Section 3.1: The Action Cycle
Sharon E. Straus, MD, MSc, FRCPC
Eman Leung, PhD
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
- For example,
- 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
- Examples of qualitative evaluation methodology:
- 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?
- To develop a sustainability action plan for changing the prescription practices of antibiotics, needs to consider the following:
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