section, fi ve theories, frameworks, and models that can be used to guide and explain KT im plementation strategies are described. KT theories, frameworks, and models Di \200 usion of innovations In his classic and oft -c ited work, fi rst published in 1962, Rogers (2003) describes a theory that seeks to explain the process and rate of spread of an innovation (new ideas or technology) within a social system. Th e theory defi nes four main factors that are infl uen- tial in the process of in novation diff usion: (1) the innovation itself (referring to the idea, the practice or the object that is new); (2) the communication channel (the method used to inform others of the innovation); (3) time (the time taken for an individual to make the transition from fi rst knowledge of the innovation to its acceptance or dismissal); and (4) the social system (th ose involved in decision- making about adoption of the innovation). According to Rogers, di ff usion is a process whereby \200\230(a) an innovation (b) is commu- nicated through cert ain channels (c) over time (d) among the members of a social system \200\231 (2003, p. 11). According to the theory, individuals progress through fi ve stages in the process of decis ion- making about innovation adoption: (1) knowledge \200\224acquiring an awareness and un derstanding of the innovation; (2) persuasion \200\224 the stage of forming an opinion abo ut the value of the innovation; (3) decision \200\224the process of making a decision abou t adoption or rejection of the innovation; (4) implementation \200\224the act of using or applying the innovation in practice; and (5) confi rmation \200\224refl ec- tion upon the decision to adopt or reject the innovation, which may lead to a reversal of the decision. Why use a theory-informed approach to KT? In the fi eld of KT, increasing emphasis has been placed on the importance of using theory to inform: (1) selection and develop- ment of str ategies to promote implementation of KT interven- tions, and (2) evaluation of the implemen tation strategies (Eccles et al., 2005; Rycroft -Malone and Bucknall 2010; Sales et al., 20 06). Systematic review evidence exists for the eff ectiveness of a number of KT interventio ns (Bero et al., 1998; Grimshaw et al., 2001; Oxman et al., 1995; Prior et al., 2008; Wensi ng et al., 2006). However, the evidence indicates that eff ectiveness of such interventions var- ies; they are eff ective in some situations but not all (Hrisos et al., 2008a, 2008b) . A theory-informed approach can help provide an understanding of what has been described a s the \200\230black box \200\231; that is, theory can illuminate how, why and under what c ircumstances an intervention works (Hrisos et al., 2008a, 2008b; Rycroft -Malone, 2007). Ac cording to the UK Medical Research Council Framework for Developing and Evaluating Complex Interventions (2008), interventions should be underpinned by a coherent theory and the theo ry should be used, systematically, to develop the intervention. A theoretical understanding about how an intervention infl uences behavior enables weaknesses in, and barriers to the success of the intervention, to be targeted and overcome. Rogers (2003) suggests that individual (adopter) and setting characteristics infl uence the rate and extent of diff usion of an inno- vation. He defi nes fi ve adopter categories acc ording to the relative speed of uptake of an innovation: What do we mean by theory, frameworks, and models? Th eory Th eories can be used to describ e, explain, and predict, for exam- ple, health professionals \200\231 behaviors related to KT (Rycroft -Malone and Bucknall, 2010). Behavioral theories have been described on a knowl edge continuum ranging from broad to narrow in scope. Mid-range theories, such as the theor y of planned behavior (Azjen, 1991), are less abstract and more concrete compared to macro or grand theories. Mid-range theories are used in KT activi- ties and can focus on changing health professionals \200\231 behaviors at the level of the individual, group, or organiza tion (Rycroft -Malone and Bucknall, 2010). 1. Innovators , also described as venturesome, have an interest in new innovations and are responsible for introducing the new idea to the system. 2. Early adopters readily adopt the new idea, provide advice and information about the inno vation to others within the social network, and assist in hastening the diffusion process. 3. Early majority adopt the new idea following a period of decision- making, and prior to t he average member of the system adopting the initiative. 4. Late majority cautiously adopt the new idea once most other Conceptual framework Conceptual frameworks diff er from theories in that they inform or gui de practice, versus predicting practice (Rycroft -Malone and Bucknall, 2010). Examples of c onceptual frameworks applied to KT evaluations are the Promoting Action on Research Impleme ntation in Health Services (PARiHS) framework (Kitson et al., 1998) and the Knowledge to Ac tion (KTA) framework (Graham et al., 2006). members of the system have embraced the innovation. 5. Laggards who possess somewhat traditional values and are suspi- cious of new ideas are t he last members of the system to adopt the innovation. A critical mass is achieved when enough individuals have decided to adopt the innovation th at its continued adoption becomes self- sustaining. Model Models are more specifi c about the relationships that should be expected between con cepts in the model (Rycroft -Malone and Bucknall, 2010). Th e Ottawa Model of Research Use (Logan and Graham 1998) is an example of a KT model. In the following With respect to the innovation, several characteristics are con- sidered important to adopt ion, including the innovation \200\231s relative advantage (the extent to which the innovat ion is perceived as supe- rior to existing practices or technologies), compatibility (the e xtent to which the innovation is perceived as compatible with existing CHAPTER 61 theory-informed approaches to translating pain evidence into practice 635 values, practices and resources), complexity (perception of the ease with which the innovat ion can be understood and used), trialability (the ease with which the innovation can be tr ialed or tested), and observability (the extent to which the innovation and its eff ects ar e visible) (Rogers 2003). control in the development of interventions to promote the uptake of research evidence in p ractice might contribute to the success of such interventions. Edwards et al. (2001) used t he TPB to identify determinants of nurses \200\231 (including pediatric nurses) intention t o administer opioids for analgesia. Attitudes, subjective norms and perceived control predi cted nurses \200\231 intention to administer opioids to patients experiencing pain, account ing for 39.1% of variability in intention (F(4, 441) = 708, p <0.01). In the health literature, Roger \200\231s (2003) diff usion of innovation the- ory has been highly infl uential and has generally been assumed to represent, or be synonymous with, th e theoretical underpinnings of research utilization or KT. However, according to Estabrooks et al. (2006), this assumption is yet to be rigorously tested. Voepel-Lewis et al. (2008) used diff usion of innovation theory to assess the clini- cal utility of three tools design ed to assess pain in children in order to determine which tools were more likely to be adop ted in clini- cal practice. Th e attributes (complexity, compatibility and relative advanta ge) of the revised-Face, Legs, Activity, Cry, Consolability (r-FLACC) tool (Malviya et al., 2006) and the Nursing Assessment of Pain Intensity (NAPI) (Schade et al, 1996) instrument rated most favorably, when compared with those of the Non-Communicating Children \200\231s Pain Checklist-Postoperative Version (NCCPC-PV) (Breau et al., 2002). Promoting Action on Research Implementation in Health Services (PARiHS) Framework PARiHS is an interactive, multidimensional KT framework. Successful implementation of evidence into practice is defi ned as a function of sources of evidence used to support a practice change , the practice context and strategies to facilitate change (Kitson et al., 1998). Successfu l implementation occurs when the research evidence, practice context in which the change oc curs, and facili- tation strategies used to promote change are \200\230high \200\231 on th e utiliza- tion continuum (Kitson et al., 1998; Rycroft -Malone et al., 2002). Elements of the framework (i.e. evidence, context, facilitation) were identifi ed in a theoretical anal ysis of four case studies (Kitson et al., 1998). Further refi nements to the framework were made through concept analyzes of the three PARiHS elements (Harvey et al., 2002; McCormack et al., 2002; Rycroft -Malone et al., 2004). Rigorous, relevant and generalizable quantita tive and qualitative research evidence such as systematic reviews of, for example, eff ec- tive pharmacological (e.g. Stevens et al., 2013) and non-pharmaco- logical interventions fo r procedural pain in infants (Pillai-Riddell et al., 2011) are rated \200\230high \200\231 on the evidence to practice continuum (Rycroft -Malone, 2004; Rycroft -Malone et al., 2004 ). Knowledge from clinical or practice-based experience and patient experience is considere d \200\230high \200\231 on the evidence continuum when it is refl ected upon, and viewed a s relevant (Rycroft -Malone, 2010). Local data/ information collected from the practice con text is considered \200\230high \200\231 on the evidence to practice continuum when these data are evalu- ated and interpreted as relevant (Rycroft -Malone, 2010). Th eory of planned behavior Th e theory of planned behavior (TPB) is a social cognitive the ory where certain stimuli trigger cognitive processes (thinking), which in turn infl uence an individual \200\231s behavior. Th us, the TPB, which is based on the theory of reasoned action (Azjen and Fishbein, 1980; Fishbein and Azjen, 1975), seeks to predict and explain i ndi- vidual behavior under certain conditions (Azjen, 1991). Intent of the individual to be have in a certain way is central to the TPB. Intention is assumed to refl ect factors that motivate behavior and the strength of the individual \200\231s willingness to behave in a c ertain way; the greater the intent the more likely it is that the behavior will be exhibite d (Azjen, 1991). However, the decision to behave in a certain way must be within the indivi dual \200\231s control (i.e. opportu- nities for the behavior must exist and resources, suc h as time and skills to enable the behavior, must also be available). Th us, carry- ing out the behavior is a function of the opportunities, resources, and the individual \200\231s i ntention to act. Th e concept, perceived behav- ioural control , refers to an individual \200\231s perception of the degree of diffi culty associated with behaving in a certain way . Th is concept is an important element in the TPB, and diff erentiates it from the theory of reasoned action. Th e TPB proposes that intention to act and perceived behavioral contro l are direct predictors of an individual \200\231s behavior (Azjen, 1991). Th e strength of an intention to act or behave in a certain way is determined by the individu- al \200\231s attitudes towards the behavior (based on their beliefs about, and evaluation of, the conse quences of the behavior), subjective norms (beliefs about what others think about the behav ior), and perceived behavioral control . According to the theory, behavior change requires a change in intentions, which in turn requires a change in the beliefs that support the int ention or the introduction of new beliefs (Fishbein and Ajzen, 1975). Context refers to the environment where pain practice change occurs (Kitson et al., 1998; M cCormack et al., 2002). A receptive context includes supportive networks, available resourc es (e.g. human, fi nancial resources), and initiatives that are consistent with an organiza tion \200\231s strategic plans (Kitson et al., 2008; Rycroft -Malone, 2010). Culture, leade rship and evaluation are sub-elements of con- text. Culture is referred to as \200\230the way things are done around here \200\231 (Drennan, 1992). Culture is considered \200\230hi gh \200\231 on the continuum within a supportive learning environment that includes collabo ra- tion/teamwork, and decentralized decision-making (McCormack et al., 2002; Rycroft -Malo ne, 2010; Rycroft -Malone et al., 2004). \200\230High \200\231 leadership occurs when transformational leaders enable, and empower health care professionals to share a common vision by establishing clear roles, and promoti ng teamwork and decision- making (McCormack et al., 2002). Evaluation and feedback regard- ing practice change at the individual, team, and system levels are eff ective when strategi es such as performance audits or feedback from health professionals are incorporated into t he practice change process (McCormack et al., 2002). Th e TPB has been used to study the cognitive processes that motivate individual health pro fessionals to incorporate research fi ndings into their practice (Eccles et al., 2007; Perk ins et al., 2007). Some researchers have found evidence in support of the predic- tive abil ity of the TPB constructs (Eccles et al., 2007; Perkins et al., 2007). Th ese fi ndings ind icate that consideration of attitudes towards the behavior, subjective norms and perceived behavioral Facilitation is defi ned by enabling or making easier, the transla- tion of evidence into p ractice (Harvey et al., 2002). Th e facilitation process occurs on a continuum where the pu rpose or role includes low intensity, episodic contact (task oriented), to high-intensity SECTION 9 special topics 636 Th e Knowledge to Action (KTA) Framework Th e KTA framework is a systems focused framework that can be used to guide health professionals to change their practice (Graham and Tetro, 2007; Graham et al., 2006). Th e KTA framework includes a knowledge creation component and an action cycle (Figure 61.1 ). Th is iterative, interactive framework also includes an ass essment of the local context and culture when planning the implementation of evidence into practice. roles (holistic oriented) that enable individuals to achieve their goals or practice change s (Harvey et al., 2002). Facilitators can be internal or external to an organization and ar e usually appointed to their role (Harvey et al., 2002; Rycroft -Malone et al., 2002). Faci litation is considered \200\230high \200\231 on the knowledge to practice con- tinuum when appropriate supports are utilized, and when task and enabling skills are applied based on the needs of the practice change (Harvey et al., 2002). Kavanagh et al. (2010) applied the three elements from the PARiHS framework to explain the eff ects of an organizational KT in tervention, appreciative inquiry (AI) to improve nurses \200\231 pain practices in a pediat ric setting. Twelve nurse facilitators focused on improving evidence-based pain assess- men t documentation in a pediatric surgical unit. Th e AI proc- ess was viewed as a positive ap proach to change; however, change overload, logistics, busyness of the unit, and lack of or ganized follow-up within the practice context were barriers to the inter- vention implement ation. Application of the PARiHS concepts in this study provided further support for the el ements of this frame- work (Kavanagh et al., 2010). Th e knowledge creation process funnel includes three phases: (1) knowledge inquiry; (2) kn owledge synthesis of best evidence, and (3) development of knowledge tools/products. At eac h phase of the knowledge creation process, knowledge or evidence is further synthesized for the knowledge user. During the knowledge creation phase, knowledge producers identify pote ntially relevant evidence. Synthesis of best evidence involves generation of systematic rev iews and meta-analysis of existing knowledge. Evidence-based clinical practice guidelines a nd decision aids are examples of knowledge tools/products created during the third phase of the knowledge creation process. Knowledge tools/products such as clinical prac- tice guide lines can then be implemented during the action cycle. All phases of the knowledge creation process can be tailored to the needs of the knowledge user. Th e knowledge creation proces s can be used to inform each step in the action cycle, as noted by the dot- ted lines surro unding the knowledge creation funnel. In a study by Stevens and colleagues (2011), three key themes described health professional s \200\231 opinions related to factors that facilitated or hindered pain practices in the n eonatal intensive care unit: (1) the culture of collaboration and support for evidence- bas ed pain practices; (2) threats to autonomy when making deci- sions about pain practices, an d (3) complexity in delivering pain care (Stevens et al., 2011). Th e authors used sub-elem ents of con- text from PARiHS to explain the study results. For example, in the PARiHS fram ework, practice cultures that did not value individu- al \200\231s judgements were consider ed threats to autonomy and therefore were barriers to successful implementation of evidence into prac- tice (Stevens et al., 2011). Th e action cycle refers to activities required to implement knowl- edge or evidence into p ractice and is based on 31 planned action theories that focus on changing how individuals p ractice within a social system (Graham and Tetro, 2010). Th e action cycle consists of seve n phases: (1) identifying the problem, identifying, reviewing and selecting knowledge to tr anslate into practice; (2) adapting/tai- loring knowledge to the practice context; (3) iden tifying barriers and Lost in Knowledge Translation Monitor Knowledge Use Select, Tailor, Implement Interventions Evaluate Outcomes KNOWLEDGE CREATION Knowledge Inquiry e g d wle o n g K Products Tailorin Knowledge Synthesis Assess Barriers to Knowledge Use Knowledge Tools/ Sustain Knowledge Use Adapt Knowledge to Local Context Identity Problem Figure 61.1 Knowledge to Action (KTA) Framework. Reprinted with permission from Ian D. Grah am et al., Lost in knowledge translation: Time for a map? Journal of Continuing Education i n the Health Professions , Volume 26, Issue 1, pp. 13 \200\22324, Copyright 2006 Wiley P eriodicals, Inc, http:// onlinelibrary.wiley.com/journal/10.1002/%28ISSN%291554-558X. Identity, Review Select Knowledge ACTION CYCLE (Application) CHAPTER 61 theory-informed approaches to translating pain evidence into practice 637 facilitators to knowledge use; (4) selecting, tailoring and implement- ing KT interventions ; (5) monitoring knowledge use such as changes in knowledge and attitudes; (6) evaluating h ealth, health care pro- vider and system-related outcomes, and (7) identifying strategies t o sustain knowledge use or a practice change (Graham et al., 2006). Th e steps within the k nowledge to action process are not necessar- ily sequential. For example, identifi cation o f new barriers to practice changes might occur, thus requiring revisions to KT strategies. To date, the KTA framework has not been cited in published paediat- ric pain research. Howe ver, Bandstra (2007) uses components of this framework to describe how translation of evide nce-based paediat- ric psychological pain management interventions (e.g. distraction) could be achieved. In the knowledge creation cycle, Bandstra (2007) emphasizes the importance of developing clinically meaningful and cost-eff ective psychological pain management interve ntions. In the knowledge application or action cycle, a multidisciplinary approach to deliv ering psychological pain management interventions using the steps outlined in the KTA frame work is recommended. Th ere are several assumptions about the KT process that are inherent in the model. First, elements of the OMRU are based on an interactive approach, where KT is achieved through col labora- tion between individuals (i.e. researchers and health professionals; Denis et al., 2004; Graham and Logan, 2004). Secondly, patients and families are integral to the KT proce ss. Finally, aspects of the practice environment infl uence the process of adopting evidenc e (Graham and Logan, 2004). Logan and Graham (2010) propose that additional theories could be applied to the elements of the OMRU. Th e innovation refers to a new guideline, policy, or procedure that would be implemented i nto practice, and it should be evidence- based. Th e innovation attributes refer to the pot ential adopters \200\231 per- ceptions of the relative advantage, complexity, fi t, and fea sibility of the innovation (Logan and Graham, 2010). Potential adopters refer to health pro fessionals, patients, and parents who may adopt the inno- vation. Four sub-elements include : (a) awareness of the innovation, (b) knowledge and intention to adopt the innovation, (c) knowl- edge and skill required to implement the innovation, and (d) con- cerns about the i nnovation or practice change (Logan and Graham, 2010). Th e practice environment includes f our sub-elements: (a) structural factors including decision-making structure, policies, pra ctice standards, physical structure of the practice environment, workload, and current prac tice; (b) culture/social factors including local politics, leadership, peer opinion; (c) pa tients; and (d) eco- nomic factors including available resources (Logan and Graham 2010). I nterventions/KT strategies are tailored to the needs of potential adopters. Interventions a re described within three sub- elements: (a) barrier management strategies to promote adopt ion of the innovation; (b) transfer strategies used by facilitators to train potential adop ters, and (c) follow-up strategies to ensure uptake and sustainability of the innovation. A series of steps are used in the adoption process including testing the innovation and sust ain- ing its use. Success of the innovation is measured by patient, health professionals, a nd system outcomes. Ottawa Model of Research Use Th e Ottawa Model of Research Use (OMRU) is an interactive, pl anned action model of change (Logan and Graham, 1998, 2010). Th e OMRU includes six element s that are assessed, monitored and evaluated prior to, during and aft er KT interventions h ave been implemented: (1) evidence-based innovation; (2) potential adopters; (3) practice e nvironment; (4) knowledge translation (KT) strategies to translate evidence into practice; (5) adoption and use (both initial and sustained) of the evidence, and (6) out- comes (Loga n and Graham, 1998, 2010) (Figure 61.2). Th e ele- ments of this model are grounded in Roge rs \200\231 (2003) diff usion of innovations theory, and health behavior change. Barriers t o and facilitators of research utilization are identifi ed in the fi rst three elements and are used to develop and guide the intervention. Th e OMRU has been applied at the level of individuals, teams, organ- izations, and healthcare systems (Graham and Logan, 2004). Assess barriers and supports Monitor process and degree of use Evaluate impact + + Innovation \200 Development process \200 Innovation attributes Potential adopters \200 Awarness \200 Attitudes/intention \200 Knowledge/skill \200 Concerns Interventions \200 Barrier management \200 Transfer \200 Follow-up Outcomes \200 Patients \200 Practitioner \200 System Adoption \200 Initial use \200 Sustained use Practice environment \200 Structural \200 Culture/social \200 Patients \200 Conomic Figure 61.2 Ottawa Model of Research Use. Reproduced with permission from J. Logan and I. D . Graham, Th e Ottawa Model of Research Use in Rycroft-Malone and Tracey Bucknall (eds.) Mo dels and Frameworks for Implementing Evidence-Based Practice: Linking Evidence to Action , Wiley-Blackwell, Chichester, UK, Copyright 2010. Originally adapted from I. D. Graham an d J. Logan, Translating Research: Innovations in Knowledge Transfer and Continuity of Care, Canadian Journal of Nursing Research , Volume 36, Issue 2, pp. 89 \200\223103, Copyright 2004. Th is excerpt is reproduced under a license given by Copibec. SECTION 9 special topics 638 Case example Context During the implementation of KT strategies to improve pain assessment practices, pa in became a hospital wide priority and a component of the hospitals \200\231 strategic plan . Senior medical and nursing staff in the NICU began to discuss PIPP pain intensity scores and pain management strategies during daily patient rounds. Th ese transformational leaders contributed to change in pain assessment practices at the local level. Staff were updated at regularly scheduled unit workshops that included education on pain assessment. Creating an awareness of the importance of pain assessment contributes to a receptive practice conte xt for change. As part of the EPIQ implementation process the RPC, supported by the unit ed ucator, evaluated the practice change by conducting regular practice audits; the results of which were fed back to the unit. A 6-month audit showed that documentation of PIPP scores had improved from 15% to 75%. Th e practice aim was achieved and pain assessment using the PIPP became part of unit culture over time. Th e following example illustrates application of the elements of the PARiHS framework to g uide implementation of a KT inter- vention to improve pain practices in infants. Th e Evide nce-Based Practice for Improving Quality (EPIQ), an interactive KT inter- vention developed by Lee et al. (2009), has been shown to improve health professional practices in relation to reducing nosocomial infection and chronic lung disease in NICUs (Lee et al., 2009). Cont inuous quality improvement methods that incorporate Plan-Do-Study-Act (PDSA) cycles are emb edded within the EPIQ intervention. Stevens et al. (2011) recently applied a more tailored version of EPIQ to improve pediatric pain practices in medical, surgical and critical care hospital units across pediatric tertiary care centers in Canada. Th e EPIQ intervention con sists of two phases: in the fi rst phase of EPIQ, known as the Preparation Phase, a multidi sciplinary group of health professionals known as the Research Practice Council (RPC) are i dentifi ed as facilita- tors of the practice change(s). Th ese individuals review sources o f evidence to highlight a research or evidence-to-practice gap. Th e implementation and cha nge phase is the second phase of EPIQ whereby the RPC introduces evidence-based KT strate- gies to encourage health professionals to modify their current practices. An initial assessment of the potential barriers and facilitators, potential adopters and th e practice environment is required prior to implementing the intervention. Ongoing monitori ng of the intervention implementation and degree of adoption will contrib- ute to tailoring of the intervention to achieve the desired outcomes. Th e impact of the innovation is meas ured by evaluating patient, practitioner and system outcomes. Evidence During the Preparation Phase, RPC members in a neonatal intensive care unit (NICU) evaluated the units \200\231 pain assessment and management practices by evaluating local evidence in the form of a chart audit. A review of medical charts prior to the intervention indicated that pain assessment using the Premature Infant Pain Profi le (PIPP: Stevens et al., 1996) was documented in patient charts only 15% of the time. RPC members and health pr ofessionals confi rmed a need to improve pain assessment prac- tices in the unit. A recent systematic review supported the strong psychometric properties of the PIPP to assess proced ural pain in infants (Stevens et al., 2010). Th erefore, local evidence, clinical evidence and research evidence contributed to identifying gaps and supporting evidence-based pain pr actices. Th e RPC aimed to improve pain assessment documentation using the PIPP to 50% over the following 6 months. Ellis and colleagues (2007) implemented and evaluated a com- prehensive pain management pro gram (CPMP) to improve pae- diatric nurses \200\231 pain practices with hospitalized childr en. A nursing management team developed a 4 h pain education workshop that focused on pain assessment and management strategies and they, along with pain resource nurse champions, im plemented the CPMP components using various modes of delivery, including email, news- lette rs, information pegboards, and audit and feedback. Th e OMRU was used to guide, monitor and evaluate the implementation of the CPMP. Th e authors monitored nurses \200\231 adoption o f pain practices by evaluating process outcomes that included aspects of the prac- tice env ironment, nurses \200\231 pain assessment and management knowl- edge, attitudes and skill, and KT strategies used to promote pain practices. Practice outcomes were measured using pai n audits pre and post intervention implementation. Focus groups were used to identify barri ers, facilitators and factors that infl uenced implemen- tation of the CPMP. Statistically signifi cant improvement in nurses \200\231 perceptions about the adequacy of their pain as sessment (p <0.004), and management (p <0.017) practices were noted as well as statisti- ca lly signifi cant improvements in use of pain measures (p = 0.005) and pain assessment narra tives (p <0.01). Facilitation In the second phase of EPIQ, the RPC, as facilitators of practice change, impl emented evidence-based KT strategies to improve use and documentation of the PIPP. Th e RPC members were individuals who, in accordance with the requirements of the PARIHS framework, have the skills and ability to assist individu- als, teams, and organizations to translate evidence into practice (Rycroft -Malone, 2010). Th e RPC engaged in task-based activities by organizing educational sessions for staff nurses on how to use and document the PIPP. Po sters were situated in patient rooms to remind health professionals to assess and document pain intensity scores for their patients using the PIPP. Additionally, the RPC used a holis tic approach to improving pain assessment practices by empowering unit staff to refl ect on the KT strategies implemented and to participate in tailoring strategies based on the need s of the unit. Implications for practice and education, research, and theory Evidence-based KT strategies Evidence-based KT strategies can facilitate integration of pain evi- dence into practice. F or example, the use of reminders to promote health professionals \200\231 use of guidelines has been shown to produce small to moderate improvements in care (Grimshaw et al., 2004; P rior et al., 2008). Audit and feedback alone or in combination CHAPTER 61 theory-informed approaches to translating pain evidence into practice 639 PARiHS framework, consists of eight concepts that are used to meas- ure organizational cont ext in healthcare settings. Th e ACT has been validated in a sample of eight pediatric hosp itals that participated in the Translating Research on Pain in Children (TROPIC) study (Ste vens et al., 2008 \200\2232012) (Estabrooks et al., 2011). McCormack and colleagues (2009) have developed the Context Assessment Index (CAI), also based on the PARiHS framework, to p rovide health professionals with a tool to assess their practice context and readiness for use of evidence in practice. Testing of this instrument in pediatric settings has not yet b een undertaken. with other strategies has been shown to have small but important eff ects in health care pr ofessionals \200\231 practices (Ivers et al., 2012). Educational strategies, specifi cally educational outreach, have been shown to result in small to moderate improvements in patien t care (Cochrane Eff ective Practice and Organization of Care Review Group, 2002; Grimshaw et al., 2004; Prior et al., 2008). Local opin- ion leaders (e.g. health care professionals who are members of the unit pain committee), alone or in combination with other interven- t ions, may also facilitate the integration of evidence into practice (Flodgren et al., 2011) . Understanding the context of practice Th e context of healthcare has been conceptualized in diff erent ways, ranging from the physical environment, as the most basic concep- tualizat ion, to more complex defi nitions such as that proposed by French: \200\230the organizatio nal environment of health care, composed of physical, social, political, and economic infl uences on the practi- cal reasoning and choices of practitioners about how clinical issues are address \200\231 (2005, p. 174). Promoting and sustaining behavior change Th e tendency for health professionals to adhere t o tradition and rituals and to become automated in their practice (Kerfoot, 1999; Monforto et al., 2012) means that unlearning previously well-entrenched behav- iour is necessary in order for them to adopt new evidence and modify their clinical practice accordingly. Docume nting PIPP scores 75% of the time in patient charts is an example of a notable improvement in clinical practice. However, sustaining this practice improvement remains a challenge and should be a focus of future research Over the past 20 years, studies conducted in several countries to examine the barriers to u se of research in practice have consistently highlighted the importance of time to implemen t change, time to read research, the nurse \200\231s authority to change practice, reportin g of understandable statistical analyzes in the research literature, and accessibility of r elevant literature, as the most prominent barriers to KT (Carlson and Plonczynski, 2008; Hu tchinson and Johnston, 2006; Kajermo et al., 2010). KT initiatives should, therefore, take into consideration the potential for such barriers to impede uptake of pain evidence within the specifi c practice context and incorpo- rate strategies to minimize or overcome them. Creating opportunities for interactive sharing of new knowledge, peer review, and dialog an d debate about how evidence could be incorporated into practice, are strategies that can be used to promote and sustain behavior change in order to facilitate KT. Additionally, promo ting positive attitudes and approaches towards pain assessment practices, engaging health p rofessionals in refl ec- tive practice, leadership that includes ongoing support, education , commitment to the practice change and performance evaluation can support and help sustain integration of evidence into practice (Davies et al., 2010). While much of the early work in the fi eld of KT focused on char- acteristics of the indivi dual and the research itself, it has become increasingly evident that the context in which knowledge is used is another important ingredient in the KT equation. In particular, eviden ce that research is adopted at diff erent rates and with diff er- ent levels of success in diff erent contexts has highlighted the impor- tance of context. In light of empirical evid ence to indicate that context can infl uence the success of KT (Cummings et al., 2007, 2010 ), it is essential that a careful assessment is undertaken of the pediatric healthcare cont ext in which pain evidence is to be imple- mented. Strengths and weaknesses in contextual c haracteristics can then be taken into account; capitalizing on the strengths and imple- men ting strategies to overcome or reverse the weaknesses. As well as identifi cation of potent ial barriers or challenges, an assessment of the receptiveness or readiness of the context to change is impor- tant. Meetings with key stakeholders (including health profession- als, administrators, educators and children and families) may be helpful in revealing issues an d concerns that should be taken into consideration. In summary, a theory-based approach to KT research can be used to guide and plan the study design, data collection methods, and analysis. Additionally, theoretical concepts can be us ed to explain study results and strengthen the construct validity of the specifi c theory, conceptual frameworks, and models used. Further, evi- dence-based KT strategies (i.e. educa tional strategies, reminders, audit and feedback) can be used to promote pain practice chan ges. References Azjen, I. (1991). Th e theory of planned behavior. Organ Behav Hum Decis Process , 50 , 179 \200\223211 . Azjen, I. and Fishbein, M. (1980). Understanding attitudes and predicting social behavior. Englewood Cliff s, NJ : Prentice-Hall . American Academy of Pediatrics. (2000). Prevention and management of pain and stress in the neonate. Pediatrics , 105 , 454 \200\223461 . Anand K.J., Aranda J. V., Berde C. B., Buckman, S., Capparelli, E. V., Carlo, W., et al . ( 2006). Summary proceedings from the neonatal pain-control group , Pediatrics , 117 , S9 \200\223S22 . anonymous. (2000). Prevention and management of pain and stress in the neonate. American Ac ademy of Pediatrics. Committee on Fetus and Newborn. Committee on Drugs. Section on Anesthe siology. Section on Surgery. Canadian Pediatric Society. Fetus and Newborn Committee. [Guid eline Practice Guideline]. Pediatrics , 105 (2), 454 \200\223461 . Several measures have been developed for health professionals and researchers to evaluate t he practice context. Kitson et al. (2008) developed a practical diagnostic assessment tool (which comple- ments the PARiHS framework) to inform development of an imple- mentation str ategy. Th e tool is designed, to help identify aspects of the current environment or contex t that need to be addressed in order to optimize KT. An aggregated score can be plotted on an evaluative grid to enable visualization of the level of facilitation support required to optimize implementation. Th e Alberta Context Tool (ACT) (Estabrooks et al., 2009), based on elements from the Bandstra, N. (2007). Knowledge translation in psychological interventions for pediatric pai n: bridging the gap between research and practice . In C. L. von Baeyer (ed.) Pediatric pai n letter , 9 (3). Available at: <http:// childpain.org/ppl/issues/v9n3_2007/v9n3_bandstra.p df>. Batton, D. G., Barrington, K. J., and Wallman, C. (2006). Prevention and management of pain in the neonate: an update. Pediatrics , 118 , 2231 \200\2232241 . SECTION 9 special topics 640 Bero, L. A., Grilli, R., Grimshaw, J. M., Harvey, E., Oxman, A. D., Th omson, M. A. (1998). Getting research fi ndings into practice: closing the gap between research and practice: a n overview of systematic reviews of interventions to promote the implementation of research fi ndings. Br Med J , 317 , 465 \200\223468 . Estabrooks, C.A., Th ompson, D. S., Lovely, J. J., and Hofmeyer, A. (2006). A guide to know ledge translation theory. J Contin Educ Health Prof , 26 , 25 \200\22336 . Fishbein, M. and Azjen, I. (1975). Belief, attitude, intention and behavior. an introduction to theory and research . Reading, MA : Addison-Wesley . Flodgren, G., Parmelli, E., Doumit, G., Gattellar i, M., O \200\231Brien, M. A., Grimshaw, J., et al . (2011). Local opinion leaders: eff ect s on professional practice and health care outcomes. Cochrane Database Syst Rev , 8 , CD000 125 . DOI: 10.1002/14651858.CD000125.pub4. Breau, L. M., Finley, G. A., McGrath, P. J., and Camfi eld, C. S. (2002). Validation of the Non-communicating Children \200\231s Pain Checklist- Postoperative Version. Anesthesiology , 96 , 528 \200\223535 . Carbajal, R., Rousset, A., Danan, C., Coquery, S., Nolent, P., Ducrocq, S., et al . (2008). Epidemiology and treatment of painful procedures in neonates in intensive care units. JAMA , 300 , 60 \200\22370 .