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THE ROLE OF KNOWLEDGE TRANSLATION IN A CLINICAL SETTING: FROM THEORETICAL KNOWLEDGE BASE TO PRACTICAL SKILLS

Abstract

Lots of literatures have indicated that there is an existence of a widening theory-practice gap, especially based on many international journals of nursing. Since the transfer of nursing education to universities, however, there are limited sources of evidence proving a follow-up on the success of the translation of knowledge acquired into practical skills, and the available sources of evidence lack sufficient comprehensiveness. Much criticism has been received regarding the lack of application of evidence-based practice into clinical practice despite many governments’ expenditures on training nurses (Brundage et al., 2011). The purpose of this review is to critically analyse the role of knowledge translation in a clinical setting with particular attention to the transition of theoretical knowledge to practical skills. To achieve this objective, the research explores information presented by available literature a specific focus on theories of learning that aid knowledge acquisition (O’reilly & Mcnamara, 2007). The paper concludes that there is are limited incidences of applied knowledge to clinical practice as compared to the amount of knowledge offered in nursing learning institutions.

Introduction

Knowledge translation refers the ability of nursing or medical students to integrate the theoretical information offered in the classroom into practical clinical skills. Several research materials have been published bearing a wide coverage of new approaches towards clinical complications (Gera, 2012). Apparently, when such knowledge is incorporated into clinical practice, it is expected to create some positive change with a betterment in the patient outcomes. On the contrary, however, the literature shows that there is a low rate of integration of the knowledge acquired in the classroom into a clinical context, especially after the transfer of nursing learning into the university settings (Markowitsch et al., 2008). Nursing educators equip student nurses with theories on easier and more technologically advanced approaches towards disease eradication. As students proceed into a clinical context, however, the skills learned are either ignored, forgotten, or just assumed to be classwork staff that has no basis in the clinical context (Savory & Fortune, 2015). To address this controversial state of affairs, several learning models and theories have been developed cutting across all academic disciplines. The models devise mechanisms of acquiring knowledge from scratch into professionalism, and most of them are applicable in the medicine, clinical and nursing settings. Among the theories and models include behavioural, constructivist, and cognitive learning theories (Gustafsson & Borglin, 2013). Major attention, however, is accorded to the Dreyfus model of knowledge acquisition developed by Benner and Dreyfus in 1998. Such is a theory that explains the various stages involved in the acquisition of knowledge, especially in the clinical context, making it necessary for use in critically analysing knowledge translation in a clinical setting. Therefore, this paper aims at addressing the role of knowledge translation in a clinical context, critically considering the migration from a theoretical base to practical skills (Oborn et al., 2013).

Role of Knowledge Acquisition into the Clinical Context

Evidence-based practice is a term that has been devised in the recent years to refer to the application of nursing and clinical interventions suggested by researchers into actual clinical practice. Most of the evidence-based practices are actualised through pilot studies that involve thorough trails on higher organisms as research subjects (Nancarrow et al., 2014). The humans are used as the last option in the clinical trials of such probable practices after all other laboratory organisms used proved tolerance towards the intervention with no traces of toxicities, in particular among organisms with systems closely related to those of humans. When practical implemented, such interventions may turn out to be a solution to some of the biggest problems witnessed in nursing and medical practice. Evidence-base Practice is a product of the translation of knowledge acquired in learning institutions into practical skills within a clinical context (Razzaque & Karolak, 2010).

Consider, for example, the utilisation of bariatric surgery in the management of type 2 diabetes and its symptoms among patients that are extremely obese. Before its acceptance, the practice faced a lot of rejection and resistance, most of it based on the fear of the unknown among nurse practitioners and medical physicians. Indeed, its basis was entirely from evidenced-based materials from medical and scientific researchers with optimum success being achieved among various laboratory animals on which the approach was tried before its application on volunteer human beings (O’reilly & Mcnamara, 2007). Before its invention, there lacked efficient interventions suitable for managing type 2 diabetes occurring in combination with extreme obesity. In fact, most of the medications used for attempting the treatment plans produced extreme adverse effects, calling for an alternative treatment strategy. Bariatric surgery, a product of knowledge translation into clinical practice, came at the right time to salvage the situation with great successes being registered in the United States, Australia, the United Kingdom, and many other parts of the developed countries (Razzaque & Karolak, 2010).

Translating knowledge acquired from the classroom or published literature into clinical practice has its benefits and drawbacks. One of the most significant benefits of such knowledge, when applied in clinical practice, is the reduction in the cost of medication. Insurance companies, third party payers, and individual patients look for treatment strategies that are offered at affordable costs. On the realisation of this fact, scientists and advanced nursing practitioners engage in educational research to find out treatment plans that produce the best patient outcomes at the most affordable prices. Knowledge translation into clinical skills, therefore, is one way of addressing patient concerns regarding their expenditure on medical bills (Guzman, 2008).

Another advantage of using such knowledge in the clinical setting is the previous of better patient outcomes when compared to the existing methods of doing things in the clinical setting. Still looking at the bariatric surgery intervention, the patient outcomes initially remained wanting due to the development of complications brought about by the adverse reactions of the used medications (Ghosh & Scott, 2007). After the implementation of the evidence-based approach, there was an increased hope of returning to the normal conditions without a lifetime dependence on drugs that eventually cause complications resulting from adverse reactions. Apparently, knowledge acquired in the training institutions continues to equip the medical nursing fields with newer and better methods of managing chronic disease conditions (Savory & Fortune, 2015).

Such knowledge also increases the security and safety of patients, factors that promote the rate of recovery based on the comfort experienced with secure clinical settings. A good example is the implementation of the use of electronic health records in most of the healthcare facilities in the US and parts of the UK (Porcaro, 2011). Electronic health records improved the methods of patient data storage, enhancing their retrieval and improving confidentiality of patient information. This method of data storage with hospital facilities increased the convenience of patients because patients could access their laboratory results among other important information concerning their health conditions at any time of their convenience. Data stored in online databases was also confirmed to be safer as compared to the previously used paperwork (Park, 2011).

On the other hand, there are various disadvantages associated with the translation of knowledge into clinical skills, one of which is the fear of the unknown. Sometimes the knowledge applied into clinical practice may have proven to be successful in other higher organism but lower than humans. However, due to the distinct differences that exist between such organisms, the intervention may fail in humans leading to unwanted repercussions (Gera, 2012). Worst of all, some effects start showcasing long after the intervention has been applied, perhaps due to many different healthcare consumers with resultant irreversibility. Such a scenario is one of the primary reasons behind the rejection of evidence-based practices and limited integration of acquired knowledge onto clinical practice (Wallin et al., 2011).

Moreover, the knowledge-based practice may turn out to be more expensive than the existing treatment interventions (Brundage et al., 2011). Such is a reason as to why many clinicians and patients may be against the implementation of such a practice into the clinical setting. As a result, there is an apparently limited likelihood of implementing the knowledge acquired in learning institutions to actual practice in the hospital environments (Van Kleef & Werquin, 2013).

Learning Theories Guiding the Knowledge Translation

One of the learning theories guiding translation of knowledge is the theory of behaviourism, a model that has been dominated mostly by psychological researchers (Porcaro, 2011). From a traditional perspective, this theory explained that knowledge was acquired through an observable behaviour change promulgated by a stimulus and a response. According to this theory, knowledge is acquired and positively utilised through repeated behaviour (Guzman, 2008). For instance, repeated traumatising events in an individual’s life result in continued feelings of fear and anxiety of the unknown. In a similar manner, behavioural repetition of knowledge acquired in nursing learning institutions is important in ensuring that knowledge sticks in the minds of the student nurses. Many published nursing literature sources, especially in the Iranian context and the world as a whole confirm that the application of nursing knowledge acquired in the classroom is limited (Razzaque & Karolak, 2010). One reason behind this fact is that student nurses tend to forget the theoretical concepts acquired in the classroom following their graduation from the various nursing institutions. The theory of behaviourism, can, therefore, be essentially considered useful in creating a smooth transition of the knowledge acquired in the clinical settings (Savory & Fortune, 2015).

In spite of the fact that the behaviourism theory can be used in ensuring the translation of theory and knowledge into clinical skills, other factors also affect the transition, making the theory useless in performing this task. It is possible that negative behaviours can be acquired in the nursing education process with subsequent transfer to the clinical practice as per the requirements of the behaviourism theory (O’reilly & Mcnamara, 2007). Consequently, the student nurses end up passing on negative clinical practices into the nursing context, a situation equally or even more harmful than lacking practical skills in the clinical context. Some sources of literature, in fact, cite the lack of sufficient sources of evidence-base practice materials, implying the presence of a barrier towards the achievement of adequate theoretical knowledge for transfer to the clinical settings (Timmermans et al., 2011). As a result, the student nurses find insufficient information for conversion into useful skills in the management of problematic clinical conditions. Apparently, the behaviourism theory needs support from other stakeholders to apply to the clinical environments in a successful manner (Rusly et al., 2012).

Knowledge may also be translated into clinical skills for use in clinical settings through a theoretical constructivism approach. In actual sense, the creation of knowledge in the academic institutions occurs through a learning process governed by an instructor who in this case is the nursing educator (O’reilly & Mcnamara, 2007). Nursing educators are constructivists who instill knowledge on student nurses, showing them better and cheaper methods of managing chronic disease conditions for a healthier world (Timmermans et al., 2011). In this way, knowledge is acquired through being exposed to a learning environment whereby skills may be acquired from a novice state to sufficient mastery of concepts and intuitive decision-making capabilities, an approach to knowledge acquisition also supported by the Dreyfus model. Some theorists suggest knowledge acquisition through a cognitive mechanism as propped in the various cognitive theories of acquiring knowledge (Wallin et al., 2011). This method, however, lacks scientific provability; hence, it is ignored by most scientific researchers as an efficient way of acquiring clinical skills. As such, any skills intended to be transmitted into the clinical setting have to be properly screened to identify the specific theoretical approach used during the knowledge acquisition process (Wang et al., 2007). An unacceptability of the learning theory implies a rejection of the proposed knowledge for inclusion into the clinical practice, explaining the few knowledge-based approaches implemented into clinical practice (Porcaro, 2011).

Relating Knowledge Translation to Clinical practice to the Dreyfus Theory of Knowledge and Skill Acquisition

 Of particular importance among the theories of learning is the Dreyfus theory of knowledge and skill acquisition developed by Stuart and Benner. The theory proposes a stage-wise system of skill acquisition consisting of five stages (Brundage et al., 2011). The first stage is the novice stage, followed by competence, proficiency, expertise, and mastery stage in that order. While acquiring knowledge provided by instructors from published materials in a formal setting, the nursing student has to undergo all the five stages before reaching a point of translating the knowledge into clinical practice (Porcaro, 2011).

At the novice stage, the student strictly follows the rules administered by the instructor or the nurse in charge if the student is on an internship programme under a particular nurse leader within a clinical setting (Wallin et al., 2011). The student at this stage lacks the confidence to do anything on their own, and they can only do what they are asked to do. As time goes by, the student nurse acquires enough knowledge to facilitate their decision-making ability, attaining the competency stage as proposed by the Dreyfus theory (Guzman, 2008). With adequate exposure to decision-making in the clinical setting, the student nurse becomes self-proficient and starts working through self-developed rules and regulations as opposed to performing duties in the way they are usually done (Savory & Fortune, 2015). At this level of knowledge acquisition, the student develops intuition and starts acting without analytical reasoning, implying that decisions made by such an individual are independent of any existing rules. It is the first step of developing expertise in a certain specialty, finally followed by the ability to master all theory and to be guided by instincts while making decisions (Razzaque & Karolak, 2010).

Critiques of the Dreyfus theory argue that all experts at some point need to apply analytical skills in critical decision-making processes as opposed to the current state of affairs in the Dreyfus model. The critiques deny the idea of only acting from intuition, an approach that entails responding to instincts rather than reasoning from consciousness to make sound decisions. Such an approach to knowledge acquisition id related to acquiring knowledge cognitively, an idea that was scientifically rejected for lack of provability (Savory & Fortune, 2015). Other critiques claim that the journey from a novice status to the development of expertise in any area of study does not follow a particular process. Such critiques slow the ability of knowledge to be translated into skills for the benefit of patients who expect research scientists to come up with the best practices that serve them at lower prices and with enhanced patient outcomes (Savory, 2006)

Challenges Facing Fast Knowledge Translation to Practical Skills

Translating the knowledge obtained from learning institutions by students who successfully undergo the five stages of skill acquisition proposed by Dreyfus is not with challenges. The biggest of all drawbacks is the possible resistance of the changes proposed to the clinical setting. Most healthcare facilities are occupied by nurses and practitioners that are adamant and resistant to the slightest changes in clinical practices (Savory & Fortune, 2015). In fact, most of them openly claim that the introduced change is not part of their usual practice; hence, they may not be receptive to the practice per se. in this regard, therefore, much blame should not be directed towards the failure of learning institutions to aim towards converting theory into practice. On the contrary, the traditional forms of leadership and work experience possessed by other stakeholders in the healthcare industry are to blame. In fact, they ought to change their attitudes towards newer clinical practices based on scientific knowledge (Wang et al., 2007). The possibility of embracing clinical practice from scientific knowledge is majorly in the hands of healthcare managers who need to steer a revolutionary regime, encouraging the adoption of evidence-based practice in clinical settings. Behaviourism can also apply in this particular case whereby the managers and nurse leaders are exposed to a positive behaviour change towards the acceptance of the approach to allow the translation of acquired knowledge to clinical practice (Rusly et al., 2012).

When a student nurse enters the healthcare industry, they establish their basis in the specific facility, first as novice students. As a result, it may take quite some time before the student nurse traverses the other stages of skill acquisition for them to manage activities on their own (Wallin et al., 2011). Research does not provide the exact length of time taken to transition from one stage of knowledge acquisition to the next. In this regard, the novice nurse may take an extremely long time to get to a point whereby they can make their decisions based on the knowledge they acquired in class (Van Kleef & Werquin, 2013). The time taken to transform is also dependent on the willingness of the management to adopt new methods of administering nursing care and medication. During the novice stage, also, the nurse only follows the rules laid for them by the nurse in charge of their orientation. They are only able to implement their acquitted knowledge much later, perhaps when the get to the proficient, expert or the mastery stage of the Dreyfus model of skill acquisition. Depending on the amount of time taken for such changes to occur, the application of knowledge into practice in the clinical setting may be said to be delayed, or apparently ignored (Timmermans et al., 2011).

In other occasions, managerial problems such as the excessive workload entrusted to the nurses may be a potential cause of the lack of implementation of acquired knowledge in clinical practice. Some evidence-based practice requires an investment in time, a resource that nurses in an understaffed facility may lack (Van Kleef & Werquin, 2013). As a result, it may appear like there is a limited implementation of acquired knowledge to clinical practice, yet factors beyond the control of the student nurses may be the cause of the phenomenon. For there to be an effective congruence between theory and practice in healthcare, it is important for the respective stakeholders to play their respective roles adequately (Wang et al., 2007).

This paper, however, does not object that fact that there is a possibility of a divergence between nursing theory and clinical practice. In fact, some learning institutions lack sufficient amenities to facilitate adequate equipping of knowledge to student nurses who finally lack the knowledge to translate into practice (Rusly et al., 2012). Some nurse educators stick to the old ways of doing things, dragging the process of knowledge translation to skills, especially in the clinical setting. According to behaviourists, the student can only be as good as the teacher; hence, the chances of such nurse educators to produce efficient, evidence-based practitioners are minimal. Again, as long as there continues to occur loopholes in the facilitation of skill acquisition, it will continue to appear like student nurses no longer integrate acquired knowledge into practice (Porcaro, 2011).

Conclusion

Knowledge acquired from the classroom only becomes essential for the benefit of the patients if it is translated into clinical skills in healthcare settings. Such knowledge is acquired from nurse educators and other relevant healthcare stakeholders through various learning theories. Examples of such theories applicable not only in the healthcare sector but across all academic disciplines include the behaviourism, cognitive, and constructivist theories. Of particular importance in the nursing sector, however, is the Dreyfus theory of skill acquisition characterised by five stages: the novice, competent, proficient, expert and master stages. Evidently, the amount of knowledge applied to clinical practice is not sufficient when compared with the volumes of new nursing practices taught in classrooms and available on published nursing literature.

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