Lost in Translation or Just Lost?
2008; Elsevier BV; Volume: 52; Issue: 5 Linguagem: Inglês
10.1016/j.annemergmed.2008.05.041
ISSN1097-6760
AutoresJoan Sargeant, Katrina Hurley, Jack Duffy, Ingrid Sketris, Doug Sinclair, James Ducharme,
Tópico(s)Clinical Reasoning and Diagnostic Skills
ResumoIn his recent pediatrics editorial,”Lost in Translation,”1Wears R.L. Lost in translation.Ann Emerg Med. 2008; 51: 78-79Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Robert Wears responds to 2 articles addressing the challenges of incorporating new evidence into clinical practice2Hurley K. Sargeant J. Duffy J. et al.Perceptual reasons for resistance to change in the emergency department use of holding chambers for children with asthma.Ann Emerg Med. 2008; 51: 70-77Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar, 3Wright S.W. Trott A. Lindsell C.J. et al.Evidence-based emergency medicine Creating a system to facilitate translation of evidence into standardized clinical practice: a preliminary report.Ann Emerg Med. 2008; 51: 80-86Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar and criticizes the recent research emphasis upon “knowledge translation.” As the authors of one of these articles,2Hurley K. Sargeant J. Duffy J. et al.Perceptual reasons for resistance to change in the emergency department use of holding chambers for children with asthma.Ann Emerg Med. 2008; 51: 70-77Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar we wish to respond to his critique and use it as an opportunity to increase understanding and continue dialogue about the role of knowledge translation.Wears suggests that knowledge translation disregards the “messiness of clinical work” and its influence upon the uptake of new knowledge, and instead uses a mentality of “scientific positivism” or “one size fits all” to inform change. In fact, the science of knowledge translation actually explores this messiness to better understand how specific factors help or hinder clinicians in making changes to practice. “At the clinical front, providers are caught in the gap between global evidence and local realities…”4Cochrane L.J. Olson C.A. Murray S. et al.Gaps between knowing and doing: understanding and assessing the barriers to optimal health care.JCEHP. 2007; 27: 94-102Google ScholarThe role of knowledge translation is to create better understanding of this gap and of clinicians' local realities so that new knowledge is practical and useful.How can we help clinicians practically within the context of their busy and “messy” work? A first step is to increase understanding of their clinical contexts, uncertainties related to the new evidence, and influences upon their decisionmaking regarding its adoption. Qualitative research can help here. For example, an ethnographic study of the adoption of evidence by groups of UK primary care clinicians found that, in reality, these physicians rarely accessed explicit evidence from research but instead relied on “mindlines” – “collectively reinforced, internalized tacit guidelines” informed predominantly by “…their own and colleagues' experiences, interactions with each other and opinion leaders…”5Gabbay J. le May A. Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care.BMJ. 2004; 329Crossref PubMed Scopus (670) Google ScholarPerhaps most helpful is to use a Canadian Institute of Health Research approach to knowledge translation, “integrated knowledge translation.”6Canadian Institutes of Health ResearchAbout knowledge translation: the knowledge translation portfolio.http://cihr-irsc.gc.ca/cgi-bin/print-imprimer.plGoogle Scholar The Canadian Institute of Health Research proposes this as a different way to do research in which researchers and research users work together to design the research process, conduct the research and synthesize results. The intent of this kind of research, known as action-oriented or collaborative research, is to actively involve those who will be using the results in the research process so that they are co-owners of the new knowledge. By engaging clinicians throughout the knowledge translation process, ie, in identifying new evidence relevant to practice, exploring factors influencing their adoption of that evidence, and developing strategies to address these factors, they will “own” the new knowledge. It will not be something that researchers are “doing to them.” For example, in the study reported by Hurley et al,2Hurley K. Sargeant J. Duffy J. et al.Perceptual reasons for resistance to change in the emergency department use of holding chambers for children with asthma.Ann Emerg Med. 2008; 51: 70-77Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar 3 investigators (KH, DS, JD) were active emergency physicians; KH was also a clinician scientist.In summary, knowledge translation remains a new, complex and poorly understood field. Yet figuring it out, customizing it for the setting and using it are critical to prevent the loss of new evidence that has the potential to improve health outcomes. Continuing to discuss and debate it, and engaging clinicians in the discussion and the research, are 2 approaches that can aid its progress. In his recent pediatrics editorial,”Lost in Translation,”1Wears R.L. Lost in translation.Ann Emerg Med. 2008; 51: 78-79Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Robert Wears responds to 2 articles addressing the challenges of incorporating new evidence into clinical practice2Hurley K. Sargeant J. Duffy J. et al.Perceptual reasons for resistance to change in the emergency department use of holding chambers for children with asthma.Ann Emerg Med. 2008; 51: 70-77Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar, 3Wright S.W. Trott A. Lindsell C.J. et al.Evidence-based emergency medicine Creating a system to facilitate translation of evidence into standardized clinical practice: a preliminary report.Ann Emerg Med. 2008; 51: 80-86Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar and criticizes the recent research emphasis upon “knowledge translation.” As the authors of one of these articles,2Hurley K. Sargeant J. Duffy J. et al.Perceptual reasons for resistance to change in the emergency department use of holding chambers for children with asthma.Ann Emerg Med. 2008; 51: 70-77Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar we wish to respond to his critique and use it as an opportunity to increase understanding and continue dialogue about the role of knowledge translation. Wears suggests that knowledge translation disregards the “messiness of clinical work” and its influence upon the uptake of new knowledge, and instead uses a mentality of “scientific positivism” or “one size fits all” to inform change. In fact, the science of knowledge translation actually explores this messiness to better understand how specific factors help or hinder clinicians in making changes to practice. “At the clinical front, providers are caught in the gap between global evidence and local realities…”4Cochrane L.J. Olson C.A. Murray S. et al.Gaps between knowing and doing: understanding and assessing the barriers to optimal health care.JCEHP. 2007; 27: 94-102Google Scholar The role of knowledge translation is to create better understanding of this gap and of clinicians' local realities so that new knowledge is practical and useful. How can we help clinicians practically within the context of their busy and “messy” work? A first step is to increase understanding of their clinical contexts, uncertainties related to the new evidence, and influences upon their decisionmaking regarding its adoption. Qualitative research can help here. For example, an ethnographic study of the adoption of evidence by groups of UK primary care clinicians found that, in reality, these physicians rarely accessed explicit evidence from research but instead relied on “mindlines” – “collectively reinforced, internalized tacit guidelines” informed predominantly by “…their own and colleagues' experiences, interactions with each other and opinion leaders…”5Gabbay J. le May A. Evidence based guidelines or collectively constructed “mindlines?” Ethnographic study of knowledge management in primary care.BMJ. 2004; 329Crossref PubMed Scopus (670) Google Scholar Perhaps most helpful is to use a Canadian Institute of Health Research approach to knowledge translation, “integrated knowledge translation.”6Canadian Institutes of Health ResearchAbout knowledge translation: the knowledge translation portfolio.http://cihr-irsc.gc.ca/cgi-bin/print-imprimer.plGoogle Scholar The Canadian Institute of Health Research proposes this as a different way to do research in which researchers and research users work together to design the research process, conduct the research and synthesize results. The intent of this kind of research, known as action-oriented or collaborative research, is to actively involve those who will be using the results in the research process so that they are co-owners of the new knowledge. By engaging clinicians throughout the knowledge translation process, ie, in identifying new evidence relevant to practice, exploring factors influencing their adoption of that evidence, and developing strategies to address these factors, they will “own” the new knowledge. It will not be something that researchers are “doing to them.” For example, in the study reported by Hurley et al,2Hurley K. Sargeant J. Duffy J. et al.Perceptual reasons for resistance to change in the emergency department use of holding chambers for children with asthma.Ann Emerg Med. 2008; 51: 70-77Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar 3 investigators (KH, DS, JD) were active emergency physicians; KH was also a clinician scientist. In summary, knowledge translation remains a new, complex and poorly understood field. Yet figuring it out, customizing it for the setting and using it are critical to prevent the loss of new evidence that has the potential to improve health outcomes. Continuing to discuss and debate it, and engaging clinicians in the discussion and the research, are 2 approaches that can aid its progress. Lost in TranslationAnnals of Emergency MedicineVol. 51Issue 1PreviewSEE RELATED ARTICLES, P. 70 and 80. Full-Text PDF In replyAnnals of Emergency MedicineVol. 52Issue 5PreviewHurley et al have contributed thoughtfully to this discussion in their letter,1 and I think our areas of agreement are greater than our differences. We certainly agree on the goals and role of knowledge translation, and also on the value of qualitative, ethnographic, or cognitive engineering approaches to the problem. (Just imagine what knowledge translation would be like if it were dominated by ethnographers and cognitive engineers, rather than by epidemiologists and MPHs). And, we agree that to the extent knowledge translation helps clinicians reduce the gap between global evidence and their local realities, it does good. Full-Text PDF
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