Closing the gap: applying the Theoretical Domains Framework to improve knowledge translation

Abstract

Knowledge translation is defined as the ''synthesis, dissemination, exchange and ethically-sound application of knowledge to improve the health of Canadians…''. 1 The lag between the conduct of clinical research and its realization into practice is a vexing problem for health researchers worldwide. 2,3 A knowledge translation time lag of 17 years has often been quoted in the literature, and even then, implementation has ranged from 11-79% of recommended care. 2,3 The past decade has seen an intense interest in knowledge translation and implementation science to address the gap between knowledge and practice more effectively, including identifying the barriers and enablers to implementation. 1-5 With respect to the practice of anesthesiology, the adverse outcomes of inadvertent perioperative hypothermia (IPH) are well known. Yet, despite published guidelines and the wide availability of effective patient warming modalities, the prevalence of IPH remains problematically high. 6 The reasons for the gap between evidence and implementation are poorly understood, particularly as they apply to the practices of anesthesiologists. In their study, Boet et al. 6 interviewed 15 anesthesiologists using the Theoretical Domains Framework (TDF) as a guide in order to understand those factors that promote or hinder anesthesiologists' perioperative temperature management. The authors discovered nine relevant theoretical domains, including those pertaining to uncertainty about the impact on patient outcomes and individual performance, lack of clarity about the guidelines, and the organizational or social environment. The authors make specific recommendations for interventional strategies based on these findings. This study is noteworthy for several reasons. First, it addresses an often overlooked aspect of anesthesia care wherein relatively simple interventions may result in significantly positive impacts on perioperative and economic outcomes. The authors found that the lack of feedback on temperature regulation practices and patient outcomes was an important barrier to effective implementation of the guidelines. Based on this, the authors recommend the development of a comprehensive formal audit and feedback process to improve practices. Interestingly, their finding is in keeping with a recent study by Görges et al. 7 in which pediatric spine anesthesiologists were provided with both individual and team feedback regarding the time delay from the start of the case to the first temperature monitoring. The provision of intraoperative thermoregulation data resulted in a significant and sustained reduction in the time delays for temperature monitoring at the individual and team levels, which underlines the importance of providing feedback for consistency of practice. Second, this study illustrates the usefulness of qualitative methods in clinical research to probe for barriers and enablers to the implementation of practice guidelines. Typically, quantitative methodologies are characterized by deductive testing of pre-set hypotheses in controlled settings and use large sample sizes to be able to generalize the findings. On the other hand, qualitative methodologies focus on inductively exploring complex phenomena in their real-life settings-where there is often little preexisting knowledge-in order to understand and explain social processes and behaviours. 8,9 Because anesthesiologists have an important role in intraoperative temperature regulation, the use of qualitative methods is