Understanding context in knowledge translation: a concept analysis study protocol

Background

Healthcare professionals’ use of research evidence in clinical practice is suboptimal. A seminal study conducted in the USA showed that patients, on average, received just 55% of care recommended by research evidence and that the quality of this care varied vastly by medical condition, from 11% (for alcohol dependence)–79% (for senile cataracts) (McGlynn et al. 2003). Similar findings are reported globally (Grol 2001) resulting in considerable interest in healthcare professionals’ research use in clinical practice. In several studies, researchers have identified the need to assess the context where implementation is to occur to improve research use in clinical practice (Glaser et al. 1983, Backer 1991, Rich & Oh 1994, Landry et al. 2001, Greenhalgh et al. 2004, Mitton et al. 2007, Kimberley & Cook 2008, Dogherty et al. 2010, Squires et al. 2011a,b,c).

While consensus exists on the importance of context, there is lack of agreement on what comprises context. It is unclear what is meant by ‘context’ or even if authors are referring to the same concept when they refer to context. For example, Ovretveit (2011) defines context broadly as all factors that are not part of the intervention. May et al. (2007) adopt a more specific definition: ‘the physical, organizational, institutional and legislative structures that enable and constrain and resource and realize, people and procedures’. French (2005) define context as ‘the organizational environment of healthcare, composed of physical, social, political and economic influences on the practical reasoning and choices of practitioners about how clinical issues are addressed’ (p. 174), while Rycroft-Malone (2004) defines it as ‘the environment or setting in which the proposed change is to be implemented’ (p.299).

In addition to multiple definitions, context has been examined in knowledge translation research from a variety of perspectives including syntheses on the determinants of innovation adoption (Fleuren et al. 2004, Greenhalgh et al. 2004, Berta et al. 2005), the role of context in quality improvement (Kaplan et al. 2010), context features associated with research utilization (Estabrooks 2003, Meijers et al. 2006, Hutchinson et al. 2010); as well as its role in knowledge translation frameworks (e.g. Kitson et al. 1998, Damschroder et al. 2009, Kitson et al. 2008, Ward et al. 2012) and in the development of instruments to measure context (e.g. (French et al. 2009, Estabrooks et al. 2009, McCormack et al. 2009, Helfrich et al. 2009, Brennan et al. 2012). While each of these reports suggests that context probably influences healthcare professionals’ use of research and there is some agreement across them with respect to some domains of context, there is also considerable disagreement across them on what context is (i.e. a definition) and what domains and features of context are important to assess in studies that aim to increase healthcare professionals’ research use in clinical practice. Context will often vary by setting; however, a core set of domains of context that is important to nurses’ and other healthcare professionals’ use of research in clinical practice may exist. While each domain may be more or less important in different settings and professional groups, they should, at minimum, be assessed prior to designing and implementing knowledge translation activities to determine their potential for influencing healthcare professionals’ use of research in that clinical setting. This first requires that we be able to define context and determine what this core set of domains of context (and their features) might be.

It is also unclear from the literature whether authors are identifying conceptually distinct constructs of context or similar constructs but using different terms. As a result, a concept analysis of what comprises context is needed. For example, Greenhalgh et al. (2004) in a review of innovations in service organizations (including clinical practice settings such as hospitals) identified structural (organizational size, functional differentiation, slack resources, specialization) and non-structural (culture, climate, leadership, power balances, social relations, attitudes to risk taking) aspects of organizations as important context features. More recently, two systematic reviews examined context features associated with nurses’ and all healthcare professionals’ use of research in clinical practice. Hutchinson et al. (2010), in a synthesis of 89 publications across multiple health professionals, identified four groups of context factors: cultural, structural, physical and social. Meijers et al. (2006), in a synthesis of 10 studies in nursing, identified six context features: role, access to resources, organizational climate, support, education and time to participate in research. Some of these ‘context’ features (e.g. role, education) are also identified as individual (not context) features important to knowledge translation in other nursing reviews (Estabrooks et al. 2003, Squires et al. 2011c). Thus, while there is considerable agreement that context has an important influence on the use of research evidence by healthcare professionals in clinical practice, there is little agreement as to: (i) what comprises context or an accepted definition of it; (ii) the domains of context and the features that play a role in facilitating or hindering research use by healthcare professionals and thus; (iii) the domains of context and the features that should be assessed prior to developing and implementing activities to improve healthcare professionals’ use of research evidence in clinical practice.

Aim

The aim of this study is to conduct a concept analysis of clinical practice contexts (work environments) that facilitate or militate against the uptake of research evidence by healthcare professionals in clinical practice. This will involve developing a clear definition of context by describing its features, domains and defining characteristics.

Design

We will conduct a concept analysis. ‘Concept analysis is a formal, rigorous process by which a concept is explored, clarified, validated, defined and differentiated from similar concepts to inform theory development’ (Xyrichis & Ream 2008, p. 233). We will use the Walker and Avant (2005) concept analysis method, which is based on the Wilsonian original concept analysis method (Wilson 1963, Avant 2000). The Walker and Avant method was chosen because it has been successfully used to explore a variety of concepts in nursing and other healthcare professional disciplines (e.g. Holmstrom & Roing 2010, Hansen 2006, Cianelli et al. 2003, Ream & Richardson 1996, Wiseman 1996, Montes-Sandoval 1999, Dennis 2003). It is also regarded as the most influential concept analysis model in nursing science (Nuopponen 2010).

For Walker and Avant, concept analysis is a concept development method that is a critical element in theory development. Concept analysis for them is ‘a process of determining the likeness and unlikeness between concepts’ and its ‘basic purpose is to distinguish between the defining attributes of a concept and its irrelevant attributes’ (Walker & Avant 2005). The eight steps of the Walker and Avant concept analysis method are described next.

The Walker and Avant concept analysis method

Search methods

We will develop search strategies in an iterative manner. Initially, we will examine indexing and unique key terms associated with known, relevant discussions of the topic (e.g. Greenhalgh et al. 2004, Greenhalgh & Peacock 2005, May et al. 2007, Hutchinson et al. 2010, Kaplan et al. 2010) and develop a strategy based on these terms. Results from this strategy will be screened and search terms reconsidered based on citations selected for inclusion. Using the knowledge gained from this exercise, we will remove and add search terms, conduct a second search and repeat the screening process. This method is used in systematic reviews for the Cochrane Effective Practice and Organisation of Care (EPOC) Group and is a successful method for developing vocabulary for emerging and heterogeneous concepts.

Due to the interdisciplinary and heterogeneous nature of our topic, we will search biomedical and social science databases; we will search for dissertations and theses in an effort to identify research not yet in journal publications; we will also search for books. We will search grey literature, primarily by exploring the publications of government health departments, organizations involved in quality improvement, knowledge translation, or health policy development. We will search the Cochrane Database of Systematic Reviews, with a focus on reviews by the Effective Practice and Organisation of Care Group, the reviews of which focus on organizational and health professional-directed interventions.

We will also: seek out input from researchers whose work we encounter as we scan the literature; scan the reference lists of relevant articles and reports; scan individual issues of journals should we discover issues with a focus on our topic; and conduct searches for authors working in our topic area.

All search methods, strategies and sources will be reported comprehensively in our final report. Search strategies will be replicable.

Database list

Inclusion/exclusion criteria

Screening

Screening and searching will occur concurrently. Full-text copies of all potentially relevant articles will be retrieved and independently assessed for inclusion by two team members. Disagreements will be resolved through consensus; when necessary, a third team member will act as an arbitrator and make the final decision.

Data extraction and synthesis

Extracted data will include, but not be limited to: the definition of context, the key domains (and their features) of context, setting, population and data needed for the 8-step concept analysis methods previously described. A detailed comparison of all context theories/frameworks/models will be conducted. Articles will be summarized and coded by two team members independently. Quality assessment on individual publications will not be conducted as we are not extracting data on the ‘findings’ from the studies. We are interested in the concept of context – how it is defined and its domains and their features. Our goal is to create a definition and framework of domains (and their features) of context that influence healthcare professionals’ use of research evidence in clinical practice from the perspective of researchers.

Ethical considerations

This study is a concept analysis that will use secondary publically available data from primary research studies and therefore Research Ethics Committee approval is not necessary. All team members will be required to make an explicit declaration of conflict of interest with any of the studies included or excluded from the concept analysis.

Validity and rigour

Challenges

Rather than limitations, this study has challenges. A core challenge to this concept analysis is the potential complexity in the concept and the extent and diversity in the use of the term ‘context’ in the published literature. A second limitation is that our a priori scoping indicated that existing health theories insufficiently address context. Therefore, we will also need to draw on theoretical literature from the organizational field that describes theories, frameworks and/or models where context is a component. This will significantly increase the amount of literature to be analysed. Finally, as the concept of ‘context’ is evolving at a relatively fast pace, its empirical referents will be subject to change, making it challenging to identify a core set of measures of the domains of context.