Articles

Knowledge Translation in Audiology:

Promoting the Clinical Application
of Best Evidence

Trends in Amplification
15(1-2) 522
The Author(s) 2011
Reprints and permission:
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DOI: 10.1177/1084713811420740
http://tia.sagepub.com

Sheila T. Moodie, MClSc1, Anita Kothari, PhD2, Marlene P. Bagatto, AuD1,

Richard Seewald, PhD1, Linda T. Miller, PhD3, Susan D. Scollie, PhD1

Abstract
The impetus for evidence-based practice (EBP) has grown out of widespread concern with the quality, effectiveness (including
cost-effectiveness), and efficiency of medical care received by the public. Although initially focused on medicine, EBP principles
have been adopted by many of the health care professions and are often represented in practice through the development
and use of clinical practice guidelines (CPGs). Audiology has been working on incorporating EBP principles into its mandate
for professional practice since the mid-1990s. Despite widespread efforts to implement EBP and guidelines into audiology
practice, gaps still exist between the best evidence based on research and what is being done in clinical practice.A collaborative
dynamic and iterative integrated knowledge translation (KT) framework rather than a researcher-driven hierarchical approach
to EBP and the development of CPGs has been shown to reduce the knowledge-to-clinical action gaps. This article provides a
brief overview of EBP and CPGs, including a discussion of the barriers to implementing CPGs into clinical practice. It then
offers a discussion of how an integrated KT process combined with a community of practice (CoP) might facilitate the
development and dissemination of evidence for clinical audiology practice. Finally, a project that uses the knowledge-to-action
(KTA) framework for the development of outcome measures in pediatric audiology is introduced.
Keywords
audiology, evidence-based practice, knowledge translation, knowledge-to-action, community of practice

Evidence-Based Practice (EBP)

The origins of evidence-based practice (EBP) come largely
from clinical medicine. The EBP paradigm provides techniques
and procedures to critically examine the abundance of scientific evidence in order to assist clinical decision making and
improve the quality, effectiveness, and efficiency of health
services received by the public. The desired clinical outcome
of EBP is an increase in the number of patients who get treatment of proven quality and effectiveness. The generally
agreed-upon definition of EBP is that it is the conscientious,
explicit and judicious use of current best evidence in making
decisions about the care of individual patients. Evidence-based
practice integrates individual clinical experience with the best
available external clinical evidence from systematic research
(Sackett, Rosenberg, Muir Gray, Haynes, & Richardson, 1996,
p. 71). Incorporating evidence into practice is regarded as a
process that begins with a search for research literature
about how best to solve specific clinical problems and results
in treatment decisions based on the best possible evidence
(Stetler, 2001). As clinicians and their organizations learn
more about EBP and the components of EBP, workshops,
seminars, training kits, books, and educational opportunities

have been developed to assist clinicians in developing the

necessary EBP skill set that includes the ability to develop
focused and appropriately structured clinical questions, search
and locate high-quality evidence in the literature, evaluate
the strength of the evidence, critically appraise the evidence,
and implement evidence within the clinical context.

Evaluating the Strength of the

Evidence: Hierarchy of Evidence
In order to provide professionals with a method for ranking
the quality of research, hierarchies of evidence were intro1
National Centre for Audiology, Faculty of Health Sciences, University of
Western Ontario, London, Ontario, Canada
2
Faculty of Health Sciences and Schulich School of Medicine & Dentistry,
University of Western Ontario, London, Ontario, Canada
3
Faculty of Health Sciences and School of Graduate and Postdoctoral
Studies, University of Western Ontario, London, Ontario, Canada

Corresponding Author:
Sheila T. Moodie, MClSc, National Centre for Audiology,
University of Western Ontario, 1201 Western Road,
Elborn College Room 2262K, London, ON, Canada, N6G 1H1
Email: sheila@nca.uwo.ca

Trends in Amplification 15(1-2)

Table 1. Level of Evidence Hierarchy for high-quality studies

Level
1
2
3
4
5
6

Type of Evidence
Systematic reviews and meta-analyses of
randomized controlled trials or other highquality studies
Randomized controlled trials
Nonrandomized intervention studies
Nonintervention studies; cohort studies, casecontrol studies, cross-sectional surveys
Case reports
Expert opinion

Source: From Evidence-based practice in provision of amplification, by R.

M. Cox (2005). Journal of the American Academy of Audiology, 16(7), p. 430.
Copyright 2005 by American Academy of Audiology. Reprinted with
permission.

duced in the early 1990s. According to Rolfe and Gardner

(2006), this notion of a tree-like hierarchy was evident in the
seminal 1992 paper on EBP published by the evidencebased medicine working group (EBMWG), and although it
has been modified somewhat since that time, it still exists
today (EBMWG, 1992). Table 1 shows an applied hierarchy
of evidence used in the profession of audiology (Cox,
2005). At the bottom of this hierarchy is expert opinion and
case reports, which are often seen as unsystematic and
subject to bias, thus making them the least trustworthy
sources of information to use when making treatment
decisions. Randomized controlled trials (RCTs) are viewed
as the gold standard and are regarded as the most trustworthy sources of evidence because they are systematic and
bias is greatly reduced; therefore, they receive the highest
ranking in the hierarchy.
It should be noted here that the requirement of randomized controlled trials (RCTs) as the highest level of evidence
in pediatric audiology presents considerable challenges. The
incidence rate of permanent childhood hearing impairment
of reportedly 1-3/1,000 births (Hyde, 2005a) can make obtaining sufficient sample sizes for RCTs in order to detect a clinically important effect difficult. It may also mean that pediatric
audiology RCTs would have to be multisite in nature, and
this could become relatively expensive and time intensive.
There is certainly a lack of pediatric audiology research centers and researchers relative to adult audiology research
centers. There are also unique ethical considerations when
conducting research with very young children, including
concerns about consent by proxy and financial incentives to
parents for enrolling their children in research studies (Cohen,
Uleryk, Jasuja, & Parkin, 2007).
The historical purpose of EBP was to blend the clinical
experiences of health care professionals: their skill and
understanding of individual patients needs, with their knowledge about the strengths, weaknesses, applicability of the
evidence, and the clinical significance of the treatment under

consideration (Bess, 1995; Cox, 2005; Jerger, 2008; Palmer,

2007). The contemporary purpose of using an evidence-based
approach to clinical practice is to close the gap between
research and practice, reduce practice variation, and to ultimately improve patient care based on informed decision making. To start, locating and appraising the scientific literature
can be a formidable task. Catherine Palmer and colleagues at
the University of Pittsburgh have provided audiologists with
a helpful article to assist with evaluation of the research literature in audiology (Palmer et al., 2008). However, even with
information to assist the process, most health care professionals may not have the time or the expertise to review the
literature each time they have important clinical questions to
be answered. Therefore, professionals and their organizations
generally work together to provide scientific review of the
relevant literature and produce succinct guidelines that clinicians can use as tools to inform evidence-based practice.
These efforts are published as Clinical Practice Guidelines.

Clinical Practice Guidelines (CPGs)

In a 2007 article, George Weisz and colleagues describe the
historical changes in health care that resulted in the development of CPGs (Weisz et al., 2007). These included (a) the
dissatisfaction with training and credentials in medicine and
the wide variability of competence among practitioners,
(b) the need for protocols and guidelines for complex therapeutic technologies and procedures (e.g., cancer treatment
and in vitro fertilization), and (c) the demand by the public
for accountability, transparency, and regulation. These factors
have resulted in layer upon layer of guidelines in health
care (Weisz et al., 2007).
The most frequently used definition of CPGs is that they
are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances (Field & Lohr, 1990, p. 38). The
systematic development of an evidence-based CPG begins
with a well-formulated question about a specific clinical condition. It is also important at the beginning of the process to
define the relevant populations and clinical settings, potential
interventions, and desired outcome measures. The next step
is to conduct a comprehensive literature search and a systematic review of the literature. Ideally, this work is conducted
by a broad and representative sample of individuals from
within the profession who have the skills required to independently and critically appraise the literature and apply the
explicit grading criteria (see Table 1) to document the findings and summarize the literature review (Dollaghan, 2007).
When CPGs can be based on a large number of high-quality
studies it reduces the need for recommendations based on
expert opinion. In many of the health sciences professions,
including audiology, much of the scientific research literature
has significant limitations and/or lacks sufficient relevance,
limiting its use as high-quality evidence (Hyde, 2005b). This
leaves a CPG development group to decide whether they are

Moodie et al.
willing to make recommendations based on less than adequate evidence. Often the end result is a frustrated committee
who continue to try to write the guideline based on consensus and their expert opinions while trying to ensure that they
do not introduce their own bias. The other result may be the
production of a guideline with the neutral conclusion that
there is insufficient evidence to make a recommendation (Hyde,
2005b; Kryworuchko, Stacey, Bai, & Graham, 2009; Weisz
et al., 2007; Woolf, 2000). Knowing that the practice of guideline production is not perfect, a guideline committee works
to draft a document that reflects the strength of the evidence
and is offered as a means of improving patient care and outcomes while providing a strategy for more efficient use of
resources (Graham et al., 2003).

Evidence-Based Practice
and Clinical Practice
Guidelines in Audiology
Audiology, like most of the health sciences professions, has
been working on incorporating evidence-based practice principles into its mandate for professional practice since the
mid-1990s (Bess, 1995; Wolf, 1999). A review of professional
activity in speech-language pathology and audiology presented by Lass and Pannbacker (2008) show the commitment
of The American Speech-Language-Hearing Association
(ASHA) and the Canadian Association of Speech-Language
Pathologists and Audiologists (CASLPA) in promoting the
application of evidence-based principles in clinical practice,
classrooms, and research settings. Implementation of EBP is
part of CASLPAs 2008 vision, mission, and values statement
and is included as a core value by the American Academy
of Audiology (AAA, 2003, n.d; CASLPA, n.d.). AAA defines
EBP as To practice according to best clinical practices for
making decisions about the diagnosis, treatment, and management of persons with hearing and balance disorders, based
on the integration of individual clinical expertise and best
available research evidence. (AAA, n.d.). The publication of
The Handbook for Evidence-Based Practice in Communication
Disorders in 2007 provides professionals in the area of communication disorders with a resource that can be used to
develop the skills to become critical consumers of research
literature (Dollaghan, 2007).
In audiology, clinical uptake of evidence-based procedures
can be relatively rapid. For example, when research indicated that the use of a higher probe-tone frequency (1000 Hz)
provided a more valid indication of middle-ear function for
infants and young children (Keefe, Bulen, Arehart, & Burns,
1993), pediatric audiologists in clinical practice were relatively quick to implement this into their protocols, even
though lower frequency probe-tone (220 to 226 Hz) measures
were the standard for many years. On the other hand, there
is still lack of adherence to best practice recommendations
for the use of other important clinical measures. For example, real-ear probe-microphone measures for the fitting and

verification of hearing aids have been an important component of best practice guidelines for adults and children for
many years (AAA, 2003; College of Audiologists and
Speech-Language Pathologists of Ontario [CASLPO],
2000, 2002; Joint Committee on Infant Hearing [JCIH], 2007;
Joint Committee on Infant Hearing, American Academy of
Audiology, American Academy of Pediatrics, American
Speech-Language-Hearing Association, & Directors of
Speech and Hearing Programs in State Health and Welfare
Agencies, 2000; Modernising Childrens Hearing Aid
Services [MCHAS], 2007; Valente et al., 2006). In clinical
practice, however, studies have shown that 59% to 75% of
adult hearing aid fittings are not verified with real-ear
probe-microphone measures of hearing aid performance
(Lindley, 2006; Mueller & Picou, 2010; Strom, 2006, 2009),
despite the fact that these measures are related to customer
satisfaction (Kochkin et al., 2010). Recent research indicates that individuals who had purchased hearing aids that
were not verified with real-ear probe-microphone measures
at the time of fitting were significantly less (by 18%) satisfied
with their hearing aids after 1 year than did individuals who
had real-ear measures performed at the time of fitting
(Henson & Beck, 2008). It is often suggested that lack of
uptake is associated with lack of understanding about realworld practice by those extolling the virtues of EBP. The current challenge facing the practice of audiology is how do
we address the knowledge-to-action (KTA) gaps? In recent
years, the profession of audiology in North America has
worked diligently to produce high-quality CPGs, make them
available to audiologists, and to work with professionals and
students to ensure that they have the skills to evaluate the
guideline and implement it for use with their individual patients
(Kent, 2006; Orange, 2004). But it does not appear that the
multiple-practice organizations are working together to coordinate guideline development, training, or uptake. There is a
lack of knowledge in audiology about the possibility of using
national and/or international repositories so that a CPG produced by an organization in a specific content area might
serve as a template or starting point for another organization
working on the same CPG topic. Instead, each organization
is producing its own practice guidelines leading to a multitude of CPGs on the same topic.

Criticisms and Challenges

of Evidence-based Practice
Most professionals support the fundamental reasoning behind
EBP. However, since the early 2000s, scholars have started
to voice criticism over EBP. In a recent article, several
authors lament that EBP reduces health care to a routinised,
quantifiable practice driven by utility, best practices and
reductive performance indicators (Murray, Holmes, &
Rail, 2008, p. 276).
Some of the most common criticisms of evidence-based
practice include (a) the current definitions of gold standard research are restrictive; (b) the use of expert opinion

8
is undervalued; (c) the shortage of coherent, consistent scientific evidence limits the ability to conduct EBP reviews;
(d) there are difficulties in applying evidence in the care of
individual patients; (e) it denigrates the value of clinician
and patient experience; (f) time constraints, skill development, and resource limitations restrict its application; and
(g) there is a lack of evidence that evidence-based medicine
works (Cohen, Stavri, & Hersh, 2004; Mullen & Steiner,
2004; Murray et al., 2008; Rolfe & Gardner, 2006; Straus &
McAlister, 2000).

Alterations in the View of What

Constitutes Gold Standard
Status in Evidence Hierarchies
A primary trait of the EBP hierarchy of evidence is the ranking of randomized controlled trials (RCTs) as the gold standard. Despite initial widespread promotion of this grading
system, recent publications have suggested alternative methods (see Rolfe & Gardner, 2006, for more detail). Some
members of teams who promoted a hierarchy of evidence
with systematic reviews of RCTs as the gold standard
have recently rescinded their belief that this is appropriate
(Thompson, 2002). Some experts have moderated their views
by advocating different gold standards or different hierarchies for different questions (DiCenso, Cullum, & Ciliska,
1998; Evans, 2003; Logan, Hickman, Harris, & Heriza, 2008).
The Joanna Briggs Institute, an international not-for-profit
research and development organization specializing in evidencebased resources for health care professionals, has twice
modified its Level 4 evidence criteria, once in 1999 and again
in 2004 (Rolfe & Gardner, 2006). The changes had to do with
accepting and/or denying clinical experience and expertise as
forms of evidence. An important point in this discussion is
that any changes in hierarchy criteria may impact the ongoing validity of previously developed evidence reviews and
resulting CPGs (Rolfe & Gardner, 2006).

Expert Opinion Versus Evidence

There continues to be ongoing debate on the use of scientific
knowledge versus clinical expertise in EBP across health sciences professions (Fago, 2009; Wolf, 2009; Zeldow, 2009).
The proponents of EBP would argue that the current definition of EBP includes clinical expertise and patient values.
They would also argue that clinicians can, at times, choose
to override the scientific evidence and still be engaged in
EBP. However, it is important to note that relying solely
on clinical judgment and expertise has known problems.
Opinion can be affected by such factors as past and/or personal experience, belief in and expectation for success, selective use of evidence, predetermined bias, motivation, distortion
of memory, persistence in belief that there is only one best

Trends in Amplification 15(1-2)

way to do something, professional norms, business pressures,
and other factors (Ismail & Bader, 2004; Kane, 1995; Rinchuse,
Sweitzer, Rinchuse, & Rinchuse, 2004; Woolf, 2000). For
these reasons, an approach to integrating and balancing information from research, from clinical experience, and from
individual patient needs remains an important goal. The following section will discuss the specific difficulties encountered
when trying to integrate these three sources of information.

Difficulties in Applying Evidence in

the Care of Individual Patients
A major criticism of EBP is based on providing clinicians
with study results that are established from trends from group
data based on average behaviors of acceptably similar
groups of participants (Cohen et al., 2004; Mullen & Steiner,
2004; Murray et al., 2008; Straus & McAlister, 2000). This
ignores the fact that there is always group and individual
variability. If a clinician blindly applies a proven procedure,
assuming the individual will benefit, there could be a significant practice error. For example, infants are not average
adults. Until the 1990s, the predicted output performance of
hearing aids were based on measurements of the acoustic
characteristics of average adult ears. We know that an
infants ear is much smaller than an adults ear. The output
of a hearing aid fitted to an infants ear using these average
adult transformation values could be 30 decibels greater at
some frequencies than the same hearing aid on an adults ear
(Seewald, Moodie, Scollie, & Bagatto, 2005; Seewald & Scollie,
1999). Speech sounds and loud environmental sounds could
be overamplified, potentially causing discomfort and increased
risk of additional hearing loss. Unfortunately, the infant cannot tell anyone the hearing aid is too loud because of their
lack of communication skills. Treating individuals like the
masses is a valid criticism and it can be addressed in
numerous ways.

Denigrates the Value of Clinician

and Patient Experience
Evidence-based practice can be seen as both self-serving
and dangerously exclusionary in its epistemological methodologies (Murray et al., 2008, p. 275). By relying primarily on the methodological fundamentalism associated with
RCTs and quantitative evidence, other forms of knowledge,
including clinician and patient experiences, are denigrated
(House, 2003; Murray et al., 2008). Critics of the current
state of EBP emphasize that there are other sources and types
of clinically relevant and important evidence and additional
ways to categorize quality (Cohen et al., 2004; Upshur,
VanDenKerkhof, & Goel, 2001). They also caution that by
depreciating the value of clinician and patient experience we
are not fully treating our patients with the best evidence
(Charlton & Miles, 1998).

Moodie et al.

Time Constraints, Skill Development,

and Resource Limitations
If professionals are going to implement EBP procedures into
their work life, they must develop the necessary skills to find
and critically appraise the evidence. This takes time and
resource allocation from not only a personal level but also
from an organization level. Even if the evidence is gathered
and organized for clinicians (as it often is in CPGs), the
implementation of evidence into practice often takes
redefining or learning a new skill set. This also takes time
because it is easier to habitually continue to do what you
know how to do than it is to implement something new
into your repertoire (Rochette, Korner-Bitensky, &
Thomas, 2009).
An examination of health sciences research literature
on barriers to implementing evidence into clinical practice
reveals that lack of time is a major limitation cited by most
clinicians across professions (Iles & Davidson, 2006; Maher,
Sherrington, Elkins, Herbert, & Moseley, 2004; McCleary &
Brown, 2003; McCluskley, 2003; Mullins, 2005; Zipoli &
Kennedy, 2005). The same authors note lack of skill or
knowledge about implementing EBP or reviewing research
literature as another limitation across the health science professions. The virtual explosion of articles and books written
about EBP and EBP procedures for specific professions also
can make it overwhelming for the clinician who is interested
in studying the topic (Rochette et al., 2009).

Lack of Evidence That Evidence-Based

Medicine Works
Critics of EBP point out that there is little research to date
that shows that implementing EBP improves the quality of
health care. Certainly, they point out, there are no RCTs or
compelling evidence that have validated EBP as an intervention
(Cohen et al., 2004; Coomarasamy & Khan, 2004; Murray
et al., 2008; Parkes, Hyde, Deeks, & Milne, 2001).

Limitations of CPGs
Given shortcomings in EBP, it is not surprising that there are
limitations associated with the development and use of CPGs.
The most fundamental limitation of CPGs is that they often do
not change practice behavior. Analyses of the barriers to practice change indicate that obstacles to change arise at many
different levels, including (a) at the level of the guideline,
(b) the individual practitioner, (c) the organization, (d) the
wider practice environment, and (e) at the level of the
patient (Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou,
2004; Grol, Bosch, Hulscher, Eccles, & Wensing, 2007;
Grol & Grimshaw, 2003; Lgar, 2009; Rycroft-Malone,
2004). A discussion of the first four limitations listed above
is provided in the following sections and a summary is
provided in Appendix A. A discussion of patient-related
behavior that affects the use of evidence in practice will not be

provided in this manuscript as it is not the focus of this current work.

Although the following section discusses the characteristics of guidelines, practitioners, organization, and practice
environments as obstacles to implementation of evidence, it
should be noted that many of these same characteristics could
be facilitators to implementation of evidence in practice. Facilitators are factors that promote or assist implementation of evidence-based practice (Lgar, 2009). For
example, lack of time could be a considerable barrier, but
having enough time would facilitate the transfer of evidence into practice. Similarly, clinician attitude to implementation of guidelines into clinical practice could be a
barrier or facilitator depending on whether the attitude was
conducive to change or not.

Characteristics of Guidelines That Affect

Implementation in Clinical Practice
The Appraisal of Guidelines Research and Evaluation (AGREE)
Instrument has outlined the criteria that CPGs should meet
in order to provide practitioners with comprehensive and valid
practice recommendations (AGREE Collaboration, 2001;
The AGREE Collaboration Writing Group et al., 2003).
AGREE recommendations suggest that explicit information
related to the following domains should be clearly presented
as part of guidelines: scope and purpose, stakeholder involvement, and rigor of development (including quality of evidence informing recommendations, clarity and presentation,
applicability, and editorial independence;AGREE Collaboration,
2001; The AGREE Collaboration Writing Group et al., 2003).
Research that appraises guidelines in the health sciences
professions has shown that many guidelines do not meet the
AGREE criteria for high quality, and this may have an impact
on their use (Bhattacharyya, Reeves, & Zwarenstein, 2009;
Veldhuijzen, Ram, van der Weijden, Wassink, & van der
Vleuten, 2007). In a recent review of guideline development,
dissemination, and evaluation in Canada it was reported that
most guidelines were English-only publications. In addition,
6% of the written guidelines submitted to the Canadian
Medical Association Infobase did not indicate a review of the
scientific literature and less than half of the guidelines graded
the quality of the evidence (Kryworuchko et al., 2009).
Table 2 provides an overview of guideline characteristics
that might influence their adoption in clinical practice
(Grol et al., 2007).

Characteristics of the Practitioner

That Affect Implementation of
Guidelines in Clinical Practice
There have been numerous studies examining the obstacles
to EBP by individual practitioners in health care (Bhattacharyya
et al., 2009; Carlson & Plonczynski, 2008; Damschroder et al.,
2009; Davis & Taylor-Vaisey, 1997; Estabrooks, Floyd,
Scott-Findlay, OLeary, & Gushta, 2003; Green, 2001; Iles &

10

Trends in Amplification 15(1-2)

Table 2. Characteristics of innovations/guidelines that might promote or hinder their implementation.

Characteristic

Description

relative advantage or utility

better than existing or alternative working methods

compatibility

consistent with existing norms and values

complexity

easy to explain, understand and use

costs

balance between cost and benefits, necessary level of investment

risks

degree of uncertainty about result or consequences

flexibility, adaptability

degree to which innovation can be adapted to needs/situation of target group

involvement

degree to which target group is involved in development and the potential that their input
has modified or resulted in adaptation(s)

divisibility

degree to which parts can be tried out separately and implemented separately

visibility, observability

degree to which other people can see and observe the results

trialability, reversibility

degree to which an innovation can without risk be tried out, stopped, or reversed if it does
not work

centrality

degree to which the innovation affects central or peripheral activities in the daily working
routine

pervasiveness, scope, impact

how much of the total work is influenced by the innovation, how many persons are
influenced, how much time it takes, and what the influence on social relationships is

magnitude, disruptiveness, radicalness

how many organizational, structural, financial and personal measures the innovation requires

duration

the time period within which the change must take place

form, physical properties

what sort of innovation or change it is (material or social, technical or administrative, etc)

collective action

degree to which decisions about the innovation must be made by individuals, groups or a
whole institution
nature of presentation, length, clarity, attractiveness

presentation

Source: From Planning and studying improvement in patient care: The use of theoretical perspectives. by R. P. T. M. Grol, M. C. Bosch, M. E. J. L. Hulscher,
M. P. Eccles, & M. Wensing, 2007, Milbank Quarterly, 85(1), 93-138. Copyright 2007 by Blackwell Publishing Inc. Reprinted with permission.

Table 3. Characteristics of the practitioner that influence guideline

adoption and implementation

Table 4. Characteristics of the context in which the practitioner

works that influence guideline adoption and implementation

Characteristic

Characteristic

perception or reality that it will take too much clinical time to

implement
lack of authority to change practice
lack of support from organization for practice change
perception of legitimacy of the source of the guideline
perception of quality/validity of guideline
habits/Customs of clinicians or organization
beliefs of clinician peers/colleagues
social norms/practice norms
clinician attitude with respect to the use of guidelines in practice
lack of outcome expectancy
lack of self-efficacy
lack of motivation
lack of awareness of existence of guideline
chosen non-compliance
age of clinician

structure of the workplace/institution

organizational agenda
support for change/conduciveness to change
available resources
staff capacity
staff turn-over
organization of care processes
efficiency of the system
degree to which the organization is networked both within the
organization and with other external organizations (social
capital of practitioners and organization)
level of in service education; continuing education opportunities
policy and procedure documentation
leadership with good communication
relationships between practitioners and between practitioners
and manager(s)

11

Moodie et al.
Table 5. Characteristics of the broader health care system that
influence guideline adoption and implementation

et al., 2009; Davis & Taylor-Vaisey, 1997; Grol et al., 2007;

Grol & Wensing, 2004).

Characteristic
Nature of financial arrangements/reimbursement to health
professionals and to their organizations
Support for change
Regulation of health professions
Financial stability
Pressure from other health professions or the public

Davidson, 2006; Ismail & Bader, 2004; Kryworuchko et al.,

2009; Lgar, 2009; Michael & John, 2003; Mullins, 2005;
Pagoto et al., 2007; Veldhuizen et al., 2007; Zipoli & Kennedy,
2005). Lack of time is ranked as the greatest obstacle to
implementing evidence and/or CPGs into clinical practice.
Table 3 provides a list of other factors cited in the literature
that hinder practitioner-level implementation of evidence
and/or guidelines in clinical practice.

Characteristics of the Context in Which

the Practitioner Works That Affects
Implementation of Guidelines in Clinical Practice
Context can be defined as the environment or setting in which
people receive services or the clinical setting in which proposed
evidence-based uptake is to take place (Rycroft-Malone, 2004).
The context is dynamic and interacts with the individuals
and the systems in which they work (Estabrooks, Squires,
Cummings, Birdsell, & Norton, 2009; Masso & McCarthy,
2009; McCormack, Kitson, Harvey, Rycroft-Malone, Titchen,
& Seers, 2002; Rycroft-Malone, 2004). The contexts in
which practitioners work can have a significant impact on
their ability to change practice behaviour primarily because
of the focus on standard operating procedures and behavioural norms (Rosenheck, 2001). The importance of leadership within the practice context is imperative for change to
take place (Aarons, 2006; Cummings, Estabrooks, Midodzi,
Wallin, & Hayduk, 2007; Estabrooks et al., 2009; Masso &
McCarthy, 2009). Table 4 provides a list of characteristics of
the context that influence guideline adoption and implementation (Aarons, 2006; Cummings et al., 2007; Damschroder
et al., 2009; Davis & Taylor-Vaisey, 1997; Estabrooks et al.,
2009; Glasgow & Emmons, 2007; Greenhalgh et al., 2004;
Masso & McCarthy, 2009; McCormack et al., 2002;
Rosenheck, 2001; Rycroft-Malone, 2004).

Characteristics of the Broader Health

Care System That Affects Implementation
of Guidelines in Clinical Practice
As shown in Table 5, the broader health care system is also a
factor in guideline adoption and implementation (Bhattacharyya

Putting Evidence in Its Place:

Evidence-Based Practice and
Knowledge Translation (KT)
Tables 2 to 5 make it clear that implementation or uptake of
new knowledge into changes in clinical practice is not generally
achieved simply by creating the knowledge, distilling it into
useable CPG formats, and disseminating it to clinicians, administrators, and/or policy makers. In an effort to close the knowledge-to-clinical action gap, many of the health sciences professions
are taking a knowledge translation (KT) approach to the development and dissemination of evidence for clinical practice.
The Canadian Institutes of Health Research (CIHR)
defines KT as a dynamic and iterative process that includes
synthesis, dissemination, exchange and ethically-sound
application of knowledge to improve the health of Canadians,
provide more effective health services and products and
strengthen the health care system. The definition is combined
with a description of the KT process. KT takes place within
a complex system of interactions between researchers and
knowledge users which may vary in intensity, 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 (CIHR, n.d.). This definition has
been adopted by the United States National Center for
Dissemination of Disability Research and the World Health
Organization (WHO; Straus, 2009).

The Knowledge-to-Action (KTA)

Framework: A Model for Knowledge
Translation (KT) in Audiology
After reviewing 31 different conceptual knowledge translation (KT) frameworks, Graham and colleagues developed a
two-category KT framework that has been widely adopted
by researchers and may be useful for consideration by the
profession of audiology. They divide KT into two categories: (1) end-of-grant KT, and (2) integrated KT (Graham et
al., 2006; Graham & Tetroe, 2007). End-of-grant KT
includes research dissemination, communication, summary
briefings to stakeholders, educational sessions with practitioners, and publications in peer-reviewed journals. Moving
a KT product from the research laboratory into industry is
also considered a form of end-of-grant KT. Integrated KT
represents a more modern way of conducting research studies and involves active collaboration between researchers
and research users in all parts of the research process, including designing the research questions, shared decision-making
regarding methodology, data collection and tools development
involvement, interpretation of the findings, and dissemination

12

Trends in Amplification 15(1-2)

Figure 1. The knowledge-to-action process. Adapted from Lost in knowledge translation: Time for a map?, by I.D. Graham, J. Logan, M.
B. Harrison, S. E. Straus, J. Tetroe, W. Caswell, and N. Robinson. Journal of Continuing Education in the Health Professions, 26, p. 19. Copyright
2006 by Wiley and Sons. Reprinted with permission.

and implementation of the research results. One significant advantage to an integrated KT approach to research
is that it should enhance the development of best evidence
because the collaborative approach takes into consideration
values, preferences, and determinants to implementing change
in clinical practice (Graham et al., 2006; Graham & Tetroe,
2007; Harrison, Lgar, Graham, & Fervers, 2010; Straus,
Tetroe, & Graham, 2009; Straus, Tetroe, Graham, Zwarenstein
& Bhattacharyya, 2009). The end result should be a reduction
of the barriers to implementation of evidence summarized in
Appendix A, and more high-quality, effective, and efficient
health care services delivered to the public.
An integrated KT method that may be applied to evidencebased audiology research is the KTA Process (Graham et al.,
2006; Harrison et al., 2010; Straus et al., 2009). The KTA
process is illustrated in Figure 1. There are two cycles occurring in the KTA method: (1) a knowledge creation funnel,
and (2) an application of knowledge cycle. The boundaries
between the two cycles can be permeable and fluid if desired,
or one cycle could be independent from the other (Graham
et al., 2006; Graham & Tetroe, 2007; Straus et al., 2009).
The knowledge creation funnel takes the multitude of
available evidence, or works with end users of research to
create the evidence (at the knowledge inquiry stage) and
synthesizes it (synthesis stage), ultimately filtering it until

the best evidence is compiled (see Figure 1). At the final

stage, knowledge, in the form of knowledge tools or products, is presented in clear, concise, and appropriate formats
to influence clinical practice, stakeholders, and end users in
such a way to promote uptake of the knowledge. An important component to the knowledge creation cycle is that at
each stage the knowledge should be tailored and/or customized, ideally with input from the end users, to facilitate
implementation.
The action (application) cycle of the process facilitates
the science of implementation (see Figure 1). It represents
the various activities that may be needed for the application
of the knowledge in clinical practice.
The action cycle includes the following:
Adaptation of the evidence/knowledge/research to
the local context;
Assessment of the barriers to using the knowledge;
Selecting, tailoring, and implementing interventions to promote the use of the knowledge within
clinical practice settings;
Monitoring of knowledge use;
Evaluation of clinical uptake outcomes of using the
knowledge;
Methods to sustain ongoing knowledge use.

13

Moodie et al.
The development of the application of knowledge cycle
in this model has taken into consideration many of the criticisms related to EBP reported in the literature (Cohen et al.,
2004; Graham et al., 2006; Mullen & Steiner, 2004; Murray
et al., 2008; Straus & McAlister, 2000; Upshur et al., 2001).
By actively collaborating with the end users of the knowledge it places value on their experience and opinion and
considers important factors related to time, skills, attitude,
resources, and organizational practice that impact the use of
knowledge in clinical practice.

Adaptation of the Evidence/Knowledge/

Research to the Local Context
Audiologists work in a variety of practice contexts. Many
audiologists work in private practice, others work in hospital
or rehabilitation settings, and still others work in public
health, industry, universities, schools, and other health care
settings. These practice contexts may differ in their workplace structure, organizational agenda, and/or leadership.
Similar to other knowledge translation frameworks such
as the Promoting Action on Research Implementation in
Health Services (PARiHS) framework, the KTA framework
postulates that the implementation of evidence will be
most successful when necessary adaptations appropriate for
the clinical context have been considered (Graham et al.,
2006; Graham & Tetroe, 2007; Rycroft-Malone et al., 2002;
Straus et al., 2009).

Assessment of the Barriers

to Using the Knowledge
According to much of the recently published implementation research, implementation interventions are likely to be
more effective if they target causal determinants of behavior
(Michie, Johnston, Francis, Hardeman, & Eccles, 2008; Michie,
van Stralen, & West, 2011). An audiologist may not implement or adhere to a CPG for fitting hearing aids to adults, for
example, if she or he perceives there is a lack of beneficial
outcome in doing so. If an audiologist lacks confidence in
performing a real-ear probe-microphone measurement it will
likely reduce his or her desire to implement the measurement
into practice. An assessment to barriers to using the evidence
in clinical practice provides an opportunity to determine how
to overcome the barriers to facilitate behavior change.

Selecting, Tailoring, and Implementing

Interventions to Promote the Use of the
Knowledge Within Clinical Practice Settings
If one considers the context in which the audiologist works
and the barriers to practice change, then implementation
interventions could be developed to promote the use of the
knowledge in the practice setting. For example, if it has been

identified that audiologists lack confidence in accurately

performing real-ear measurements of hearing aid performance then tailored, hands-on, educational opportunities
might be considered to reduce this confidence barrier.

Monitoring of Knowledge Use

After an implementation intervention has occurred, it is
important to determine how and to what extent the knowledge
has been translated into clinical use (Straus et al., 2009). In
audiology, for example, monitoring the use of knowledge
could entail measuring a change in knowledge, understanding, or attitude toward the performance of real-ear measurements. We could also perform measurements of the frequency
at which real-ear measurements were made after our targeted hands-on intervention. Monitoring of knowledge use
could also alter barriers at administration levels. For example,
if evidence-based research shows that the performance of
real-ear measurements provides patient benefit, reduces hearing aid returns, and reduces the time taken to achieve a satisfactory fitting over not performing the measurement, we
could use this information to attempt to persuade a hospital
administrator to provide appropriate appointment time for
the audiologist to conduct the measurements.

Evaluation of Clinical Uptake

Outcomes of Using the Knowledge
The focus of research and subsequently CPGs is on achieving good outcomes for the individuals in our care. Therefore,
we often measure the effectiveness of our treatment in terms
of patient-related outcome measures. When implementing
evidence into clinical practice it is also important to consider
implementation outcomes to ensure that the CPG is being
implemented (adhered to) as it was intended. It is often the
case that when a program or practice is not achieving desirable
patient-related outcomes, more effort goes into performing
more and better research on the program or practice. More
research on the program, protocol, or CPG to achieve positive outcomes will not help implementation (Fixsen, Naoom,
Blase, Friedman, & Wallace, 2005). Fixsen et al. caution that
errors may be made leading to the conclusion that a treatment intervention is ineffective, when in fact the issue is
that the program or protocol for treatment has not been
implemented appropriately.

Methods to Sustain Ongoing Knowledge Use

Sustainability can be defined as the degree to which an
innovation continues to be used after initial efforts to secure
adoption is completed (Rogers, 2005, p. 429). One challenge
to sustainability of knowledge use in audiology is within the
organizational structure. If organizational structures do not
intrinsically change to support the new evidence being put
into practice, then audiologists will have a tendency to revert

14
back to their former ways of doing things. Flexible knowledge
sustainability strategies need to be considered during the
development stages of CPGs (Davies & Edwards, 2009).

Why Is Knowledge Translation

(KT) Important to Audiology?
Despite the fact that the profession of audiology works to
develop best practice guidelines and protocols based on the
best available evidence, there is often an apparent failure to
use this research evidence in clinical practice and/or to use
it to inform decisions made by managers and/or policy makers
(Kirkwood, 2010; Lindley, 2006; Mueller, 2003; Strom, 2006,
2009). The determinants to the use or nonuse of knowledge
in clinical practice were tabulated in Tables 2 to 5. End-of-grant
and integrated KT approaches (the KTA framework) could
be used in audiology to ensure that factors influencing the
uptake of evidence in clinical practice, including characteristics of the guidelines, the individual practitioner, and the
contexts/settings in which the knowledge is used, are better
understood and addressed. There are some potential limitations in using an integrated knowledge translation
approach to knowledge development. These include the
potential for increased cost and time for guideline development using this iterative approach and difficulty obtaining
release-from-practice time for audiologists to participate in
the guideline development process without financial reimbursement to the employer. It may be difficult to reach consensus between clinicians and researchers on what constitutes
an acceptable modification to a guideline. More research on
these aspects of active collaboration between researchers
and end users is needed to address these important issues.
One positive aspect of research work to date is that governmentlevel funding agencies such as the Canadian Institutes of
Health Research (CIHR) and the National Institutes of Health
(NIH) are providing funding for knowledge translation
projects that actively engage end users (patients, clinicians,
and/or policy makers) of research.

Communities of Practice in Audiology:

Facilitators of Knowledge Into Action
An examination of the factors influencing evidence uptake
that appear in Tables 2 through 5 on the previous pages and
summarized in Appendix A provides us with a better understanding of why there is a KTA gap. The factors also reveal
the complex processes involved in diffusion of knowledge
and behavior change. The complexity may be reduced with
early and ongoing involvement of researchers, practitioners,
policy makers, and patients (Innvaer, Vist, Trommald, & Oxman,
2002; Landry, Amara, & Lamari, 2001; Lomas, 2000;
McWilliam et al., 2009; Roux, Rogers, Biggs, Ashton, &
Sergeant, 2006; Straus, 2009). The translation of knowledge
or evidence into clinical practice is an active process. In the
KTA model the process is iterative, dynamic, complex, con-

Trends in Amplification 15(1-2)

cerning both knowledge creation and application (action
cycle) with fluid boundaries between creation and action
components (Graham et al., 2006; Straus, 2009, p. 6).
Both the creation of knowledge and application of knowledge in practice are social processes, and as such, communities of practice have the potential to reduce the KTA gap,
assist with knowledge diffusion, and be facilitators of practice change. One of the primary advantages in terms of diffusion of knowledge and clinical practice behavior change is
that by collaborating with practitioners we have individuals
who will know how to grease the implementation wheels
and provide a road map to the potential mine fields inherent in
attempting to introduce change in any organization (Graham
& Tetroe, 2009).
Communities of practice (CoPs) are comprised of individuals who share common concern or enthusiasm about a
topic or problem and who deepen their knowledge and expertise about the area by frequently interacting with one another
(Barwick et al., 2005; Li et al., 2009; Wenger, McDermott, &
Snyder, 2002). Initially described in 1991, the term CoP has
evolved to be defined as a group of people with a unique
combination of three structural concepts: the domain of
knowledge, a community of people, and shared practice
(Barwick, 2008; Barwick et al., 2005; Li et al., 2009; Wenger
et al., 2002). The domain creates mutuality and a common
focus regarding the key issues among members and inspires
them to contribute their knowledge and ideas. The community
creates the social structure that is imperative for knowledge
creation, collective learning, inquiry, relationships, and trust.
The shared practice are resources created, used, and shared
by the group that include documents, ideas, information,
ways of knowing, and experiences (Barwick, 2008; Roux
et al., 2006; Wenger, 2005). When the three structural concepts of CoPs work together they can optimize the creation
and dissemination of knowledge thereby facilitating the KTA
process (McWilliam et al., 2009).

Value of a Community of
Practice for Pediatric Audiology
Approximately 30% of children in North America who are
fitted with hearing aids are receiving care that is inconsistent
with evidence-based CPGs (Bess, 2000; Lindley, 2006). In a
2003 paper, it was noted, There is a current trend to develop
test protocols that are evidence based. . . . But, before we
develop any new fitting guidelines, maybe we should first
try to understand why there is so little adherence to the ones
we already have (Mueller, 2003, p. 26). In the area of pediatric audiology, every effort is made to ensure that CPGs are
developed using systematic reviews and the best available
evidence. A review of the literature indicates that to date no
systematic appraisal of pediatric amplification CPGs or their
implementation has been conducted. Therefore, it is difficult
to say whether it is the guideline or implementation factors
that account for the fact that these children are not receiving

15

Moodie et al.
care based on current CPGs. Appendix A provides us with
information on why we may have adherence issues. Utilizing
a collaborative and integrated KT approach to the development and the subsequent implementation of knowledge into
clinical practice may provide insight into how to reduce
the barriers and facilitate the movement of evidence into
practice.
Brown and Duguid (2001) state that knowledge runs on
rails led by practice (p. 204). Developing a CoP in pediatric
audiology could facilitate the knowledge creation cycle in an
integrated KT approach by utilizing an engaged community with a shared understanding of the knowledge needed
and who would have the ability to assist in tailoring or customizing the knowledge for better use among intended
users (Fung-Kee-Fung et al., 2009; Gajda & Koliba, 2007,
2008; Koliba & Gajda, 2009; Salisbury, 2008a, 2008b; Stahl,
2000). CoPs provide an opportunity for the creation of
knowledge and knowledge products to include the tacit
knowledge that experienced practitioners have accumulated
through years of practice (Allee, 2000; Brown & Duguid,
2001; McWilliam et al., 2009; Serrat, 2008). This tacit
knowledge makes it possible for them to be advocates and
facilitators in the development of resources that reflect
accumulated ways of knowing and experiences that will
meet the cognitive needs of novice practitioners and the
experiential needs of expert practitioners (Salisbury, 2008a,
2008b; Stahl, 2000).

Examples of Communities
of Practice in Health Care
The next section of this article will provide a description of
two successful Canadian-based CoP programs in health care.
The first, Cancer Care Ontario/Program in Evidence-Based
Care (Browman et al., 1995; Browman, Makarski,
Robinson, & Brouwers, 2005; Evans, Graham, Cameron,
Mackay, & Brouwers, 2006; Fung-Kee-Fung et al., 2009;
Stern et al., 2007), is of interest because it focuses on the
use of practitioners during the guideline development process. The second, Ontario Childrens Mental Health Child and
Adolescent Functional Assessment Scale (CAFAS; Barwick,
Boydell, & Omrin, 2002; Barwick et al., 2005; Barwick,
Peters, & Boydell, 2009), is of interest because it relates to
work in the pediatric population.

Clinical Practice Guideline Development:

Guiding Practice of Cancer Care in Ontario
Since 1995, the development and maintenance of CPGs guiding the practice of cancer care in Ontario has been a joint
venture between Cancer Care Ontario (CCO) and the Program
in Evidence-Based Care (PEBC) at McMaster University.
The development of CPGs follows a cycle of development
described by Browman et al. The guidelines are initially
developed by guideline panels, working groups, and medical

experts. The report created includes the guideline questions,

the literature search strategy, a systematic review of the literature, the consensus of the panel on the interpretation of
the evidence, and draft guideline recommendations. This
document and a standardized feedback survey are then sent
to a wide group of physicians who might find the guideline
relevant (Brouwers, Graham, Hanna, Cameron, & Browman,
2004). The physicians are asked to respond to the survey
questions and to provide comments, suggestions, and opinion
on how the guideline might be improved so that implementation into clinical practice will be facilitated. The practitioners who review the CPGs developed by the Program in
Evidence-Based Care (PEBC) panel can be defined as a community of practice (CoP). Evans et al. (2006), Browman et al.
(2005), and Browman and Brouwers (2009) describe some of
the benefits experienced by CCO and the PEBC by including this CoP feedback into the CPG cycle:
1. Feedback improved the quality of the documents
and, on occasion, led to substantive changes to the
CPG;
2. By requesting feedback on the CPG, physicians
had to review the document and, therefore, were
made aware of and educated about the guideline;
3. The review stimulates learning within the CoP and
increases dialogue on important topics;
4. Despite rigorous adherence to the development
of guidelines by experts, practitioner suggested
improvements/changes were incorporated into
44% of CPGs;
5. By sending the guideline to practitioners for comment/
review it provided a heads-up to practitioners
that a guideline was about to be finalized and
released.
A recent publication (Stern et al., 2007) described the
results of using oncologists in-the-field to facilitate CPG
development and adoption of guidelines into practice. A
reduction was seen in operative mortality of pancreatic
cancer and the improvement in harvesting lymph nodes in
colorectal cancer. Significant improvements were made in
the area of colorectal and pancreatic cancer indicators, with
a mean reduction in 30-day operative mortality from 10.2%
in 1988-1996 to 4.5% in 2002-2004 and compliance with
treatment guidelines increased from 27% in 1997-2000 to
69% in 2005. Therefore, it was concluded that active participation of practitioners and a CoP approach were essential
components to changing practice and improving quality care
in surgical oncology practices in Ontario.
Ontario Childrens Mental Health Child and Adolescent
Functional Assessment Scale (CAFAS) Initiative (Barwick et al.,
2002, 2005, 2009). Since 2000, 117 Child and Mental Health
Organizations in Ontario have been mandated to adopt an
electronic version of a standardized outcome measurement
tool called the Child and Adolescent Functional Assessment

16

Trends in Amplification 15(1-2)

Scale (CAFAS; Hodges, 2003). For this group of first users

of the CAFAS, Barwick et al. (2002) used a KTA approach
to develop software training, web, wiki, email, and telephone
support systems. They also provided face-to-face group and
individual consultation and training services to facilitate
implementation of the CAFAS. Recently another group of
new CAFAS users were mandated to adopt the outcome tool.
Barwick and colleagues (2009) used this opportunity to
study the use of a community of practice (CoP) approach to
implementation versus a practice as usual (PaU) approach.
Both the CoP and PaU groups received standard 2-day training on the use of the functional assessment scale (CAFAS) in
clinical practice. The CoP approach included 6 meetings
over 11 months where additional support/training were provided. The research questions focused on the use of a CoP
model to facilitate practice change and increase the use of
the functional assessment scale, knowledge of the scale,
satisfaction with support, and materials for implementation
of the functional assessment scale relative to the practice as
usual group. Although some methodological concerns have
been raised about this study (Archambault et al., 2009),

results generally suggest that the use of CoPs might facilitate

implementation of evidence into practice. Practitioners in the
CoP group demonstrated greater use of the tool in clinical
practice. They also demonstrated better knowledge of the
tool at the end of 1 year and more satisfaction with the implementation supports than did the PaU group.

Using an Integrated Knowledge Translation

Process for the Development of Outcome
Measures in Pediatric Audiology
In 2008, members of the Child Amplification Laboratory
(CAL) at the National Centre for Audiology (NCA),
University of Western Ontario (UWO), met with a purposely
selected group of pediatric audiologists from across Canada.
The overall aims for this meeting were (a) to discuss potential interest in establishing a CoP in pediatric audiology
across Canada with the aim of reducing the KTA gap for
children receiving audiological services, and (b) to define
areas of practice where these pediatric audiologists felt that

Appendix A
Characteristics That Influence the Use of Knowledge and Evidence in Clinical Practice
Characteristics of the ________________ that influences adoption and implementation
Guideline
Relative advantage or
utility
Compatibility
Complexity

Practitioner

Context

Broader health system

Time

Workplace structure
Organizational agenda
Available resources
Staff capacity

Financial stability

Staff turnover

Involvement

Lack of authority to change practice

Lack of support from organization for
practice change
Perception of legitimacy of the source
of guideline
Perception of quality/validity of
guideline
Habits/customs

Nature of financial arrangements

Reimbursement
Support for change
Regulation of health professionals

Pressure from other health

professions or public

Divisibility
Trialability/reversibility

Beliefs of peers
Social norms

Visibility observability

Attitude about guidelines

Centrality

Lack of outcome expectancy

Costs
Flexibility/adaptability

Pervasiveness, scope, impact Lack of self-efficacy

Magnitude, disruptiveness,
radicalness

Lack of motivation

Duration
Form, physical properties
Collective action
Presentation

Lack of awareness of existence

Chosen noncompliance
Age
Country of residence

Organization of care
processes
Efficiency of the system
Social capital of practitioners
and organization
Level of in-service, CE
opportunities
Policy and procedure
documentation
Leadership/good
communication
Relationships: practitioners
and practitioners to
managers

17

Moodie et al.
there was a lack of knowledge in the treatment for children
receiving audiological services. During the one-and-a-half
day meeting, the pediatric audiologists discussed the challenges to implementing evidence into clinical practice. The
stated factors affecting the use of evidence in their practices,
regardless of practice setting, were similar to those outlined
earlier in this article in Tables 2 to 5. The audiologists
reached consensus that the area that they would like to have
more knowledge and evidence for use in clinical practice
was outcome measures to evaluate the auditory development
of children with permanent childhood hearing impairment
(PCHI) aged birth to 6 years who may or may not wear hearing aids. They also agreed that they would like to work as a
country-wide CoP and in collaboration with researchers at
the NCA to develop this knowledge. In 2009, researchers in
the CAL began work to develop a guideline that focused on
providing pediatric audiologists with appropriate measurement tools and protocols that could be used to assess aided
auditory-related outcomes for children aged birth to 6 years.
The aim was to actively collaborate with the pediatric CoP
using an integrated KT approach to develop this knowledge
for use in clinical practice. The results of this knowledge
development will be discussed in the subsequent articles in
this issue, with Bagatto and colleagues (2011a) providing an
overview of the considerations and issues associated with
outcome evaluation tools and a summary of the literature
associated with the selection of outcome measures for use
when examining the auditory development of children with
PCHI aged birth to 6 years. Moodie and colleagues (2011)
provide the results of the individual assessment of each of the
outcome evaluation tools by individual audiologists within
the country-wide pediatric CoP. Bagatto and colleagues
(2011b) provide information about the final guideline called
the University of Western Ontario Pediatric Audiological
Monitoring Protocol (UWO PedAMP) version 1.0 and provide data from a clinical sample of children with permanent
childhood hearing impairment who wear hearing aids.
List of Abbreviations
AAA: American Academy of Audiology
AGREE: Appraisal of Guidelines Research and Evaluation Instrument
ASHA: American Speech-Language-Hearing Association
CAFAS: The Child and Adolescent Functional Assessment Scale
CAL: Child Amplification Laboratory
CASLPA: Canadian Association of Speech-Language
Pathologists and Audiologists
CASLPO: College of Audiologists and Speech-Language
Pathologists of Ontario
CCO: Cancer Care Ontario
CIHR: Canadian Institute of Health Research
CoP: Community of Practice
CPG: clinical practice guideline

EBM: evidence-based medicine

EBMWG: Evidence-Based Medicine Working Group
EBP: evidence-based practice
KT: knowledge translation
KTA: knowledge-to-action
MCHAS: Modernising Childrens Hearing Aid Services
NCA: National Centre for Audiology
PARiHS: Promoting Action on Research Implementation
in Health Services
PaU: Practice as usual
PCHI: Permanent childhood hearing impairment
PEBC: Program in Evidence-Based Care
RCTs: randomized controlled trials
UWO: University of Western Ontario
UWO PedAMP: University of Western Ontario Pediatric Audiological Monitoring Protocol
WHO: World Health Organization
Acknowledgments
The authors gratefully acknowledge the helpful comments and suggestions provided by Professor J. B. Orange on an earlier version
of this manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.

Funding
The author(s) received the following financial support for the
research, authorship, and/or publication of this article: This work was
supported with funding by the Canadian Institutes of Health
Research [Sheila Moodie: 200710CGD-188113-171346, Marlene
Bagatto: 200811CGV-204713-174463, and Anita Kothari:
200809MSH-191085-56093]. This work has also been supported
by the Ontario Research Fund, Early Researcher Award to Susan
Scollie, Starkey Laboratories, Inc., and the Masonic Foundation of
Ontario, Help-2-Hear project.

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