Commentary on "moving research knowledge into dental hygiene practice".

Abstract

Dental hygiene, as an emerging profession, needs to increase the number of intervention studies that identify improvements in oral health outcomes for clients. Historically, dental hygiene studies have typically been atheoretical, but the use of theoretical frameworks to guide these studies will increase their meaningfulness. Rogers' theory of diffusion of innovations has been used to study research utilization across many disciplines, and may offer insights to the study of research use in dental hygiene. Research use is an important component of evidence-based practice (EBP), and diffusion of research knowledge is an important process in implementing EBP. The purpose of this paper is to use diffusion of innovations theory to examine knowledge movement in dental hygiene, specifically through the example of the preventive practice of oral cancer screening by dental hygienists, considered as an innovation. Diffusion is considered to be the process by which an innovation moves through communication channels over time among a social network. We suggest diffusion theory holds promise for the study of knowledge movement in dental hygiene, but there are limitations including access to and understanding research studies as innovations. Nevertheless, using a theoretical framework such as Rogers' diffusion of innovations will strengthen the quality of intervention research in dental hygiene, and subsequently, health outcomes for clients.

Key words: Diffusion of innovations, evidence-based practice, research utilization, theoretical frameworks, dental hygienists

Background

Evidence-based practice (EBP) contributes to optimal oral health outcomes for dental hygiene clients, yet dental hygienists' practice behavior varies; for example, with oral cancer screenings (OCS). With OCS, studies have found that in many cases, practitioners' knowledge was not consistent with current scientific findings, and when knowledge was current, practices were not consistent with that knowledge. (1-3) Research utilization is an important component of EBP, and diffusion of research knowledge is an important process in implementing EBP. The process appears to be more complex than existing models for EBP suggest, with their focus on individual actions to seek new knowledge. (4-7) We need to study how research knowledge moves into practice in dental hygiene, to promote EBP using mechanisms consistent with empirical findings about successful knowledge movement. Using a theoretical framework, such as Rogers' theory of diffusion of innovations, provides a mechanism for studying knowledge movement, or diffusion, among practitioners. (8) In this paper, Rogers' theory of diffusion is used as a framework for examining, via existing literature, complexities associated with movement of research knowledge regarding OCS into practice.

Rogers' Theory of Diffusion of Innovations

Rogers defines diffusion as the process by which an innovation is communicated through certain channels over time among members of a social system. (8) Many studies have described the spread of change as innovations have diffused through given populations, (9) examining relationships between attributes of the innovation, communication channels used to spread knowledge of the innovation, characteristics of the social system of potential adopters, and the time it takes for implementation to occur. This paper looks at OCS in terms of each element of the diffusion process.

Oral cancer is the only known oral disease or condition that can and does lead to death or severe disfigurement. Dental hygienists can contribute to reducing morbidity and mortality associated with these cancers. (1) Although its advantages have been widely known for some time, OCS is not yet adopted consistently due to the following factors.

* Dental hygienists perceive a lack of time and lack of expectation on the part of their employer dentists to conduct OCS. (2)

* Dental hygienists feel discomfort and uncertainty about their skills for providing OCS. (2)

* The majority of dental hygienists probed for present tobacco use, but fewer probed for past tobacco use, and still fewer probed for present or past alcohol use. (3)

* Inconsistency exists between knowledge and practitioner behavior with regard to OCS. (1,10)

Innovation Attributes

Between 49 percent and 87 percent of the variance in adoption rates can be explained by five attributes of the innovation, as perceived by potential adopters. (11) If an innovation has a greater relative advantage than the idea it is replacing; is more compatible with existing values, beliefs, past history and needs of potential adopters; has low complexity and is easy to understand and use; can be tried in a small way to see its advantages; and can be observed by those considering adoption, that innovation is more likely to diffuse rapidly.

OCS may not be perceived as an advantage, as it does not replace an existing practice and may be perceived to take more time than is available. The fact that early detection influences survival (1) is consistent with the notion of greater relative advantage, but several factors, including confidence in skills and knowledge, perceived time constraints, and unclear influence of practice context for supporting routine OCS by hygienists, suggest that the advantage of early detection may be moderated by other influences.

OCS is compatible with dental hygiene's existing values of disease prevention and health promotion, aligning with professional rather than occupational models of practice, (12) yet some dental hygienists still believe it is the dentists' role. (1)

Innovations of low complexity diffuse more rapidly. Screening has been taught to other primary health practitioners in one hour, using a standardized form to identify and refer lesions. (13) OCS can be a "death-defying act" requiring only minutes of time, (14) but one explanation for dental hygienists' reluctance to perform this seemingly low-complexity screening may be that OCS also uses higher complexity skills of interpretation and judgment.

Communication Channels

Different communication channels are more useful at different times for diffusing different kinds of knowledge. There are three main types of knowledge about innovations: awareness knowledge--that the innovation exists; how-to knowledge--the user's individual or subjective evaluation knowledge that comes from evaluating how they incorporated it into practice; and principles knowledge--functioning principles underlying how it works. (8) Mass media channels work best for awareness knowledge, and interpersonal channels work best for "how-to" knowledge. Awareness knowledge can be communicated from outside the social system, but diffusion studies show that, aside from the most innovative of potential adopters, most do not make decisions to adopt on the basis of scientific studies. (8,9) Most people within a social system prefer to receive subjective evaluation information, "how to" knowledge, about an innovation from a near-peer, primarily through social interaction. Dental hygienists increasingly request continuing education (CE) about oral cancer and performing OCS, yet CE has not translated into changed practice behaviors, (1-3) and studies of knowledge sources show high use of interpersonal (15,16) and experiential (17) sources. Dental hygienists' comfort with principles knowledge of OCS may be influenced by lack of consensus among guidelines regarding the procedure. The American Cancer Society (ACS) recommends routine screening every three years for those between ages 20 and 40, and annually for those 40 and over. The Canadian Task Force on Periodic Health Examination (CTFPHE) does not include a recommendation for OCS, but this stems from lack of evidence rather than evidence of no benefit. (1)

Time

The decision to adopt an innovation occurs through five steps over time: knowledge of existence of the innovation; persuasion or forming a favorable or unfavorable attitude; the decision to adopt or reject; implementation (may involve reinvention to fit local context); and confirmation, when the adopter seeks support to confirm the decision is right. The length of time for the decision period varies, and can take years from awareness to adoption and confirmation. (2) No studies have looked at time related to diffusion within dental hygiene.

Social System

Spread of adoption is influenced by adopter characteristics relating to how quickly they adopt new ideas. Studies have found these groups approximate a normal frequency distribution. (8) See Figure 1 for frequency distribution of adopter categories. There are five groups:

* Innovators: 2.5 percent of the total population, 2 standard deviations (S.D.) above the mean, active information seekers, wide external networks, travel further to communicate with others, high degree of media exposure (8)

* Early adopters: 13.5 percent, between 1 and 2 S.D. above the mean, more connected to the local social system than innovators, high degree of local opinion leadership, some network connections outside of the local system, communicate readily with each other, have short innovation-decision time (8)

* Early majority: 34 percent; 1 S.D. above the mean; adopt just before the average adopter; well connected with peers in local network; not opinion leaders but watch opinion leaders' actions; rely on personal familiarity, rather than science, to assist decision to adopt. (9) At this point, adoption reaches "critical mass," when diffusion spreads with less external influence and more internal influences and information sharing. (8)

* Later majority: 34 percent, 1 S.D. below the mean, more conservative, adopt as a result of peer pressure, adopt after all uncertainty has been removed (8)

* Laggards: 16 percent; over 1 S.D. below the mean; smaller, locally based social system networks; may be resistors or just ultra-cautious and wishing to stay with the "tried and true." (9)

So what do we know about the influences of the social system on dental hygienists' uptake or adoption of research findings?

* An early study (1995) found the main sources of practice information were discussions with colleagues and browsing journals, books, and newsletters, while conducting or having someone else conduct a database search was used infrequently. (18,19)

* A study of diffusion of a fluoride guideline found that the most frequently used information sources were discussions with colleagues, journal articles, mailings from professional associations and licensing bodies, textbooks and CE courses. Usage of computerized information sources was low, but this study (1996) was early relative to general diffusion of computers. (16)

* Practitioners most frequently used CE courses, journals, asking a dentist, newsletters and asking a dental hygiene colleague. The increase in use of computer-based information sources among dental hygienists, including Internet and databases, was possibly consistent with increased computer use in general (2002).

* Reading research articles in professional journals was the most frequently reported research-related activity among Swedish dental hygienists, followed by sharing research findings with colleagues. Higher support for research use was found in public health settings and may be related to groups of dental hygienists working in such settings providing opportunity for discussions. (20)

* Top knowledge sources used by Alberta dental hygienists include information learned about each patient/client as an individual, personal experience of dental hygiene patients/clients over time, and information obtained from attending inservices/conferences. The least likely source was "information I get by searching PubMed," a step recommended in EBP approaches. (17)

* Findings about discussions with colleagues is consistent with diffusion literature that suggests the importance of interactivity for knowledge transfer. (8,11)

* Teaching the skills necessary for EBP varies across dental hygiene programs (21) and is more likely to be found in baccalaureate curricula than associate degree or diploma-level programs. Often, application of this knowledge does not extend to making patient/client decisions at chairside. (22)

* Differences exist between U.S. dental hygiene educators and practitioners, with educators more likely to be classified as early adopters or early majority, and practitioners more likely to fall into late majority or laggard classifications. (15)

Challenges to Moving Research Knowledge into Practice

Dental hygienists face challenges in movement of knowledge from research into practice. Models for EBP include locating, accessing and appraising relevant systematic reviews or research studies, then applying and evaluating the new knowledge in practice. (4-7,23) Sometimes dental hygienists do not have access to research literature (as research journals typically have limited circulation among practitioners) nor appropriate skills to appraise it, and they may not have the authority over their own practice to implement the innovations. Dental hygienists work in relative isolation, without social interaction opportunities favored for knowledge transfer. Interprofessional conflict and patriarchal traditions have influenced dental hygienists' authority over their practice, but increases in legislated autonomy may facilitate more timely uptake of research findings. There may be conflicting perspectives about the dental office/practice among the individuals involved--is it to be a health service provider, or a small business with a profit-driven orientation? While an uncomfortable thought, and largely unacknowledged, this could affect the choice of evidence to support decision-making in practice. The influence of these conditions needs to be studied to determine how they constrain or facilitate strategies for successful EBP.

What Are the Implications for Practice?

* Practitioners should seek CE opportunities consistent with their characteristics as an adopter. Those in the early majority can seek interactions with opinion leaders, and those in the later majority can seek interactions with their peers to get subjective evaluation information to help their decision-making. Adopters may display differing characteristics regarding different innovations.

* Practitioners who have incorporated an innovation, for example routine OCS, into their practice need to share their successful implementation strategies with their peers.

* CE facilitators should structure sessions to provide opportunities for interaction and exchange of feedback regarding implementation of the innovation.

* Researchers need to use theoretical frameworks, where applicable, in their research designs to strengthen the science. For example, Rogers' theory of diffusion provides a good framework to study movement of research knowledge into dental hygiene practice.

Conclusions

While Rogers' theory of diffusion of innovations holds promise to study knowledge transfer in dental hygiene, including OCS, there are limitations. One challenge to use of diffusion theory is whether the findings of research should be considered the innovation, or whether a communication vehicle, such as a clinical practice guideline, should be considered the innovation. Studying diffusion of translated research, such as a clinical practice guideline, may be more accessible and understandable, but use of practice guidelines in dental hygiene is not yet common. (20)

Dental hygiene could benefit from a facilitation role to communicate new research findings such as a Clinical Nurse Specialist or Clinical Nurse Educator, as found in nursing, (24) but such a role is unlikely in the small-business setting of clinical dental practices. However, public health dental programs may be ideal locations for such a role.

We need to increase the number of intervention studies that seek to move knowledge from research more rapidly into practice. The use of a theoretical framework will improve the quality of these studies, and Rogers' theory of diffusion of innovations holds promise for this purpose. Here diffusion theory is used to examine movement of knowledge about OCS in dental hygiene practice, and to identify its strengths and limitations. This knowledge can be useful in design of theoretically driven clinical trials to test interventions.

Acknowledgments

The author thanks Karen Golden-Biddle, PhD, for her constructive and helpful comments on an earlier version of this paper, Eunice Edgington and Joanne Clovis for their work on the paper that appeared in Journal of Dental Hygiene, and Nigel Brachi for preparation of the graphic representing distribution of the adopter categories.

ADHA members can access the full article online at http://adha.publisher.ingentaconnect.com/ content/adha/jdh.

Glossary of Terms

Adopters: Members of a social system to which an innovation has been introduced, typically categorized by the rate or timing at which they incorporate a new practice

Diffusion of innovations: The process by which an innovation is communicated through certain channels over time among the members of a social system (8)

Empirical: Based on observations/data collected during research

Evidence-based practice (EBP): An approach to practice that integrates the best external evidence with individual clinical expertise and patients' choice (25)

Guideline or clinical practice guideline: Statement that is based on research and includes information about the process used to develop it; may be used by patients/clients or health professionals for diagnostic, preventive, or therapeutic decisions (see the National Guideline Clearinghouse at www.guideline.gov)

Innovation: An idea, object, or practice that individuals perceive as new; it may have been in existence for some time, but may not have been adopted by all members of a social system yet (8)

Knowledge transfer: An intentional process that transfers knowledge (e.g. research findings) from the creators (e.g. researchers) to the users

Oral cancer screenings (OCS): Although 'screening' and 'examination' are sometimes used interchangeably, 'screening' and 'oral cancer screening (OCS)' are used where a screening implies the potential for referral for further in-depth examination, whereas an examination leads to a diagnosis (26)

Research utilization: The application or use of findings from research in any aspect of practice; includes three types: direct, indirect or persuasive research utilization (27)

Theoretical framework: An existing theory used to explain anticipated actions of the variables in a study

References

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Sandra J. Cobban, RDH, MDE, is an associate professor in the Dental Hygiene Program at the University of Alberta in Edmonton, Alberta, Canada. She is currently a PhD student in the Knowledge Utilization Studies Program in the Faculty of Nursing at the University of Alberta. She has been studying research utilization by dental hygienists, and her doctoral work will include studying research uptake regarding mouth care in long-term care. She has been a fulltime faculty member at the University of Alberta for 10 years, prior to which she worked in public health in rural communities throughout Alberta.

Figure 1. Distribution of Adopter Categories on the Basis of
Innovativeness.

Innovators:         25%
Early adopters:   13.5%
Early majority:     34%
Late majority :     34%
Laggards:           16%

Note: Table made from bar graph.