DISCUSSION PAPER

From theoretical model to practical use: an example of knowledge

translation

Ida Torunn Bjørk, Kirsten Lomborg, Carsten Munch Nielsen, Grethe Brynildsen,

Anne-Marie Skovsgaard Frederiksen, Karin Larsen, Inger Ase Reierson, Irene Sommer &

Britta Stenholt

Accepted for publication 22 December 2012

Correspondence to I.T. Bjørk:

e-mail: i.t.bjork@medisin.uio.no

Ida Torunn Bjørk MNS PhD RN

Professor

Department of Nursing Science,

Institute of Health and Society,

University of Oslo, Norway

Kirsten Lomborg MNS PhD RN

Associate Professor

Department of Public Health,

Aarhus University, Denmark

Carsten Munch Nielsen MEd RN

Curriculum Coordinator

VIA University College, Aarhus,

Denmark

Grethe Brynildsen MNS RN

Assistant Professor

Lovisenberg Diaconal

University College, Oslo, Norway

Anne-Marie Skovsgaard Frederiksen MLP

RN

Lecturer

VIA University College, Aarhus, Denmark

Karin Larsen MLP RN

Educational Coordinator

Department of Endocrinology and Internal

Medicine, Aarhus University Hospital,

Denmark

B JØRK I .T . , LOMBORG K . , N IEL SEN C .M . , BRYN ILDSEN G . , FREDER IKSEN

A . -M . S . , LARSEN K . , RE I ERSON I . A . , SOMMER I . & STENHOLT B . ( 2 0 1 3 )

From theoretical model to practical use: an example of knowledge translation.

Journal of Advanced Nursing 00(0), 000–000. doi: 10.1111/jan.12091

AbstractAim. To present a case of knowledge translation in nursing education and practice

and discusses mechanisms relevant to bringing knowledge into action.

Background. The process of knowledge translation aspires to close the gap

between theory and practice. Knowledge translation is a cyclic process involving

both the creation and application of knowledge in several phases. The case

presented in this paper is the translation of the Model of Practical Skill

Performance into education and practice. Advantages and problems with the use

of this model and its adaptation and tailoring to local contexts illustrate the

cyclic and iterative process of knowledge translation.

Discussion. The cultivation of a three-sided relationship between researchers,

educators, and clinical nurses was a major asset in driving the process of

knowledge translation. The knowledge translation process gained momentum by

replacing passive diffusion strategies with interaction and teamwork between

stakeholders. The use of knowledge creates feedback that might have

consequences for the refinement and tailoring of that same knowledge itself. With

end-users in mind, several heuristics were used by the research group to increase

clarity of the model and to tailor the implementation of knowledge to the users.

Implications for nursing. This article illustrates the need for enduring

collaboration between stakeholders to promote the process of knowledge

translation. Translation of research knowledge into practice is a time-consuming

process that is enhanced when appropriate support is given by leaders in the

involved facilities.

Conclusion. Knowledge translation is a time-consuming and collaborative

endeavour. On the basis of our experience we advocate the implementation and

use of a conceptual framework for the entire process of knowledge translation.

More descriptions of knowledge translation in the nursing discipline are needed

to inspire and advise in this process.

© 2013 Blackwell Publishing Ltd 1

continued on page 2

JAN JOURNAL OF ADVANCED NURSING

Inger Ase Reierson MNS RN

Assistant Professor

Telemark University College, Porsgrunn,

Norway

Irene Sommer MCN RN

Education and Development Nurse

Department of Cardiology, Aarhus

University Hospital, Skejby, Denmark

Britta Stenholt MNS RN

Lecturer

VIA University College, Silkeborg, Denmark

Introduction

Nursing is a practice discipline and one major purpose of

research in nursing is to develop knowledge that can be

applied in nursing practice or in the education of nurses.

This simple statement refers to a large and problematic gap

between science and practice that is evident in all the

healthcare disciplines. Research knowledge is produced and

published at an increasing rate, but changes in clinical prac-

tice and education are quite slow (Kitson 2008, Benner

et al. 2010).

Several terms are used in the literature to characterize

the efforts to move scientific results or other kinds of

knowledge into practical use. As literature on such efforts

is produced in many different disciplines, concepts are used

differently and with great variations in their definitions

(Thompson et al. 2006). An often-cited definition published

by the Canadian Institutes of Health Research (CIHR)

(2010) states that knowledge translation is: ‘A dynamic

and iterative process that includes synthesis, dissemination,

exchange and ethically sound application of knowledge

[…] within a complex system of interactions between

researchers and knowledge users which may vary in inten-

sity, complexity and level of engagement depending on the

nature of the research and the findings as well as the needs

of the particular knowledge user’. Although debates in

nursing focus on epistemological aspects of knowledge, dis-

cussions on the mechanisms underlying knowledge transfer

processes are almost non-existent in the nursing literature

(Aita et al. 2007). More attention is therefore urgently

needed.

In this article, we present a case of knowledge translation

in a Nordic context. The endeavour was not planned

according to a knowledge translation model from the out-

set. We cannot therefore present our translation efforts as a

theoretically structured case of knowledge translation. Our

purpose is to demonstrate the translation of the theoretical

and normative Model of Practical Skill Performance (Bjørk

& Kirkevold 2000) into nursing practice and education and

to use an existing knowledge translation framework to dis-

cuss our experiences of mechanisms relevant to knowledge

translation. We first exemplify the translation of the model

into nursing practice and education and then discuss how

interaction and teamwork between stakeholders from

research, education, and practice in nursing drove the pro-

cess of knowledge translation. Most articles that discuss

knowledge translation focus on moving knowledge into

clinical practice. We found that the issues are quite similar

in efforts to translate new knowledge into the educational

setting in nursing. Drawing on our experiences, we high-

light the value of ‘three-sided thinking’ to expedite and

strengthen translational processes and results. Knowledge

translation may involve knowledge for conceptual use,

direct use, or policy use (Ward et al. 2009). In our efforts

to move the Model of Practical Skill Performance into edu-

cation and practice, the target was both conceptual and

practical use.

Background

Moving knowledge into practice is complex. It is a process

with many facets (Rycroft-Malone 2010) and a great vari-

ety of terminology, frameworks and models have been used

to represent this process (Estabrooks et al. 2006, Graham

and Tetroe 2007, Mitton et al. 2007, Sudsawad 2007,

Pentland et al. 2011). In the USA, several models and pro-

grammes were launched during the 1970s to support

nurses’ research utilization in clinical settings. Initiatives

such as the Stetler/Marram model (Stetler & Marram

1976), later adjusted by Stetler and named the Stetler

(2001) model and Conduct and Utilization of Research in

Nursing (CURN) (Horsley et al. 1983) were developed to

enhance nurses’ use of research knowledge in practice. A

more recent framework for the implementation of research,

Promoting Action on Research Implementation in Health

Services, was first published by Kitson et al. (1998) and

further developed by Rycroft-Malone and colleagues

(Rycroft-Malone et al. 2002, Rycroft-Malone 2004).

Promoting Action on Research Implementation in Health

Services is a conceptual model that presents research imple-

mentation as the interplay between three core elements: the

level and nature of the evidence used, the context or envi-

ronment where the research is to be placed, and the method

by which the implementation process is to be facilitated

(Sudsawad 2007). The framework is focused on the imple-

mentation process of knowledge, not the creation of knowl-

2 © 2013 Blackwell Publishing Ltd

I.T. Bjørk et al.

edge. It is not a model to guide actual implementation. It

delineates the core elements so that researchers and knowl-

edge users can work together towards creating the best

environment for structured change and development in

practice (Rycroft-Malone 2004).

In this article, we use the term ‘knowledge translation’.

Knowledge can mean more than research knowledge. The

CIHR makes it clear that their definition of knowledge

translation involves interactions between researchers, who

predominantly produce research knowledge and users. The

CIHR refers to users as key stakeholders who have the

intention to improve both health outcomes and the health-

care system and state that the interaction in knowledge

translation is collaborative and two-way. The gap between

science and practice has recently been addressed by the

European Union through a presidency status report promot-

ing The European Research Area (ERA) vision for 2020

(Council of the European Union 2008). This report suggests

that the views on collaboration in knowledge translation

must be expanded by including education as a corner stone.

Special attention is given to the so-called Triangle of

Knowledge, which articulates a three-sided relationship in

knowledge translation between research, practice, and edu-

cation. The report also suggests that education has an equal

and parallel role to research and practice in the effort to

promote the use of knowledge. The report states that ‘A

wide range of activities are taking place in individual parts

of this triangle without systematic consideration of interac-

tions with the remaining two, which leads to non system-

atic policies’ (p. 13). It also suggests that ‘a better

functioning knowledge triangle has the potential to reduce

bureaucracy and increase transparency in transforming

knowledge into innovative products and services’ (p. 14).

We interpret this part of the ERA vision to mean that

knowledge translation will be strengthened by expanding

the two-way collaboration promoted by CIHR to include

education in the knowledge-to-action equation. Involving

education and the clinical learning milieu in this equation

may ultimately result in the education of students who are

qualified in knowledge-to-action activities and thereby

better qualified as stakeholders when they move into

practice as professionals.

Knowledge translation is identified as either a linear,

cyclic, or dynamic multidirectional process (Ward et al.

2009). A cyclic knowledge-to-action framework was

published by Graham et al. (2006) (Figure 1) on the basis

of a review of planned-action theories and frameworks. As

opposed to many other frameworks for knowledge transla-

tion, this framework has been tested. It was used as a

model for planning and evaluating knowledge translation

strategies for developing a mentorship strategy in contin-

uing education (Straus et al. 2008). The framework

described by Graham et al. (2006) depicts the process of

knowledge translation as ‘an iterative, dynamic and

complex process concerning the creation and application

(action cycle) of knowledge’ (Straus et al. 2009, p. 166).

The process of knowledge creation contains three phases

(Figure 1): (1) knowledge inquiry, representing primary

research; (2) knowledge synthesis, representing the aggrega-

tion of existing knowledge; and (3) knowledge tools and

Monitorknowledge

use

Sustainknowledge

Tailo

ring

know

ledg

e

use

Evaluateoutcomes

Adaptknowledge

to local context

Assess barriers/supports to

knowledge use

Select, tailor,implement

Interventions

Identify problem

Identify, Review,Select knowledge

Products/tools

Synthesis

Knowledge inquiry

KNOWLEDGE CREATION

Figure 1 The Knowledge-to-Action

Process by Graham et al. (2006), used

with permission. The Alliance for Contin-

uing Medical Education, The Society for

Academic Continuing Medical Education,

and The Association for Hospital

Medical Education.

© 2013 Blackwell Publishing Ltd 3

JAN: DISCUSSION PAPER Knowledge translation

products, representing the distillation of concise and user-

friendly formats of knowledge, such as guidelines or deci-

sion aids. Researchers involved in the process of knowledge

creation can tailor their activities in response to the prob-

lems identified by knowledge users (Graham et al. 2006).

The process of knowledge application includes seven phases

(Figure 1), from identifying a problem and identifying,

reviewing and selecting knowledge (phase 1), to sustaining

knowledge use (phase 7). These phases are based on com-

mon aspects in theories of planned action for change in

healthcare systems and groups (Graham & Tetroe 2007).

Graham et al. (2006) present these phases as a circle. They

emphasize that the phases can influence each other or be

influenced by the knowledge creation phases in a dynamic

way and thereby move back and forth between phases. This

dynamic movement depends on the cultivation of relation-

ships between stakeholders as a necessary premise in devel-

oping a common understanding of knowledge translation

and actual exchange of knowledge. In the following, we

will present the motivation to develop the Model of Practi-

cal Skill Performance and give a short description of its

intention and significance.

Knowledge creation: developing the Model of Practical

Skill Performance

The Model of Practical Skill Performance was developed as

part of a doctoral dissertation and published internationally

in three articles (Bjørk 1999, Bjørk & Kirkevold 1999,

2000). Sources of data that were combined to inform the

development of the model were both theoretical and empiri-

cal. The impetus to develop this model was based on the

repeatedly communicated worries in the literature and in

practice, about lack of proficiency in practical nursing skills

in newly graduated nurses. The model aspired to assert

practical skills in nursing as complex actions in contrast

with former renditions of practical nursing skills as simple

and technically focused motor or psychomotor skills. This

complexity would in turn have consequences for skill teach-

ing and learning, both in the skills centre and in clinical

placements. The model is generic (for practical nursing

skills) and normative, and suggests that six categories or

elements comprise and express what must be realized in a

good practical skill performance (Figure 2).

The model is visualized as a circle symbolizing unity,

wholeness, and integration. The stippled lines between the

categories suggest their interrelatedness. There is no hierar-

chical relationship between the layers, nor is any one layer

more important than the others, because all categories

should be present when a practical skill is performed. The

arrows symbolize that caring behaviour is fundamental to

acting professionally as a nurse and therefore permeates all

elements of practical skill performance (for more details

see, e.g. Bjørk & Kirkevold 2000).

Moving the model into research, practice, and education

Since first published in scientific journals at the turn of the

21st century, the model has spread to the Nordic audience

by what Thompson et al. (2006, p. 692) refer to as ‘passive

diffusion’. Through articles, books, and book chapters

aimed at nursing practice and education (Bjørk 2002, 2003,

2006, Bjørk & Breievne 2005), the model has been pre-

sented and discussed, aiming to influence nurses’, students’,

and nursing educators’ views of the constitution of practical

skills in nursing. In a more active transfer pathway, the

development and relevant use of the model have been

taught in classes with masters students and presented at

national and international conferences. It has also been the

topic of seminars with nurse educators in Norway and Den-

mark. Such activities are common among most scholars,

but there is no guarantee of use merely because information

is timely, relevant and objective and disseminated to the

right people in usable form (Rich 1979). Diffusion of

knowledge by researchers is often termed the ‘push forces’

of knowledge translation. This means that researchers ‘push

information, hoping…that someone, somewhere, will find

the fruits of our well-intended work ripe for consumption’

(Dearing & Kreuter 2010, p,. S102). The ‘pull forces’, on

the other hand, denote what potential adopters want. These

adopters may be individuals, teams, or organizations, and

they pull what they value, prefer, or pay attention to

(Dearing & Kreuter 2010).

The result of these push forces was that some Norwegian

and Danish doctoral students, masters students, and nursing

education faculties, quite independently of one another,

found that the model addressed analytical and practical

problems related to teaching and learning of practical skills

in nursing. Lomborg (2004), in her doctoral dissertation,

used the categories in the model as an inspiration in her

analysis of assisted personal body care in patients with

chronic obstructive pulmonary disease. The findings were

organized under the headings Caring conduct, Accuracy,

Fluency (and pace), and Integration. Two masters students

used the model. One as a tool to analyse the development

of students’ skills in assisting with personal body care

during clinical placement in nursing homes (Brynildsen

2007), and the other as a standard to evaluate the quality

of students’ practical skill learning in the skills centre

(Blig�ard 2007).

4 © 2013 Blackwell Publishing Ltd

I.T. Bjørk et al.

Through independent initiatives of the nursing faculty,

the model was included in the curriculum at a university

college in Norway in 2002 and at two nursing education

sites in one university college in Denmark in 2006. In these

plans, the model was presented as a norm for well-

performed practical skills and students were encouraged to

use the model during practical skill learning in the skills

centre and during clinical studies. The formalization of the

model in the curriculum inspired nurse educators at the

Norwegian university college to study students’ acquisition

of substance, sequence, and accuracy in the skills centre

during skill learning (Solli & Reierson 2006).

The faculty at the university college in Denmark had

launched a study investigating the development in practical

skills during an 8-week clinical placement period. They com-

pared the progress of students in dedicated educational units

with students in ordinary nursing units (Nielsen et al. 2005).

The researchers had come across the model while searching

for literature and decided to use it as a tool to guide analysis

of videos of the students’ skill development. Struggling with

several methodological questions pertaining to the use of the

model, they contacted the creator of the model. This was in

2004, so the diffusion period had lasted four years. At the

same time, an educational nurse working in the clinical set-

ting in a Danish hospital contacted the faculty group and

instigated a project to incorporate the model as a teaching

tool for clinical nurses in their supervision of student nurses

during clinical placements in medical units (Larsen & Nielsen

2006). One spin-off from this study was educational material

in the form of pocketsize laminated pamphlets presenting the

model. Another spin- off was a theoretical article in a Danish

nursing journal presenting and discussing the model as a rele-

vant tool for supervision and self-evaluation during practical

skill learning in the clinical setting (Nielsen et al. 2007,

2009). Skovsgaard et al. (2008) studied the relevance of

using nursing homes as clinical placements. They used the

model as an analytical tool to gauge whether students man-

aged to develop their practical skill performance sufficiently

at this type of placement.

This overview of projects shows that the model has been

used in hospitals, nursing homes, skills centres, and as a nor-

mative basis in educational curricula. Although also used as a

tool in analysis of empirical data, the model’s use in actual

education and practice is the focus in the rest of this article.

Substance

&

Sequence

Accuracy

Integration

Fluency

Caring comportment

© Ida Torunn Bjørk 1999

Model of Practical Skill Performance

Substance refers to the inclusion of relevant content in the form of movement steps, instruction and information.

Sequence reflects if movement steps, instruction andinformation come in a logical order.

Accuracy refers to exactness in each movementstep and the correctness of instruction and information included. E.g. opening bandages andequipment without contaminating the contens, giving the correct information about the purpose of the ambulation, or giving precise instructions on how to get out of bed.

Fluency is when each element of performance give an impression of ease and smoothness, whenthey seem ”finished” and without hesitation.

Integration reflects ability to harmonize and time theparallel aspects of an action such as movement steps, physical support and verbal interaction. Integration alsoincludes being attentive to what the patient in total needs whiletaking care of the specifics of the ongoing action.

Caring comportment relates to how the nurse createsan atmosphere that is respectful, accepting and encouraging.It includes concern of the whole person by relating to the patients’feelings and reactions to the instrumental steps of the action, and to the total experience of being a patient. Caring permeates all the elements of performance.

Figure 2 The Model of Practical Skill Performance.

© 2013 Blackwell Publishing Ltd 5

JAN: DISCUSSION PAPER Knowledge translation

Advantages and challenges in the use of the model

Experiences common to users of the model was that it gave

an overview of elements involved in practical skills in

nursing, functioned as a tool for supervision and evaluation

during practical skill performance and learning and used a

common, specific language that replaced former more vague

terms such as routine and handiness (Fransson 2009). A com-

mon experience was also that by using the model in discus-

sions, both students and nurses became more attuned to the

quality of performance than to the number of skills practised.

The categories in the model were also a starting point for

delving deeper into specifics of performance and stimulating

students to transfer theoretical and practical knowledge

across contexts and different nursing procedures.

Some challenges also emerged. Each category in the model

was defined and exemplified. However, masters students,

nurses, faculty and baccalaureate nursing students experi-

enced difficulties in specifying aspects of their actions in the

categories, often unable to decide between categories. The

category of ‘integration’ was especially difficult. Being able to

integrate a specific skill into the patient’s situation relies on

the ability to theorize and analyse one’s own actions during

the activity itself (Fransson 2009) and this is certainly difficult

for inexperienced students. To remedy this, the Danish fac-

ulty suggested adding two categories (Nielsen et al. 2007). In

retrospect, this was seen as an interpretation and reorganiza-

tion that undermined the theoretical consistency and the

common understanding of the model.

Adapting and tailoring the model to local contexts

While the model was being tried out in different settings

and for different purposes, in 2006, the creator of the

model gathered the people involved into the research group

Research in Nursing Skills (RiNS). The group immediately

organized their work through twice-yearly 3-day seminars.

The aim of the research group is defined on their homepage

as: ‘To develop a comprehensive understanding of practical

skills in nursing and how these skills are learned. By means

of systematic research and developmental projects we

propose to gain insight and develop knowledge that can

play a role in strengthening the performance of practical

skills in nursing. This will contribute to the delivery of

hands-on nursing at a high professional level to patients

and clients in need of nursing’ (www.rins.dk).

The problems with the model resulted in a communal

effort to further develop the model. To overcome language

and cultural barriers, the concepts in the model were pre-

cisely defined and translations into all languages concerned

were made. Educational materials and illustrative examples

from clinical practice were developed. In several workshops

during 2008–2009, the research group worked through

models of different practical skills in nursing to confirm the

appropriateness of the original six categories of the model.

They discussed ideas for development, read literature on

the development of models, and invited a researcher experi-

enced in the use of economic models to elaborate on the

development of models. Finally, the group developed a

more detailed instrumental supplement to guide students,

teachers, and nurses in the supervision, formative evalua-

tion, and self-evaluation of practical skill performance

(Figure 3). This is a supplement to – and not a replacement

for – the model. Definitions of categories are more precise

in the instrumental supplement (Figure 3) than in the

original model (Figure 2); aspects that denote quality in

performance are specified in relation to the defined

categories.

Implementing the instrumental supplement and

evaluating its use

The instrumental supplement of the model is now presented

on the RiNS website www.rins.dk in English, Danish, and

Norwegian. It has been incorporated into the curriculum

plans at the two university colleges together with the original

model and used in new projects in both countries. Members

of the research group have involved other educators at the

university colleges in action-research studies. The aims are to

improve teaching and learning at the skill centres by active

incorporation of the instrumental supplement of the model

during teaching and supervision and to supervise the

students while they use it during planning, self-study, and

self-evaluation of learning. Baseline and follow-up data were

gathered using video recordings. The primary investigators

collected detailed minutes of meetings and written logs and

plans developed in the action groups. Several members of

the research group are collaborating with supervisors and

teachers to use the model during clinical placements in hos-

pitals and nursing homes. At present, these implementation

efforts are being evaluated through focus group interviews,

written logs and surveys. Data are presently being analysed.

Questions to be answered are related to the participants

understanding of underlying values of the model and the

concepts used to describe quality performance, ease of use of

the instrumental supplement and other tools developed by

the research group, and barriers and facilitators to their use

in education and practice. These questions are related to

both conceptual and direct use of knowledge. To facilitate

the reader’s understanding of our knowledge translation

6 © 2013 Blackwell Publishing Ltd

I.T. Bjørk et al.

activities described above, we show our progression in

relation to the Knowledge-to-Action Process described by

Graham et al. (2006) (Figure 4).

Discussion

A major drive to knowledge translation is the potential and

need for improvement in clinical care (Wallin 2009). The

efforts to improve knowledge translation described in this

article were driven by the conviction of several people that

practical skill learning can and should be enhanced in both

the educational and clinical setting. At the outset, no theory

or model of knowledge translation was used to guide the

diffusion of the Model of Practical Skill Performance into

practice and education. The diffusion activities described in

this article are best portrayed as a ‘natural’ consequence of

perceiving one’s own work as important for nursing and

trying to disseminate this knowledge out into the world.

Although the many projects designed to use the model are

examples of efforts in knowledge translation, it is fair to say

that use of the model really first took off through the com-

bined efforts of the members in the research group RiNS.

The problem that needed addressing – ‘How to improve

practical skill-learning in nursing students’ – was already

Instrumental supplement

Model of Practical Skill Performance © RiNS 2009

Definition of categories in the model Characteristics of quality performance

SUBSTANCE AND SEQUENCE are the core aspects of a practical skill. Necessary steps in the skill are included and performed in a logical order

Substance and sequences are determined on the basis of content in clinical guidelines, professional standards and principles. Substance and sequence is adapted to the patient and the situation where the skill is being performed

ACCURACY refers to exactness of each movement step, instruction and information. Accuracy is important in order to ensure security of patient, nurse and environment

Accuracy implies to act: - correctly - precisely

Accuracy implies to inform and instruct: - what is necessary and sufficient - distinctly - understandably

FLUENCY signifies that tempo and rhythm is adjusted to both the patient and the type of practical skill being performed and that the practical skill is performed with smoothness

Fluency implies to act, inform and instruct: - without hesitancy - without unnecessary breaks - with ease

INTEGRATION signifies that all parallel aspects within the practical skill are harmonized.

Integration also implies that the skill as such is adjusted to the patient’s current condition and situation.

Integration implies to: - time and coordinate the elements of

action

Integration related to adjustment implies to: - be attentive - have an overview - be flexible

CARING COMPORTMENT signifies to create an atmosphere where the patient’s dignity is upheld, self-determination is ensured according to the patient’s current condition and situation and well-being is warranted

Caring comportment implies to: - acknowledge - show respect - ensure patient participation - be empathic - use appropriate touch - be engaged - use appropriate communication - work aesthetically

Figure 3 Instrumental supplement of the Model of Practical Skill Performance.

© 2013 Blackwell Publishing Ltd 7

JAN: DISCUSSION PAPER Knowledge translation

acknowledged by the group members. All members brought

with them experiences of the different ways they had tried

to solve this problem. According to Corcoran (2006), the

process of knowledge translation requires a multilevel

approach that involves prolonged interactions with a range

of individuals. By organizing the work in the research group

in a seminar format, we promoted extended interactions

among stakeholders representing all sides of the ‘knowledge

triangle’ (Council of the European Union 2008).

The primary research and systematic aggregation of

knowledge required to develop the Model of Practical Skill

Performance were done by one researcher before the

research group was established. However, the necessary

process of producing knowledge tools and tailoring the

developed model for use in practice and education occurred

as an iterative process over several years. In addition to

members of the research group, it involved students, teach-

ers, and nurses who reacted to and commented on the

model when using it or being supervised by it. This might

indicate that the knowledge we put into action was prema-

ture. It might also highlight the unfinished state of theory

and show that the use of knowledge creates feedback that

Knowledge creation and tailoring

Doctoral work resulting in the original Model of

Practical Skill Performance

Tailoring knowledge through cooperation with

stakeholders

1. Identify problem and review knowledge

• Problem of qualifying nursing students in practical skill acknowledged by educators, researchers and students

2. Adapt knowledge to local context

• Foundation of RiNS • Refinement of The Model

• Development and validation of a supplement

• Development of heuristic devices

3. Assess barriers to knowledge use

• Translation from English into Nowegian and Danish

• Examples provided in articles and folders to promote understanding

4. Select, tailor and implement interventions

• Implementation in skills centres and clinical practice

• Involvement of students, teachers and clinical supervisors

5. Monitor knowledge use

• Local monitoring as part of the defined projects

6. Evaluate outcomes

• Process and utcome evaluation of using the model in on-going studies

7. Sustain knowledge use

• To be addressed in ongoing and future evaluation

Figure 4 Activities in translating the Model of Practical Skill Performance illustrated with the phases of the Knowledge-to-Action Process

by Graham et al. (2006). The arrows symbolize the iterative process between knowledge application and knowledge tailoring.

8 © 2013 Blackwell Publishing Ltd

I.T. Bjørk et al.

might impinge on the refinement and tailoring of that same

knowledge itself. This back-and-forth process in the

development of appropriate knowledge illustrates the cyclic

nature of knowledge translation as described by Graham

et al. (2006).

The collaboration between researchers, educators, and

clinical nurses has been a major asset in the knowledge

translation endeavour. We think that our collaboration is

an example of the relevance of thinking in a ‘three-sided’

manner about knowledge translation (Council of the Euro-

pean Union 2008). In effect, education is both an end-user

of the model and acts as a co-researcher in knowledge

translation targeted at the clinical setting. The knowledge

triangle implies three equal partners in knowledge transla-

tion. Our experience is that the often-illustrated progres-

sion of knowledge translation as a linear process – with

knowledge being ‘moved’ by the researcher into clinical

practice – is far too simple. It does not match the reality of

our experience where, in fact, the active actions of end-

users, i.e. clinical nurses and educators, instigated the pro-

cess of active collaboration with the researcher in translat-

ing the model into practice.

The model was originally developed and presented in

research journals in the English language. The end-users of

the model in our knowledge translation efforts were

Norwegian and Danish nursing students and their teachers

and nurses in the clinical setting, not international fellow

researchers. As it is imperative to analyse the needs of end

users to inform the implementation planning process

(Graham & Tetroe 2007), we saw the necessity to address

barriers to knowledge use among our stakeholders. Barriers

to knowledge use in nursing have been extensively exam-

ined (see, e.g. Hutchinson & Johnston 2004) and lack of

readability and conceptual clarity in the research literature

are common barriers. Several heuristics were used by the

research group to increase the clarity of the model and to

tailor the implementation of knowledge to the users. We

also made sure that the language used in the Norwegian

and Danish versions of the model and the subsequent

instrumental supplement was properly validated.

Both push and pull strategies were used in our efforts to

move the model into education and practice. These are con-

trasting strategies brought about by cultural differences.

Roux et al. (2006) suggest that researchers should involve

end-users in the knowledge creation process to ensure that

the knowledge they develop will be received with more

enthusiasm. This may not always be possible when the

knowledge developed is the result of an unstructured

inquiry into underresearched areas and not the answer to a

recognized problem. We experienced that the push efforts

by the creator of the model were very important because

they managed to sensitize interested parties to the fact that

the theory developed could be of benefit to them in solving

problems they faced. We also experienced that the pull

forces came strongly into play when prolonged social inter-

action (Williams et al. 2008) was possible between

researchers, educators, and educational nurses in the RiNS

group. These pull forces have clearly contributed to the

knowledge-tailoring efforts during the knowledge transla-

tion process. The members of RiNS brought in valuable

experiences from students’, nurses’, teachers’, and their

own use of the model. Research into knowledge translation

is demanding and time-consuming (Rycraft-Malone 2004).

A major help in this work has been the financial support

and time provided by educational and research institutions.

Nursing facilities that support collaboration across national

borders and publication efforts have also been helpful.

The implementation process of knowledge translation

efforts must be examined (Wallin 2009). The different

What is already known about this topic

● Research knowledge is produced and published at an

increasing rate, but changes in clinical practice and

education are quite slow.

● Discussions on the mechanisms underlying knowledge

transfer processes are almost non-existent in the nurs-

ing literature.

● Passive diffusion of knowledge is no guarantee that it

will be used.

What this paper adds

● Three-sided collaboration that includes educators,

researchers, and clinical nurses is a major asset in

knowledge translation.

● A multilevel approach with prolonged interactions

between all stakeholders is necessary to gain momen-

tum in a knowledge-to-action process.

● A cyclic and not linear knowledge-to-action frame-

work, matched the actual process of knowledge trans-

lation.

Implications for practice and/or policy

● A theoretical framework of knowledge translation

should be used from the outset when knowledge trans-

lation projects are planned.

● More descriptions of knowledge translation efforts

should be published in the nursing literature.

© 2013 Blackwell Publishing Ltd 9

JAN: DISCUSSION PAPER Knowledge translation

studies published so far by members of the RiNS group

only touch on this process. We acknowledge the need to

investigate this process in detail and have chosen action-

research approaches including video-recorded observa-

tions, focus group interviews with stakeholders, and ques-

tionnaire surveys to gauge the implementation process in

our ongoing studies. By evaluating our efforts in knowl-

edge translation, we found that the phases of the cyclic

knowledge-to-action model (Graham & Tetroe 2007)

actually matched the collaborative efforts of the RiNS

members quite well. Whilst this is a very pleasing finding,

we regret that we did not actively discuss and choose a

knowledge translation framework from the outset. A

more structured approach to our translation efforts might

have reduced the resources we expended on the ‘complex,

messy, and demanding’ (Rycraft-Malone 2004) task it has

been to translate the model into education and practice.

We agree with Estabrooks et al. (2006) who suggest that

finding a fit between the context where knowledge trans-

lation is aimed and theory that can underpin these efforts

is important for knowledge translation initiatives to suc-

ceed.

Implications for nursing

This article illustrates that enduring collaboration between

stakeholders promotes the process of knowledge transla-

tion. Translation of research knowledge into practice is a

time-consuming process that is enhanced when appropriate

support is given by leaders in the involved facilities.

Limitations

This article has described and discussed how a theoretical

model in nursing has been moved into practice and

education in the Nordic countries. We acknowledge that

the scope of this endeavour may be viewed as small, but as

an example of the knowledge-to-action process, it may still

inspire and illuminate the challenges inherent in moving

research into practice.

Conclusion

We described a case of knowledge translation in a Nordic

context in this article. Although the case presented might

be viewed as a small-scale translation endeavour, it involves

many of the central phases described in a cyclic knowledge-

to-action process. A lesson to be learnt from our process is

that passive – and even active – diffusion activities are

limited in their effect. The combined effort of stakeholders

in research, clinical practice, and education in prolonged

interaction and teamwork was a necessary condition for the

knowledge translation process. More descriptions of knowl-

edge translation in the nursing discipline are needed and to

document these properly, a recognized knowledge transla-

tion framework must be implemented at the inception of

such research.

Funding

No funding for this work.

Conflict of interest

No conflict of interest has been declared by the authors.

Author contributions

All authors have agreed on the final version and meet at

least one of the following criteria [recommended by the

ICMJE (http://www.icmje.org/ethical_1author.html)]:

● substantial contributions to conception and design, acqui-

sition of data, or analysis and interpretation of data;

● drafting the article or revising it critically for important

intellectual content.

References

Aita M., Richer M.-C. & H�eon M. (2007) Illuminating the

processes of knowledge transfer in nursing. Worldviews on

Evidence-Based Nursing 4(3), 146–155.

Benner P., Sutphen M., Leonard V. & Day L. (2010) Educating

Nurses: A Call for Radical Transformation. Jossey-Bass, San

Francisco, CA.

Bjørk I.T. (1999) Practical skill development in new nurses.

Nursing Inquiry 6(1), 34–47.

Bjørk I.T. (2002) Kroppen i møtet mellom pasient og sykepleier

[The body in encounters between patient and nurse]. In Møte

mellom pasient og sykepleier [Encounters Between Patient and

Nurse] (Bjørk I.T., Helseth S. & Nortvedt F., eds), Gyldendal

Akademisk, Oslo, Norway, pp. 223–236 (Norwegian).

Bjørk I.T. (2003) �A lære praktiske ferdigheter i sykepleie [Learning

practical skills in nursing]. In �A lære i praksis [Learning in

Clinical Practice] (Bjørk I.T. & Bjerknes M.S., eds), Univer-

sitetsforlaget, Oslo, Norway, pp. 88–109 (Norwegian).

Bjørk I.T. (2006) Nyutdannede sykepleieres manglende praktiske

sykepleieferdigheter [New nurses’ lack of practical skills in

nursing]. Klinisk Sygepleje 20(4), 23–30 (Norwegian).

Bjørk I.T. & Breievne G. (2005) Kropp og velvære i sykepleien

[Body and well-being in Nursing]. In Grunnleggende sykepleie,

Bind 1 [Fundamental Nursing,Volume 1] (Kristoffersen N.J.,

Nortvedt , F. & Skaug E-A., eds), Gyldendal Akademisk, Oslo,

Norway, pp.106–136 (Norwegian).

10 © 2013 Blackwell Publishing Ltd

I.T. Bjørk et al.

Bjørk I.T. & Kirkevold M. (1999) Issues in nurses’ practical skill

development in the clinical setting. Journal of Nursing Care

Quality 14(1), 72–84.

Bjørk I.T. & Kirkevold M. (2000) From simplicity to complexity:

developing a model of practical skill performance. Journal of

Clinical Nursing 9(4), 620–631.

Blig�ard D. (2007) Formativ evaluering i det tredje læringsrum -

færdighedslaboratoriet. En kulturpsykologisk undersøgelse

[Formative evaluation in the third learning environment – the

skills centre. A cultural-psychological study]. Master’s thesis, The

Pedagogical University of Denmark, �Arhus, Denmark (Danish).

Brynildsen G. (2007) ‘Ikke bare enkle prosedyrer’. Læring og

utvikling av praktiske ferdigheter i en naturlig setting [‘Not just

simple procedures’. Learning and development of practical skills

in a natural setting]. Master’s thesis, Institute of Nursing and

Health Sciences, University of Oslo, Norway (Norwegian).

Canadian Institutes of Health Research (CIHR)(2010). Retrieved

from http://www.cihr-irsc.gc.ca/e/29418.html on April 2011.

Corcoran M. (2006) Dissemination or knowledge translation.

American Journal of Occupational Therapy 60(5), 487–488.

Council of the European Union (2008) 2020 Vision for The

European Research Area (ERA). Retrieved from http://register.

consilium.europa.eu/pdf/en/08/st16/st16767.en08.pdf on April

2011

Dearing J.W. & Kreuter M.W. (2010) Designing for diffusion: how

can we increase uptake of cancer communication innovations?.

Patient Education and Counseling 81(Suppl.), S100–S110.

Estabrooks C.A., Thompson D.S., Lovely J.E. & Hofmeyer A.

(2006) A guide to knowledge translation theory. The Journal of

Continuing Education in the Health Professionals 26(1), 25–36.

Fransson E. (2009) Modellen for Praktisk Ferdighetsutøvelse

i Sykepleie. En evaluering av bruken av Bjørks modell

i undervisning og forskning. [The Model of Practical Skill

Performance in nursing. An evaluation of its use in education

and research], Norwegian Report. Institute of Nursing and

Health Sciences, University of Oslo, Norway.

Graham I.D., Tetroe J. & the KT Theories Research Group (2007)

Some theoretical underpinnings of knowledge translation.

Academic Emergency Medicine 14(4S), 936–941.

Graham I.D., Logan J., Harrison M.B., Harrison M.B., Straus S.E.,

Tetroe J., Caswell W. & Robinson N. (2006) Lost in knowledge

translation: time for a map?. Journal of Continuing Education in

the Health Professions 26(1), 13–24.

Horsley J.A., Crane J., Crabtree M.K & Wood D.J. (1983) Using

Research to Improve Nursing Practice: A Guide. Grune

& Stratton, San Francisco.

Hutchinson A.M. & Johnston L. (2004) Bridging the divide: a

survey of nurses opinions of barriers to and facilitators of,

research utilization in the practice setting. Journal of Clinical

Nursing 13(3), 304–315.

Kitson A.L. (2008) The need for systems change: reflections on

knowledge translation and organizational change. Journal of

Advanced Nursing 65(1), 217–228.

Kitson A., Harvey G. & McCormack B. (1998) Enabling the

implementation of evidence based practice: a conceptual

framework. Quality in Health Care 7, 149–158.

Larsen K. & Nielsen C.M. (2006) Grundlæggende sygepleje/

kropspleje. Afprøving af model om kliniske færdigheder i forhold

til klinisk vejledning og bedømmelse [Fundamental nursing/body

care. Testing a model of practical skill in relation to clinical

supervision and evaluation]. Danish Report. VIA University

College, �Arhus, Denmark.

Lomborg K. (2004) Nurse-patient interactions in assisted personal

body care. A qualitative study in people hospitalized with severe

chronic obstructive pulmonary disease (COPD). PhD thesis,

Aarhus University, Denmark.

Mitton C.M., Adair C.E., McKenzie E., Pattern S.B. & Perry B.W.

(2007) Knowledge transfer and exchange: review and synthesis

of the literature. Milbank Quarterly 85(4), 729–768.

Nielsen CM, Skovsgaard AMF & Stenholt B. (2005) Studieunits

[Dedicated educational units]. Danish Report nr. 4,

Udviklingsinitiativet for Sygeplejerkeuddannelsen i �Arhus Amt,�Arhus, Denmark.

Nielsen C.M., Larsen K., Skovsgaard A.M.F. & Stenholt B. (2007)

Model for at lære praktisk Sygepleje [Model for learning

practical nursing]. Sygeplejersken 107(17), 60–64 (Danish).

Nielsen C., Larsen K., Skovsgaard A.M., Stenholt B. & Lomborg K.

(2009) Brug for fokus p�a kliniske færdigheder. [A need to focus on

clinical skills]. Sygeplejersken 109(16), 48–52 (Danish).

Pentland D., Forsyth K., Maciver D., Walsh M., Murry R., Irvine

L. & Sikora S. (2011) Key characteristics of knowledge transfer

and exchange in health care: integrative literature review. Journal

of Advanced Nursing 67(7), 1408–1425.

Rich R.F. (1979) The pursuit of knowledge. Knowledge: Creation,

Diffusion, Utilization 1(1), 6–30.

Roux D.J., Rogers K.H., Biggs H.C., Ashton P.J. & Sergeant A. (2006)

Bridging the science- management divide: moving from unidirectional

knowledge transfer to knowledge interfacing and sharing. Ecology and

Society 11(1), Art.4.

Rycroft-Malone J. (2004) The PARIHS framework – a framework

for guiding the implementation of evidence-based practice.

Journal of Nursing Care Quality 4, 297–304.

Rycroft-Malone J. (2010) Using theory and frameworks to

facilitate the implementation of evidence into practice.

Worldviews on Evidence-based Nursing 7(2), 57–58.

Rycroft-Malone J., Kitson A., Harvey G., McCormack B., Seers K.,

Titchen A. & Estabrooks C.A. (2002) Ingredients for change:

revisiting a conceptual framework. Quality & Safety in Health

Care 11, 174–180.

Skovsgaard A.M.F., Stenholt B., Nielsen C.M. & Sørensen D. (2008)

Læring af grundlæggende sygepleje i primær sunnhedstjeneste

[Learning fundamental nursing in primary health care settings].

Danish Report. Via University College, �Arhus, Denmark.

Solli H. & Reierson I-�A. (2006) Fra mesterlære til selvstudium

[From apprenticeship to self- study]. Norsk Tidsskrift for

Sykepleieforskning 8(4), 35–50 (Norwegian).

Stetler C.B. (2001) Updating the Stetler model of research utilization

to facilitate evidence-based practice.Nursing Outlook 49, 272–279.

Stetler C.B. & Marram G. (1976) Evaluating research findings for

applicability in practice. Nursing Outlook 24(9), 559–563.

Straus S.E., Graham I.D., Taylor M. & Lockyer J. (2008) Development

of a mentorship strategy: a knowledge translation case study. Journal

of Continuing Education in the Health Professions 28(3), 117–122.

Straus S.E., Tetroe J. & Graham I. (2009) Defining knowledge

translation. Canadian Medical Association Journal 181(3–4), 165–

168.

© 2013 Blackwell Publishing Ltd 11

JAN: DISCUSSION PAPER Knowledge translation

Sudsawad P. (2007) Knowledge Translation: Introduction to

Models, Strategies and Measures. Southwest Educational Devel-

opment Laboratory, The National Center for the Dissemination

of Disability Research, Austin, TX.

Thompson G.N., Estabrooks C.A. & Degner L.F. (2006) Clarifying

the concepts in knowledge transfer: a literature review. Journal

of Advanced Nursing 53(6), 691–701.

Wallin L. (2009) Knowledge translation and implementation

research in nursing. International Journal of Nursing Studies 46

(4), 576–587.

Ward V., House A. & Hamer S. (2009) Developing a framework

for transferring knowledge into action: a thematic analysis of the

literature. Journal of Health Services Research & Policy 14(3),

156–164.

Williams C.L., Kothari A., Leipert B., Ward-Griffin C., Forbes D.,

King M.L., Kloseck M., Ferguson K. & Oudshoorn A. (2008)

Accelerating client-driven care: pilot study for a social interaction

approach to knowledge translation. Canadian Journal of Nursing

Research 40(2), 58–74.

The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the advancement of

evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance

and with potential to advance knowledge for practice, education, management or policy. JAN publishes research reviews, original

research reports and methodological and theoretical papers.

For further information, please visit JAN on the Wiley Online Library website: www.wileyonlinelibrary.com/journal/jan

Reasons to publish your work in JAN:

• High-impact forum: the world’s most cited nursing journal, with an Impact Factor of 1·477 – ranked 11th of 95 in the 2011 ISI

Journal Citation Reports (Social Science – Nursing).

• Most read nursing journal in the world: over 3 million articles downloaded online per year and accessible in over 10,000 libraries

worldwide (including over 3,500 in developing countries with free or low cost access).

• Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jan.

• Positive publishing experience: rapid double-blind peer review with constructive feedback.

• Rapid online publication in five weeks: average time from final manuscript arriving in production to online publication.

• Online Open: the option to pay to make your article freely and openly accessible to non-subscribers upon publication on Wiley

Online Library, as well as the option to deposit the article in your own or your funding agency’s preferred archive (e.g. PubMed).

12 © 2013 Blackwell Publishing Ltd

I.T. Bjørk et al.