Version 2 © Russell, D., Rivard, L., Walter, S., Rosenbaum, P, Bartlett, D., Cameron, D., Roxborough, L., Darrah, J., & Hanna, S., 2009

Moving Motor Growth Research Into Clinical Practice: Do Knowledge Brokers Make A Difference?

The Knowledge Broker Study Has Been A Great Success!

The Knowledge Broker Study is now finished and we are excited to share the results with you. Twenty-five knowledge brokers (KBs) and 122 physical therapists (PTs) from 28 pediatric organizations in Ontario, Alberta and British Columbia provided us with very important information about the experience of having a KB at their sites and we have discovered some interesting results. We would like to take this opportunity to share with you what we have learned and outline our next steps.

What Is Knowledge Brokering?

Knowledge brokering is the process of “bringing people together, to help them build relationships, uncover needs, and share ideas and evidence that will let them do their jobs better. It is the human force that makes knowledge transfer (the movement of knowledge from one place or group of people to another) more effective” (CHRSF newsletter, 2003). KBs have been described in the literature as having strong skills in research, facilitation, and problem solving. In our study, we placed particular emphasis on the role of the KB in applying research. This differs somewhat from the role traditionally described in the literature which also includes a focus on the KBs’ skills in research appraisal and synthesis.

Why Did We Do This Study?

We know from the literature that research evidence is not always used in clinical practice. Different Knowledge Translation (KT) strategies for moving evidence into practice, such as publications, presentations, distribution of educational materials, tailored messaging, and audit and feedback, have been tried with varying success. One promising strategy that has been suggested is the use of a ‘local champion’ or Knowledge Broker (KB). However, little is known about the effectiveness of a KB or even the kind of activities that a broker should undertake. 

What Did We Want To Know?

We were interested in answering several questions:

1. Would having a KB (as part of a 6 month multifaceted KT intervention) have an impact on physiotherapists’ (PT) knowledge and use of a group of evidencebased measures of gross motor function (the “motor measures”, see Fig. 1 ) for children with cerebral palsy (CP)?
2. Would the brokering intervention be modified or mediated by factors such as regional differences or organizational support?
3. What do KBs, PTs and administrators think about the utility of the KB role, and the brokering process?
4. What types of activities do brokers undertake during the active brokering intervention? 

Figure 1: Parents’ questions and ways the motor measures can help answer these... 

1 GMFCS: Gross Motor Function Classification System

2 GMFM: Gross Motor Function Measure

How Did We Begin?

The KB Study began in May 2006 with the recruitment of 25 physiotherapist KBs from 28 pediatric rehabilitation organizations in Ontario (East), Alberta and British Columbia (West) (three KBs brokered to regional sites in addition to their own organizations). We also recruited 122 physiotherapists and 27 administrators. One year following the active brokering intervention, 24 (96%) KBs, 95 (78%) PTs, and 24 (86%) administrators continued to be involved in the study - a key measure of the success of the project!

What Was Done?

• KBs attended an initial workshop to encourage networking with each other and learn about their role.
• KBs were given interactive training materials and evidence-based resources regarding the motor measures.
• 
  KBs identified potential supports and barriers at their organizations for moving these evidencebased measures into practice and discussed ways to address challenges and build upon the strengths of their organizations.
• 
  KBs actively brokered to participating physiotherapists at their centres for six months, tailoring their information to meet the needs of their colleagues.
• 
  KBs participated in three teleconferences with other KBs and the study team to share strategies, successes and challenges.
• 
  KBs had access to the study team, the study coordinator (acting as a “broker to the brokers”), additional electronic resources (PowerPoint presentations, journal articles) and an intranet site for ongoing dialogue and sharing resources.

What Did We Measure?

KBs and PTs completed online surveys about their knowledge and use of the motor measures at each of four time points: prior to and immediately following the intervention, as well as 6 and 12 months post-intervention. Analysis of these data allowed us to look at the effect of the intervention over time and to explore possible mediators and regional differences.

All of the KBs, one randomly chosen PT from each site, and site administrators participated in telephone interviews immediately following the intervention and one year later, where they provided feedback about their perceptions of the KB role. Using a thematic analysis approach, major themes were identified and then verified through member checking. KBs also completed weekly log books describing the activities they carried out during the brokering.

What Did The Online Surveys Tell Us About Change In Practice?

• PT attitudes towards use of measures were high at baseline
• PT knowledge of all measures increased at six months and was maintained one year later
• PT use of the measures increased following the intervention (see Fig. 2 for an example) and the effect remained one year later, with the exception of one measure (the GMFM-88)
• Both regions (East/West) showed significant increases, even though PTs in the East had higher familiarity and use at baseline
• Organizations with a strong research culture and supervisor expectation for use of measures had a significant impact on therapists’ use of the GMFCS but not the other motor measures 

Figure 2: Change in use of GMFM-66 by PTs 

What Did The Interviews Tell Us About the Experience of Being Involved? 

What Did The Log Books Tell Us About The Brokering Process?

•  KBs brokered, on average, 2 hours per week, and the type and format of activities varied substantially across KBs and during different phases of brokering.
• Examples of brokering activities include: formal education sessions, facilitation of small group problem-solving discussions, one-on-one review of clinical cases, preparation of resource binders, development of educational flyers, use of the intranet site to network with KBs and researchers, discussions with administrators, and liaison with technology support.
• All on-site KBs brokered directly (face-to-face) with their colleagues at least once per month, ranging to as many as 10 times per month. Regional KBs maintained regular contact indirectly via phone or e-mail.
• The frequency of direct contact was higher overall than indirect contact but indirect methods were still well used, ranging from one to eight times per month. When brokering to regional sites, the use of indirect contact was higher than direct.
• All KBs interacted “one-on-one” with PTs, with a range from one to six times per month. 
• KBs also brokered to PTs in groups, brokering slightly less often than to individuals, ranging from two occasions to approximately four times per month.
• In addition to brokering to PTs within the study, all KBs brokered to individuals outside of the study (such as occupational therapists, speech language pathologists, pediatricians, orthotists, recreation staff, social workers, board members, executive directors, and students) on at least two occasions.

What Do These Results Mean? 

• The KB strategy was effective in increasing knowledge and use of evidence-based measures following an intervention of two hours per week over a six-month period.
• There was a lot of enthusiasm for the KB role from KBs, therapists, and administrators.
• Our KB model emphasized the application of research where the evidence had been synthesized and packaged. A greater resource commitment would be necessary when substantial research gathering, appraisal and synthesis are required or when evidence is less well established.
• The intervention was effective across regions in which there were differences in baseline knowledge indicating that the KB strategy was effective for therapists at different points along the knowledge/use continuum.
• There is no “one size fits all” method of brokering. It is important for KBs to assess varied needs and develop workable strategies and brokering activities to meet those needs.
• The KB role may work best within a community of practice and when supported by the organization.
• Important KB characteristics include: enthusiasm, flexibility, and willingness to adapt. Facilitation skills and context knowledge are also important.

Why Are The Results From This Study Important?

• This is the first study demonstrating the effectiveness of the KB strategy in this clinical context. 
• Information gathered from this study increases our understanding of the utility of the KB strategy and helps to highlight elements that may be critical to the success of the role.
• Common barriers to and strategies for communicating the results of the motor measures with families were identified. 

What's Next? 

Moving forward, it will be important to:

• Continue to engage clinicians, administrators, and other key stakeholders to problem-solve issues related to the implementation of the KB role more broadly
• Replicate this research using the KB model with other evidence-based materials
• Investigate the costeffectiveness of the KB role and the impact of this strategy on service delivery and health outcomes
• Develop educational materials to support therapists’ ability to share the results from measures, including prognostic information, with families