hospital or telephone follow-up• Breast care nurses keen to be involved in follow-up service

delivery• Call for new approaches • Environment changing• Mindlines changing

Comparing hospital and telephone follow-up after treatment for breast

cancer

Did practice change?

Added to body of knowledge

Part of the bigger picture

Environment (Policy context)

“The aim of the NCSI is to ensure that those living with and beyond cancer get the care and support they need to lead as healthy and active a life as possible, for as long as possible.”

2010

NCSI

• Current follow-up arrangements not meeting needs of survivors

• Patients want more information and advice

• Shift towards information provision

• Need new approaches to follow-up

Facilitators

• Clinical champions• Strong leadership from experienced BCNs

(respected and valued members of team)• Strong multidisciplinary team working• Working together (academics and clinicians)

Managing new knowledge

• Long journey to implementation (evidence, environment, facilitators, mindlines)

• What happens when we have implementation but then gain new evidence?

• Knowledge is evolving – dynamic, not static

Breast Screening

1986Breast Cancer Screening: Report to the Health Ministers of England, Wales, Scotland and Northern Ireland By a Working Group chaired by Professor Sir Patrick Forrest

“The information that is already available from the principal overseas studies demonstrates that screening by mammography can lead to the prolongation of the lives of women aged 50 and over with breast cancer. There is a convincing case, on clinical grounds, for a change in UK policy on the provision of mammographic facilities and the screening of symptomless women”

Professor Michael Baum

• Breast specialist surgeon• In 1987 commissioned by DOH to set up first

screening unit• Strong supporter of breast screening

Breast Screening

The illusions and disillusions of breast screening

“We are using state of the art imaging and modern therapy to service a programme based on data that is 20 years old”

New Knowledge8 Trials. 600,000 women

“For every 2000 women invited for screening throughout 10 years, one will have her life prolonged and 10 healthy women, who would not have been diagnosed if there had not been screening, will be treated unnecessarily. Furthermore, more than 200 women will experience important psychological distress for many months because of false positive findings. It is thus not clear whether screening does more good than harm.”

Will we abandon breast screening?

• Political suicide?• Environment and Mindlines• Early detection is a good thing• If in doubt cut it out• At its simplest level breast screening saves

lives• BUT it is not simple – it is complex

Hang in there !

• Consider environment, facilitators and mindlines

• Be receptive to change• Be open to new ideas and possibilities• Keep up with new knowledge (somehow !)• Maintain enthusiasm• Real people at the heart of what we do

What about unknown knowns?“It ain’t what you know that gets you into trouble. It’s what you know for sure that just ain’t so” Mark Twain