Moving Population and Public Health Knowledge Into Action

Occupational and workplace health

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Cases:

Knowledge translation through research-based theatre

Joan M. Eakin, University of Toronto
Marion Endicott, Injured Workers Consultants and the Bancroft Institute

This case documents the metamorphosis of an academic public health project on the implementation of Ontario's return-to-work policies and practices into a community theatre project, the production of a play called Easy Money. The result was a highly successful knowledge translation initiative. Injured workers, the focus of the academic study, intensely identified with the play and were given hope that their individual experiences could be broadly translated. For the researchers, the undertaking provided new perspectives on the original research problem, validated their original findings, and generated numerous topics for subsequent research.

Background

Joan Eakin, with research colleagues Ellen MacEachen and Judy Clarke from the Institute for Work and Health in Toronto, recently completed a study of a new system in Ontario for reducing disability from work-related injury and for getting injured workers back to work.Footnote * The system features early return to work (before recovery), modified work (tasks adapted to the injury) and workplace self-reliance (primary self-administration by the workplace parties).

The study identified a number of problematic implications for small workplaces, including the harmful effects for injured workers and for social relationships in the workplace of what the researchers called a "discourse of abuse", the broadly experienced, institutionalized expectation that workers will misuse the compensation system.

Results of the research were publishedFootnote 1 and presented to other researchers, administrators from the Ontario Workplace Safety and Insurance Board, policy makers, health practitioners and injured workers. The project resulted in a number of tangible outcomes, including change to Ontario's workplace injury reporting form, and invoked exceptional interest from the injured worker community. The success of these initial knowledge translation (KT) efforts prompted us to extend the reach of the study's findings in a novel way: using theatre.

The KT initiative

The use of theatre as a medium of research communication and social change is increasingly recognized.Footnote 2 In Canada's health research arena, the very successful plays of Ross Gray and companyFootnote 3 on the experience of cancer are probably unmatched in terms of reach and impact.

Inspired by these research-informed dramas, and in collaboration with the Injured Workers Consultants (a community legal clinic that had supported the study since its inception) and the Ontario Network of Injured Workers Groups, some funds were scrounged from other research grants to engage an experienced play writer-director. Under her guidance, we secured grants from the Ontario and Toronto Arts Councils and from several labour unions to fund the developmental stage of the project, a period of about one year culminating in the recent first staging of the play Easy Money.

The purpose of the play is to communicate the research findings to injured workers, system administrators, policy makers, government legislators and the general public, and to involve injured workers themselves in the KT effort. The play was developed incrementally, starting with the writer-director's reading of the research report and extensive brainstorming sessions with the researcher and the production group about the key research ideas and how they might best be conveyed on stage.

The Injured Workers Theatre Collective—a group of injured workers—was formed through the client base of the legal clinic and met several times with the writer-director to relay personal stories and fuel the scriptwriting. A videographer recorded the storytelling and the participatory process with workers. Seven professional actors,Footnote ** a musician and design specialists were employed to stage the play.

The central motif of the play—a Kafkaesque game of snakes and ladders and the satirical portrayal of injury and compensation as "easy money"—emerged from the confluence of research findings, worker participation and artistic expression. The core analytic concepts and arguments of the research were given artistic expression through dialogue, music, song, movement and stage props.

Results of the KT experience

The play was performed for the first time at the Toronto Mayworks Festival of the Arts in May 2005. Immediately following the show, a discussion was held with the audience (about one hundred people, largely injured workers and their families) to harvest their feedback and ideas for improving the play. Not only were valuable suggestions made about the play, but input from the audience shed new light on aspects of the research analysis and generated new research topics. Planned follow-up activities include adapting the script for general public, service provider and policy maker audiences; producing videos; and sharing the script with other communities for local productions.

The production was hugely successful in terms of the immediate response of the audience. Injured workers identified intensely with the play's content. Many appeared to feel a sense of being understood for the first time. The use of theatre and professional actors seemed to elevate and legitimize their individual experiences and gave them hope that the institutional systems, in which many felt trapped and ill-served, could be made visible to the public. The response to the play was also validating to the researcher (supporting the "truth" value of the research) and to the community legal partners (as testimony to the effectiveness of their activism).

Lessons learned

What happens to scientific knowledge when it is transformed into art and into vehicles of advocacy and change?

Despite the evident success of the play, it is important to ask questions from the more abstract standpoint of KT.

First, what happens to scientific knowledge when it is transformed into art and into vehicles of advocacy and change? Is science enriched? Dumbed down? De-theorized? In our case, the play had the capacity both to convert abstract research into concrete form and to produce generalizable abstract knowledge from the empirical research findings (i.e. it picked up the generic, universal experience underlying individual stories). Thus, through techniques of metaphor, dialogue and fiction, the characterization of experience in the play was personal and generic, individual and collective, particular and trans-situational.

A related issue stems from the observation that scientifically produced knowledge does not necessarily make "good" theatre or an effective tool for enlightenment or change. Would many people choose to attend a play that focused only on the grim hardships and despair of injured workers? But what happens when research "findings" are altered for theatrical or communicative effect, or when research ideas that are too hard to stage are left out? How does the introduction of humour and irony, for example, relate to the content of the original science? We will undoubtedly learn more about the relationship between science, art and political purpose as we turn to making the play speak to the different audiences of the general public, system administrators, service providers and policy makers.

Second, how should such KT endeavours be appraised, in terms of a return on investment? Whose benefits should be the pivot points of evaluation? In our case, the effectiveness of Easy Money as a form of KT could be assessed from multiple standpoints: as a salve and voice for injured workers, as a catalyst for reform among government legislators and administrators, as a source of public pressure for institutional change and as a source of guidance for future research. But can it do all of these without a conflict of interest and political purpose? And is theatre a better vehicle for some purposes than others?

Third, how significant are pragmatic rather than theoretical concerns in KT? Regardless of any abstract theory, its effective execution is deeply contingent upon practical, ground-level resources and considerations. For example, one practical barrier to KT activities can be inappropriate timing and availability of funding. In our case, a restrictive research grant funding policy led to the loss of unspent KT funds that could have been used for the start up of Easy Money. Collaboration for creative activities such as this requires more flexible grant arrangements than are often available.

Another practical impediment to KT can be its low value as academic "capital". Such activities (particularly unorthodox undertakings such as Easy Money) may draw researchers into unfamiliar territory that requires time and energy to navigate (e.g. securing funding in the arts arena, learning how plays are mounted) and where the risks and outcomes are unknown. In addition, genuine collaboration can mean, for the researcher, a loss of "control" over the use and interpretation of intellectual property (quelle horreur in academia!).

Conclusions and implications

KT, a quintessentially collaborative, crossdisciplinary exercise, can only be effective if there is something concrete in it for all partners.

The Easy Money experience underscores that KT, a quintessentially collaborative, cross-disciplinary exercise, can only be effective if there is something concrete in it for all partners. It cannot be induced by normative pressure alone (e.g. the belief that publicly funded research ought to be useable outside academia), nor even by practical necessity (e.g. KT being required by research funding agencies).

In our case, for the community legal clinic collaborators, Easy Money aligned clearly with their organizational mission of improving the lives of injured workers and promoting legislative reform. For the participating injured workers, the play gave voice to personal experience and fostered a sense of meaning and community. For the artists, particularly the writer-director, Easy Money was an opportunity for political engagement and for a novel experience with community-based theatre. And for the researchers, the undertaking provided new perspectives on the original research problem and significant conceptual fodder for subsequent research. This confluence of interests appeared to be a major factor in making Easy Money a KT success story. How successful the play will be in this regard when it is brought to bear on audiences who have different sorts of stakes in the messages and who may not really want to hear them, is a story for a future KT casebook.

The Agricultural Health and Safety Network

Louise Hagel, Institute of Agricultural Rural and Environmental Health, University of Saskatchewan
Helen McDuffie, Institute of Agricultural Rural and Environmental Health, University of Saskatchewan
James Dosman, Institute of Agricultural Rural and Environmental Health, University of Saskatchewan
Lori Lockinger, Institute of Agricultural Rural and Environmental Health, University of Saskatchewan
Julie Bidwell, Institute of Agricultural Rural and Environmental Health, University of Saskatchewan
Sean Siever, Institute of Agricultural Rural and Environmental Health, University of Saskatchewan

Saskatchewan's Agricultural Health and Safety Network is a knowledge translation program aimed at promoting health and safety on the farm through education, service and research. A partnership between the Institute of Agricultural Rural and Environmental Health and the Saskatchewan Association of Rural Municipalities, the Network has grown to serve 26,000 farm families since 1988. The Network's knowledge translation activities include locally delivered education and screening programs to promote awareness of hazards and to identify farmers at risk for occupational injury and illness, and the provision of practical, plain-language educational resources on agricultural health and safety issues.

Background

Farmers and their families are exposed to many different types of potential hazards: pesticides and other agricultural chemicals; viruses, moulds and endotoxins; organic dusts; zoonotic diseases; excessive vibration and noise; and work-related injuries. Research has clearly established an increased incidence of certain adverse health outcomes (respiratory diseases, selected cancers, deafness, injuries) associated with occupational and environmental exposures in this population when compared to their non-farming counterparts.

The Agricultural Health and Safety Network is a knowledge translation (KT) program aimed at preventing occupational illness and disability in Saskatchewan farmers. It was established in 1988 as a joint initiative between the Institute of Agricultural Rural and Environmental Health (formerly the Centre for Agricultural Medicine), a research unit at the University of Saskatchewan, and the Saskatchewan Association of Rural Municipalities, to translate the Institute's research results into practical, useful information for farmers.

The Network is committed to informing farmers, their families and workers in related industries about potential hazards in their workplaces and management practices which reduce their exposures. Using research findings from our own studies, as well as national and international research, we design, implement and evaluate health information and services for farm communities, in collaboration with producers and various types of experts located within numerous agencies.

The KT initiative

The evolution of the Network has been a study in cooperation, creativity, imagination and determination. Our staff, who are located at the Institute of Agricultural Rural and Environmental Health, engage in communication and consultation activities with a variety of stakeholders, including farmers, their families, researchers, policy makers and rural volunteers, to develop and implement techniques to improve the health and safety environment in all aspects of the agricultural industry. Each partner contributes time, expert knowledge, funds and in-kind support in a collaborative, interactive manner.

Membership in the Network is voluntary and subject to an annual fee paid by municipal councillors on behalf of their resident farming families. Membership fees are then used as matching funds for grant applications and to support the development of materials and provision of services to Network members. The Network typically employs one staff nurse to deliver programs, coordinate activities, communicate with members and assist in the development of educational materials.

The Network has active steering and advisory committees whose farmer and agricultural professional members generate new ideas, communicate producer concerns and provide guidance in the use of language and KT techniques for various sectors of the agricultural community, as well as to policy makers and health professionals. The Network also has volunteers, including academics, farmers, occupational health professionals, public health professionals and policy makers, who review, test and evaluate proposed programs, documents, and interventions. The success of the Network is substantially enhanced by the willingness of these volunteers to donate their time, expertise and resources to a cooperative effort.

The Network provides a number of key education and screening programs for farmers and their families, including the Respiratory Health Maintenance Program and the Hearing Conservation Program, which are delivered by trained staff in the local community and include physician follow up, if necessary. The programs aim to increase awareness of hazards, promote methods to reduce exposures and identify farmers at risk for occupational injury and illness. We also offer an accident preparedness course, which teaches farmers and family members what to do in the event of a farm emergency.

The Network offers an accident preparedness course, which teaches farmers and family members what to do in the event of a farm emergency.

The Network sponsors and coordinates regular and annual meetings, seminars, workshops and summits and provides display booths and presentations in communities across Saskatchewan. We host a farm injury control summit for producers, health and safety professionals and government policy makers each year. The summit is committed to decreasing the frequency and severity of injuries on the farm and we have developed and recommended policy changes for governments, farmers, farm managers and farm families. In 2005, for instance, the summit focused on sleep deprivation and stress as antecedents of farm injury incidents, and provided up-to-date information on coping techniques. Farmer-invented safety devices are also often featured. The Network staff are also active participants in local, provincial, national and international organizations that have a focus on agricultural health and safety through initiatives related to health promotion, educational activities, injury surveillance and targeted research.

We also provide fact sheets, Power Point presentations (which are developed, tested and made available to local speakers), booklets and videos to Network members and distribute annual educational packages on topics such as farm safety audits to farm families. Network members receive a newsletter twice a year to provide them with health and safety information and to keep them updated with Network activities and programs. We also use the print, television and radio media to advertise events, publicize research findings and promote safety messages. Rural and agricultural newspaper editors, for example, provide deeply discounted rates for publishing our material.

We have formal and structured evaluation strategies, including questionnaires, peer-reviewed grants, active advisory committees and student assessments of the economic sustainability of various initiatives. We actively solicit communication with our farm families by telephone, e-mail, fax, mail and in person. Each item that we distribute carries how-to-contact information and reply postcards are included in all publications. Our most impressive evaluation, however, is undertaken by the six municipal council members in each of the 154 rural municipalities who decide that maintaining health and safety practices is a priority for their actively farming families each year.

Results of the KT experience

The Network has increased from five to 154 rural municipalities, and from 1,000 to 26,000 farm families, representing more than half of all farms in Saskatchewan, since 1988.

Growth of the Network has been sustained in spite of the challenges of a strained agricultural economy and has increased from five to 154 rural municipalities, and from 1,000 to 26,000 farm families, representing more than half of all farms in Saskatchewan, since 1988. There has been reported evidence of an increase in awareness of farm health and safety issues and behavioural changes in response, but little quantification on a provincial basis.

Lessons learned

The Network has taught us a number of important KT lessons over the years. The Network evolved out of an identified need and a natural partnership between a research unit engaged in agricultural health and safety and the Saskatchewan Association of Rural Municipalities, which already had a rich history of advocating for the health and safety of agricultural producers. A clear vision of the issues to be addressed, coupled with dedicated and committed partners, can sustain a diverse, long-term partnership. The Network has survived and indeed, flourished, because of the trust between partners, the free flow of knowledge and a shared responsibility for program planning and development.

The Network has survived and indeed, flourished, because of the trust between partners, the free flow of knowledge and a shared responsibility for program planning and development.

When the Network began, we knew that farmers wanted practical information from a reliable source provided to them in a convenient way. One of our first challenges was figuring out how to deliver information to the farm gate in an appropriate format, and we quickly learnt that farmers wanted more than printed materials. Our mobile screening and educational programs grew out of this expressed need, and also provided new opportunities for personal contact with Network members, which was becoming an increasing challenge as the Network grew. This speaks to the importance of communication and active listening with research users, and being flexible and willing to adapt initial KT approaches in response.

In delivering these mobile programs, partnering with local councils was crucial. The support of respected local leaders was seen as testimony to the value of the program and encouraged participation. The success of the programs, as evidenced by good attendance and positive feedback, in turn creates a sense of community ownership in the program and in the wider Network.

In a province as large and geographically diverse, from an agricultural perspective, as Saskatchewan, the Network remains grossly understaffed. As our membership increases, it is increasingly difficult to deliver services in proximity to the farm gate and to collect, collate and disseminate producer ideas on topics such as health and safety practices, insurance and innovations to policy makers in a timely fashion, and to respond quickly to new initiatives.

The response to these challenges has been typically rural: the persistence and dedication of committed volunteers from academia, agriculture and government; the development of creative fundraising; and learning to accomplish a lot with limited resources.

The response to these challenges has been typically rural: the persistence and dedication of committed volunteers from academia, agriculture and government; the development of creative fundraising; and learning to accomplish a lot with limited resources.

Conclusions and implications

The challenge of developing and delivering targeted and effective prevention programs to producers in a wide geographical area remains. Models for successful program delivery at or near the farm gate have been developed, evaluated and standardized by health professionals in collaboration with producers, researchers and policy makers. We now offer professional health training days for public health nurses in partnership with all of the health regions, and provide resources on health and safety in agriculture for the nurses to use as part of their practices. However, the rapid alteration of the rural landscape continues to provide new challenges and opportunities to ensure the health and safety of farmers and their families.

The Quebec Network for Work Rehabilitation: The challenge of knowledge translation and implementing a program in clinical practice

Patrick Loisel, MD, Université de Sherbrooke
Josée Labelle, MSc, OT, Université de Sherbrooke

The Quebec Network for Work Rehabilitation (RRTQ) was founded in 2001 to develop and implement evidence-based prevention and rehabilitation programs aimed at getting injured workers back to work more quickly. The RTTQ also aimed to foster the development of new knowledge and practices in work rehabilitation through research and training. While a pilot implementation study of an evidence-based program at four rehabilitation institutions was generally successful, significant opposition to the mandated nature of the program implementation arose among certain partners. Funding for the network was not renewed, highlighting the crucial importance of involving all parties in each stage of the knowledge translation (KT) process.

Background

In Quebec, as in many industrialized countries, work-related musculoskeletal disorders (MSDs) are common and costly. The most recent data in occupational health suggest a growing awareness that rehabilitation programs targeting MSD disabilities in workers must adopt a comprehensive approach to the problem, taking into account workers' actual work environments (workplace, compensation programs, health care system and respective parties).Footnote 4,Footnote 5 Yet the establishment of such programs can encounter obstacles related to the differing perspectives and stakes involved for the concerned parties (workers, health professionals, rehabilitation counsellors, employees and unions). Research on collaboration may lead to answers to these kinds of difficulties.

In a randomized clinical trial, Patrick Loisel and his team have developed and tested the Sherbrooke modelFootnote 6, a rehabilitation program promoting an integrated approach directed at both workers and the workplace. Based on the results of this trial and ten years of experience in the field, they took the first steps towards creating a provincial public health network in work rehabilitation. From that point on, various public agencies expressed interest, and a formal interagency alliance was born in Quebec.

In 1999, an outreach plan for a work rehabilitation program was presented to the board of directors at the Commission de la santé et de la sécurité du travail (CSST), the agency in charge of administering Quebec's workplace health and safety plan (Régime québécois de santé et de sécurité au travail). In December 2000, the CSST decided to give start-up support to the Quebec Network for Work Rehabilitation (Réseau en réadaptation au travail du Québec (RRTQ)) by conducting a pilot implementation study for the work rehabilitation program in four RRTQ partner institutions (Hôpital Charles LeMoyne, Centre de réadaptation La Maison, Centre de réadaptation Lucie-Bruneau and the Institut de réadaptation en déficience physique du Québec). The CSST allocated funding to cover the costs of rehabilitation services and network coordination. Through this partnership, RRTQ brought together the public health network and a research team at Hôpital Charles LeMoyne and Université de Sherbrooke, making both groups available to employers, unions and the CSST in an effort to help them reduce the incidence of work-related musculoskeletal disabilities.

The KT initiative

RRTQ was formally founded on October 1, 2001 as a horizontal network representing a consortium of ten public rehabilitation institutions and one hospital mandated for rehabilitation in Quebec. The mission of the RRTQ was to:

  • Prevent prolonged absences from work by developing and implementing evidence-based prevention and rehabilitation programs for individuals and companies; and
  • Foster the acquisition of new knowledge and practices in work rehabilitation through research and training.

The first program implemented by the RRTQ was PRÉVICAPFootnote 7,Footnote 8, a rehabilitation program based on the results of the Sherbrooke model study. The program was for the rapid, long-term and safe return to work of injured workers by emphasizing a type of rehabilitation that progressed gradually from the clinical setting to the workplace. PRÉVICAP targeted workers whose persistent pain rendered work difficult or impossible, but for whom a return to work remained the objective.

During the thirty-month pilot study, interdisciplinary teams composed of program coordinators, occupational therapists, physical educators, physicians, ergonomists and physiotherapists were set up in each of the four rehabilitation institutions. Each team received theoretical and practical training on the program itself and on the latest available evidence on work rehabilitation. To reinforce this training, the director of the RRTQ visited pilot locations, training seminars were given via videoconference, and a professional development symposium was held, bringing together clinicians from all four institutions.

Implementing the PRÉVICAP program required collaboration with CSST personnel, who were asked to refer all workers who met the eligibility criteria to the teams at the four institutions in the pilot study. In addition, RRTQ management, in cooperation with project heads from the CSST consultants branch, provided training for managers and rehabilitation counsellors from each participating regional branch of the CSST involved in the trial. To foster early referral for injured workers, discussion and information-sharing sessions were organized between clinicians and CSST managers and counsellors.

Three committees were formed to supervise the development, coordination and follow-up of program implementation activities in the rehabilitation institutions:

  • The executive committee (all institution directors general, as well as the director and assistant director of the RRTQ) was mandated to propose the structure and operating procedures for the consortium, to administer the consortium, and to take charge of negotiations with funding organizations;
  • The steering committee (clinical directors, program heads or clinical managers from the institutions and the director and assistant director of the RRTQ) ensured that RRTQ programming activities were properly coordinated and harmonized; and
  • The coordinating committee (program coordinators from the four institutions of the pilot project and the director and assistant director of the RRTQ) supervised program management and implementation.

In addition to these committees, a project information and management system (IMS) was created to enable the director to keep a close watch on interventions with workers, as stipulated in the agreement, to ensure adequate team counselling. The IMS also allowed the director to monitor project progress and provide the CSST with regular updates. Lastly, a website was developed, detailing the structure of the RRTQ and describing its operations, members, clinical program, and research and training activities. As well as informing the general public about the network, this website was also used to disseminate new evidence on work rehabilitation to clinicians.

Results of the KT experience

Generally speaking, program implementation progressed well within the four rehabilitation institutions. Interdisciplinary teams were put into place, as planned, and expertise was developed and shared. As of December 31, 2003, 501 workers had been referred by the CSST, and 437 workers who met the eligibility criteria had been assessed by RRTQ teams. For 259 of these eligible workers, a joint decision was made between the worker, the PRÉVICAP team, the CSST rehabilitation counsellor and the attending physician to participate in the rehabilitation program, which was done. The rate of return to pre-injury work was 62%, with an overall average of 24 full weeks away from work.

One obstacle we encountered during program implementation was the low number of eligible referrals, which fell below the original CSST projection (437 instead of 630). We believe that this difficulty may be attributed to resistance to the project from the rehabilitation counsellors. A number of reasons may explain this: a feeling that decision-making independence was being threatened, an impression that workload was increasing through collaboration with clinical teams and a fear of role conflicts and job losses. In June 2003, faced with these difficulties, CSST management announced that it did not plan to renew the agreement with the RRTQ at the expiry date, which had already been brought forward from April 2004 to December 31, 2003.

Thus, the RRTQ ended its activities in December 2003. The program was not implemented in the remaining institutions, as it had been planned. Moreover, only two of the four pilot study institutions are still offering the PRÉVICAP program. With no funding and no guarantee of a sufficient number of referrals, these institutions cannot maintain interdisciplinary teams for this program alone.

Lessons learned

Acting against the will of CSST personnel did enormous damage to the RRTQ implementation process.

One lesson we learned from this experience in KT is the importance of involving all partners, at all hierarchical levels and in all institutions affected by a project, in the planning and implementation process. Acting against the will of CSST personnel did enormous damage to the RRTQ implementation process. For example, while participation by clinicians was voluntary, all of the managers and rehabilitation counsellors from participating regional branches were required to refer workers meeting the inclusion criteria to teams applying the PRÉVICAP program. Yet managers and rehabilitation counsellors typically enjoy a great deal of independence in their duties, such that imposing this constraint on them generated strong opposition to the program. It would have been preferable to involve CSST personnel in program development and implementation, so that they could better understand their role in the program and be reassured about their responsibilities. Furthermore, collaboration with the CSST in implementing the project took place through the consultants branch, which holds an advisory role in program development and training, rather than a hierarchical role with personnel who must collaborate with clinicians. Within the framework of pilot project implementation, involvement with the operations branch, which maintains a leadership role with rehabilitation counsellors, would probably have allowed us to better identify potential difficulties and work to prevent them.

It would have been preferable to involve CSST personnel in program development and implementation, so that they could better understand their role in the program.

Conclusions and implications

Even though the RRTQ no longer exists, one result of the consortium is that clinicians are now more aware of the importance of updating their knowledge about workplace health and safety. Since the demise of the RRTQ, we have received several requests for training from clinicians and rehabilitation institutions.

Implementing a complex, evidence-based rehabilitation program within an organization requires involvement from all personnel, particularly from those who will be directly responsible for undertaking the interventions.

Implementing a complex, evidence-based rehabilitation program within an organization requires involvement from all personnel from the development phase onward, particularly from those who will be directly responsible for undertaking the interventions. On the basis of the RRTQ experience, we recommend that no broad implementation effort be undertaken without prior agreement from everyone involved.

Interprovincial knowledge translation in occupational health and safety

Robert Parent, PhD, Université de Sherbrooke
Barbara Neis, PhD, Memorial University of Newfoundland and co-director, SafetyNet
Alain Lajoie, Institut de recherche Robert-Sauvé en santé et en sécurité du travail
Mario Roy, PhD, Université de Sherbrooke
Stephen Bornstein, PhD, Memorial University of Newfoundland and co-director, SafetyNet
Lise Desmarais, PhD, Université de Sherbrooke
Scott MacKinnon, PhD, SafetyNet Research Chair in Workplace Health and Safety

The Eastern Canada Consortium on Workplace Health and Safety supports workplace health and safety research and its application to real-world settings. With a focus on creating research capacity in Atlantic Canada and Quebec, the consortium's major knowledge translation activities include the translation of Quebec success stories to Newfoundland and Labrador and a learning history approach to help the consortium overcome challenges posed by its multi-sectoral, multi-province, bilingual membership. The consortium's experience points to the crucial role of capacity—the ability to generate, disseminate, absorb and adapt to new knowledge—in the success or failure of knowledge translation initiatives.

Background

Annual industrial health and safety costs in Canada are estimated at more than $10 billion, and hundreds of thousands of employees are involved in industrial accidents each year. Many more carry the burden of occupational diseases.Footnote 9 Yet research on the causation and prevention of workplace injury and illness is relatively underdeveloped in Canada, when compared to countries such as Sweden, Norway, Germany and France. In addition, regional disparities in research capacity and limited knowledge translation (KT) among provinces hinder the implementation of known prevention strategies. Canada's Atlantic provinces are particularly lacking in research capacity in workplace health and safety (WHS) and in the human and other resources needed to facilitate the routine translation of research findings into the region.

The Eastern Canada Consortium on Workplace Health and Safety was established to redress these problems by supporting research initiatives related to the creation of new WHS knowledge and its translation from the research setting to real-world applications. It is a multi-site, multi-province, bilingual venture designed to enable researchers in Quebec and Atlantic Canada to do interdisciplinary work on the analysis and prevention of injuries and occupational disease in the workplace, and to get the results of new and existing research into the hands of decision makers and workplaces. A central focus of the consortium's research is looking for ways to overcome the barriers to successful WHS KT.

The consortium is funded by CIHR, the Memorial University of Newfoundland, Université de Sherbrooke, l'Institut de recherche Robert-Sauvé en santé et en sécurité du travail (IRSST)—a major Canadian workplace health and safety research institute in Quebec—and INCO, a global nickel mining company. The three organizational members of the consortium are SafetyNet, a Community Alliance for Health Research in Newfoundland and Labrador (NL), the IRSST and the Centre d'étude en organisation du travail (CÉOT), a Quebec-based university research centre specializing in knowledge transfer.

The KT initiative

A major KT activity for the consortium is identifying research-based success stories in Quebec, with its long established traditions of university-government-workplace collaboration, and translating those to NL researchers, community partners and workplaces. These "quick hit" projects help promote WHS in a particular sector and build receptor capacity for research products within the WHS leadership in NL. From the KT perspective, the thinking, borrowed from change management literature, was that this approach would help us learn how to successfully translate WHS knowledge from one province to another and generate early success stories upon which to build support for other KT activities and for local research among WHS leaders in NL.

From a list of successful research projects and products from Quebec, consortium members identified an initial list of eleven potential quick hits in conjunction with WHS leaders in NL. However, we ran into difficulty because some didn't necessarily respond to perceived needs in the practitioner community: successful KT requires considerable buy-in (including in-kind and financial investment) from local groups. On the advice of our advisory committee, we therefore converted from a "push" ("pushing" Quebec examples into NL communities) to a "pull" approach, by identifying and building interest in KT with community organizations before jointly identifying potential quick hits with them.

We converted from a “push” to a “pull” approach, by identifying and building interest in KT with community organizations before jointly identifying potential quick hits with them.

One example of this involved the Newfoundland and Labrador Construction Safety Association (NLCSA), the largest WHS sectoral association in Newfoundland and the only association to operate in a similar fashion to the one in Quebec. SafetyNet facilitated interprovincial networking between the two associations and, through this process, two Quebec research products were identified. We are now in the process of translating these products for use in WHS prevention within the Newfoundland industry. This approach resulted in longer timelines for the projects, but reduced the overall costs and increased their likelihood of success.

As a second example, one quick hit project, a "train-the-trainer" model knife sharpening and honing program, was initially anticipated to be relatively simple to transfer to NL meat and fish processing factories. However, this also proved to take longer than planned because of financial implications. Two companies were interested in the program, but neither organization was able to pay the full costs associated with the transfer. The companies partnered with SafetyNet in a successful funding application to the Workplace Health, Safety and Compensation Commission of Newfoundland and Labrador, and the fully funded project is about to get underway.

The second major activity of the consortium is a KT effort aimed at judging the success of the consortium itself, and monitoring and improving communication among its members. We use a "learning history"—a document or series of documents disseminated in a way that helps systems, individual participants and organizations become better aware of their own learning and change efforts.Footnote 10 The learning history presents the experiences and understanding of the participants, including the people who initiated, implemented and participated in organizational transformation efforts, and those who did not participate, but were affected by these efforts.

Results of the KT experience

As a result of the consortium's KT activities, we have concluded that effective health and safety KT requires a system or network of stakeholders who work together to produce desired results. This is in sharp contrast with many early KT models that generally viewed knowledge as something (an object) that could be passed on mechanistically from the creator to a user. This implies a hierarchical, top-down relationship between the generator of knowledge and the user, and has been criticized for ignoring the reality of both the context within which the knowledge was generated, and the one within which it will be used.Footnote 11,Footnote 12

KT capacity within the entire social system or network can make the difference between success and failure of the translation.

More recent attention on KT has focused on it as a process. Szulanski, for example, investigated the role of both the context of KT and the characteristics of the knowledge being translated, and found that most of the difficulties with KT emanated primarily from the receiving unit.Footnote 13 Our experience in a broad variety of organizational settings, ranging from highly creative health and safety research organizations to more practical health care provider settings, supports Szulanski's view of the importance of receptor capacity. However, this case study also indicates that, in addition to context, KT capacity within the entire social system or network can make the difference between success and failure of the translation.

Our quick-hit exercises highlighted that the major difference between the KT situation in Quebec and NL is that the Quebec WHS network is mandated by laws that specify roles and responsibilities for different stakeholders and has formalized coordinated activities. In NL, the WHS network is more informal and less coordinated, and has fewer direct financial incentives for employers to invest in KT. In order to translate knowledge from Quebec to NL, therefore, the consortium had to find ways to strengthen the WHS network within NL, and also to build new relationships between Quebec and NL. Through the efforts of the consortium, an integrated network of capacities is now beginning to emerge.

Lessons learned

Our initial focus had been on the success stories in Quebec that could help in NL, as opposed to a focus on the needs in NL that products from Quebec could address.

Many lessons can be drawn from the first two years of the consortium's work on quick hits:

  • A push approach to KT—"pushing" successful Quebec examples into NL communities—was less successful than a pull approach that identified needs within the NL community and looked for appropriate solutions developed in Quebec. In other words, our initial focus had been on the success stories in Quebec that could help in NL, as opposed to a focus on the needs in NL that products from Quebec could address.
  • Quick hits reinforced the need to focus on the strengthening of the system or network of stakeholders. Those systems or networks need to possess specific capacities for KT to succeed, including the capacity to generate, disseminate, absorb and adapt to new knowledge.
  • Quick hits may not necessarily be quick or obvious, but they contribute significantly to the formation of the system or network required for KT to succeed.

While still in the preliminary stages, our assessment of the learning history methodology is that it will provide an invaluable history in the participants' own words of what worked and what didn't throughout the project. It offers an additional diagnostic tool for the consortium leadership to quickly address issues that may become problematic to the success of the project, and will provide us with a well-grounded understanding of what to do and not to do in similar situations in the future. While it is time consuming, it also serves as an excellent source of information for future articles and case studies about the project.

Conclusions and implications

Members of the project are currently developing a KT capacity model that will elaborate on the capacities required for successful KT. While recognizing the value of past research, we believe that the study of capacities provides a valuable new lens through which to view KT and holds enormous promise for new research on, and application of, KT capacities in a knowledge-based economy.

Translating research knowledge to stakeholders: The case of forklift safety

Jean Guy Richard, Institut de recherche Robert-Sauvé en santé et sécurité du travail
Steeve Vigneault, Institut de recherche Robert-Sauvé en santé et sécurité du travail
Lise Desmarais, Université de Sherbrooke
Robert Parent, Université de Sherbrooke

This initiative was aimed at strengthening knowledge-sharing capacities between researchers at Quebec's Institut de recherche Robert-Sauvé en santé et sécurité du travail (IRSST) and stakeholders mandated to implement Quebec's occupational health and safety legislation. The project was initially focused on the complex research required to assess the effectiveness of safety devices for forklifts, with knowledge translation limited to dissemination of scientific findings. When the people in charge learnt the stakeholders were not getting the answers they required, they invested in a knowledge transfer officer and focused knowledge translation activities on capacity building, greatly improving the effectiveness of the project.

Background

In 1990, Quebec's chief coroner noted a high rate of fatal workplace accidents involving forklifts (fourteen accidents during the preceding five years, with several caused by the forklift rolling over), and ordered an inquiry into the risks associated with operating this type of vehicle. Similarly alarmed, the Commission de la santé et de la sécurité du travail (CSST), the agency in charge of administering Quebec's workplace health and safety plan, and several other prevention-oriented joint sector-based associations, asked the Institut de recherche Robert-Sauvé en santé et sécurité du travail (IRSST) to look into the issue of protection for forklift operators in cases of vehicle rollover.

During its preliminary studies, the IRSST researchers noted that a great many safety devices for forklifts already existed. They surmised that the challenge would be to determine the varying effectiveness of these devices so that regulations could be adapted (for example, to require the installation and wearing of safety belts). The stakeholder parties wanted researchers to settle the issue on the basis of scientific evidence, much as similar research had given rise to regulations on the wearing of seat belts in automobiles. The IRSST agreed to take up the challenge, in collaboration with the Institut national de recherche scientifique (INRS) in France. A total of five teams would utilize ergonomics, modelling and digital simulation tools to better understand the risks of rollover and collision to help improve workplace design and, subsequently, issue an opinion on the effectiveness of protective devices for forklift operators.

The KT initiative

The IRSST places a great deal of importance on translating the results of the research it funds into changes in workplace settings and improvements in workplace health and safety (WHS). For the IRSST, it is essential to go beyond simple knowledge dissemination: capacities must also be in place for translating that knowledge into action. This project therefore focused on strengthening knowledge-sharing capacities between the IRSST researchers and the stakeholders mandated to implement Quebec's occupational health and safety network.

The capacity-based dynamic knowledge transfer model developed by the Knowledge Transfer Research Laboratory (Laboratoire de transfert des connaissances) at the Université de Sherbrooke suggests that the effectiveness of the knowledge translation (KT) process is closely tied to four capacities: knowledge generation, dissemination, absorption and adaptation. Generation is the capacity to create new knowledge. Dissemination is the capacity to distribute that knowledge. Absorption refers to the user's ability to see the value of that new knowledge and use it to change behaviour. Finally, adaptation is the ability to continuously learn and keep pace with changing situational needs. As a result, one hypothesis that may explain the initial failure of KT between researchers and practitioners in the forklift project could be the fact that at the beginning of the project, only one capacity—knowledge generation—was put into play. No specific attention was placed on the other three capacities.

As a result of this, our KT strategy evolved, starting with knowledge production and dissemination via research reports and scientific communications, and moving towards activities to identify and formalize needs and share knowledge arising from both the research community and WHS stakeholders. This shifting of effort towards the development of absorption capacities found its best expression in activities analyzing the practices and experiential knowledge of stakeholders (mainly work inspectors and prevention counsellors).

Results of the KT experience

At first, exchanges with the stakeholders consisted only of research follow-up committee meetings, which were conducted by researchers and focused mainly on knowledge generation and dissemination. The result, after six years, was that the stakeholders felt that they were not obtaining satisfactory answers to their requests, despite the high quality of the research. Among other things, this led to misunderstandings among the main project players, in addition to some stakeholder dissatisfaction.

The researchers argued that they needed more time, given the complex nature of the problems under investigation (the effectiveness of restraining devices and their impact on lift operators' activities) and the need to provide stakeholders with scientific evidence. On the other hand, legislators and workers were losing patience with the lengthy process, and pointed out that as they waited for results, lift operators went on dying. The project was suffering from the absence of two capacities: knowledge absorption and transfer strategy adaptation.

Faced with the extreme complexity and diversity of the needs expressed by stakeholders and workplaces, and discovering that only a fraction of expectations would be met by the research, despite the substantial resources devoted to it, the IRSST redefined its strategy, investing in a resource person to foster exchanges and facilitate communication within the researcher-user network. In addition to continuing knowledge generation and dissemination activities, considerable effort was directed towards analyzing the contexts and procedures for acquiring and utilizing this knowledge (absorption and adaptation capacities). This was expressed by:

  • Engaging in technical and scientific intelligence gathering, including the preparation of a data base and the release of information to stakeholders. This utilization of all knowledge available in the scientific and technical literature made it possible to produce bulletins on a regular basis, either electronically or using various types of summary statements;
  • Analyzing needs and knowledge utilization procedures for stakeholders via interviews, participation in training, workplace tours, presentations in regional prevention groups, etc.;
  • Creating and conducting an exchange forum that brought together the principal stakeholders; and
  • Presenting various summaries of the knowledge acquired during the preceding activities to the research follow-up committee and researchers.

Experience has shown that when researchers know more about realities in the field, research results are often more effective.

Experience has shown that when researchers know more about realities in the field, research results are often more effective. Giving researchers access to the experience of practitioners responsible for the dissemination and absorption of new knowledge enriches their research experience and enables them to tailor the presentation of their results to best match the absorption capacity of research users.

Lessons learned

This research project and its accompanying KT activities led us to make several discoveries. The three most important lessons are listed below.

Constant effort must be exerted in conducting KT in encouraging exchanges and in forging links.

  1. Constant effort must be exerted in conducting KT in encouraging exchanges and in forging links. From this perspective, the role of the transfer officer is to relay information in both directions: not only from research towards other stakeholders but also from stakeholders towards research.
  2. The effectiveness of KT depends upon the degree of understanding of needs and operational procedures prevailing in each of the three following universes: research, intervention and decision-making. It is important to be familiar with the other party's work, context, needs and KT capacities. Those responsible for KT must be able to circulate freely among various spheres and foster interactions. They must be able to explain research limitations and possibilities, help prioritize needs, identify what is relevant for public release and in what form, format information and supervise the path knowledge takes, right down to its implementation in various work settings.
  3. Transfer or exchange officers build their own knowledge based on practice. By doing this, they become experts in the sectors in question and can thus provide information to both the researcher and stakeholder communities. An analysis of this new way of functioning in KT illustrates the challenges that must be taken up by parties involved in research activities: in this case, researchers, who want to meet the needs of WHS decision makers and practitioners, and the practitioners themselves, who need to acquire this scientific knowledge and convert it into action. A third party—the transfer officer—has greatly improved exchanges between these two other spheres and, by doing so, has increased the effectiveness of research, a crucial component in improving health and safety in the workplace.

Conclusions and implications

The KT activities associated with this project enabled us to create a database for use by health and safety researchers and practitioners. This also contributed to creating our dynamic approach to information sharing, which increases the return on investment in research. The transfer or exchange officer is now playing a key role on this project, leading to numerous requests for collaborations in the production of technical and educational material. The emergence of such requests is an excellent measure of the success of these initiatives and requires that we adapt our KT strategy once again. The results obtained on this project, among others, are now informing an in-depth review by the IRSST's management team of its global strategy to improve the use of research findings.

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