Abstract
Safe and effective healthcare requires that new knowledge or skills, once learned, are incorporated into professional practice. However, this process is not always straightforward. Learning takes place in complex contexts, requiring practitioners to overcome various motivational, systemic, emotional, and social barriers to the application of knowledge. This paper explores the mechanisms through which individuals translate knowledge into action to provide insight into why disconnects between knowledge and action can arise. As a critical review, the aim was to draw on key literature from multiple fields to analyse and synthesize existing schools of thought and lay a strong conceptual foundation on which knowledge to action gaps might be considered. We iteratively consulted clinicians and experts in various fields to guide literature searches focused on theoretical perspectives that could inform educational and research efforts around knowledge-to-action gaps. Key theoretical perspectives on motivation address when and how individuals decide to take action. Literatures from cognitive science address how clinicians and learners self-regulate to (sometimes) overcome barriers to action. Sociocultural theories examine the ways in which action might be prevented by social norms that conflict with what the individual knows and believes, potentially also giving rise to counter-normative action. No single perspective will entirely explain how health professionals and learners implement knowledge in practice. As a result, the authors offer multiple lenses through which to view the problem, and then propose how each of these lenses might better guide educational and research efforts to untangle this challenging but important issue.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Baumeister, R. F., Vohs, K. D., DeWall, C. N., & Zhang, L. (2007). How emotion shapes behavior: Feedback, anticipation, and reflection, rather than direct causation. Personality and Social Psychology Review,11(2), 167–203. https://doi.org/10.1177/1088868307301033.
Blanchette, I., & Richards, A. (2010). The influence of affect on higher level cognition: A review of research on interpretation, judgement, decision making and reasoning. Cognition and Emotion,24(4), 561–595. https://doi.org/10.1080/02699930903132496.
Bolte, A., & Goschke, T. (2010). Thinking and emotion: Affective modulation of cognitive processing modes. In B. Glatzeder, V. Goel, & A. A. C. von Muller (Eds.), Towards a theory of thinking (pp. 261–277). Berlin: Springer.
Bolte, A., Goschke, T., & Kuhl, J. (2003). Emotion and intuition: Effects of positive and negative mood on implicit judgements of semantic coherence. Psychological Science,14(5), 416–421.
Bramesfeld, K. D., & Gasper, K. (2008). Happily putting the pieces together: A test of two explanations for the effects of mood on group-level information processing. British Journal of Social Psychology,47(2), 285–309. https://doi.org/10.1348/000712607x218295.
Brehaut, J. C., & Eva, K. W. (2012). Building theories of knowledge translation interventions: Use the entire menu of constructs. Implementation Science,7(1), 114. https://doi.org/10.1186/1748-5908-7-114.
Cabana, M. D., Rand, C. S., Powe, N. R., Wu, A. W., Wilson, M. H., Abboud, P.-A. C., et al. (1999). Why don’t physicians follow clinical practice guidelines? A framework for improvement. Journal of the American Medical Association,282(15), 1458–1467. https://doi.org/10.1001/jama.282.15.1458.
Clore, G. L., & Huntsinger, J. R. (2007). How emotions inform judgment and regulate thought. TRENDS in Cogntive Sciences,11(9), 393–399. https://doi.org/10.1016/j.tics.2007.08.005.
Cook, D. A. (2016). Tips for a great review article: Crossing methodological boundaries. Medical Education,50(4), 384–387. https://doi.org/10.1111/medu.12983.
Cook, D. A., & Artino, A. R. (2016). Motivation to learn: An overview of contemporary theories. Medical Education,50(10), 997–1014. https://doi.org/10.1111/medu.13074.
Corno, L. (1993). The best-laid plans: Modern conceptions of volition and educational research. Educational Researcher,22(2), 14–22. https://doi.org/10.3102/0013189x022002014.
Corno, L., & Kanfer, R. (1993). The role of volition in learning and performance. Review of Research in Education,19, 301–341.
Coudeyre, E., Rannou, F., Tubach, F., Baron, G., Coriat, F., Brin, S., et al. (2006). General practitioners’ fear-avoidance beliefs influence their management of patients with low back pain. Pain,124(3), 330–337. https://doi.org/10.1016/j.pain.2006.05.003.
Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science,4(1), 1–15. https://doi.org/10.1186/1748-5908-4-50.
Davis, M. A. (2009). Understanding the relationship between mood and creativity: A meta-analysis. Organizational Behavior and Human Decision Processes,108(1), 25–38. https://doi.org/10.1016/j.obhdp.2008.04.001.
de Vries, M., Holland, R. W., Corneille, O., Rondeel, E., & Witteman, C. L. M. (2012). Mood effects on dominated choices: Positive mood induces departures from logical rules. Journal of Behavioral Decision Making,25(1), 74–81. https://doi.org/10.1002/bdm.716.
Deci, E. L., Koestner, R., & Ryan, R. M. (1999). A meta-analytic review of experiments examining the effects of extrinsic rewards on intrinsic motivation. Psychological Bulletin,125(6), 627–668. https://doi.org/10.1037/0033-2909.125.6.627.
Deschepper, R., Grigoryan, L., Lundborg, C. S., Hofstede, G., Cohen, J., Kelen, G. V., et al. (2008). Are cultural dimensions relevant for explaining cross-national differences in antibiotic use in Europe? BMC Health Services Research,8, 123. https://doi.org/10.1186/1472-6963-8-123.
Dreisbach, G., & Goschke, T. (2004). How positive affect modulates cognitive control: Reduced perseveration at the cost of increased distractibility. Journal of Experimental Psychology. Learning, Memory, and Cognition,30(2), 343–353. https://doi.org/10.1037/0278-7393.30.2.343.
Eccles, J. S., & Wigfield, A. (2002). Motivational beliefs, values, and goals. Annual Review of Psychology,53, 109–132. https://doi.org/10.1146/annurev.psych.53.100901.135153.
Elsbach, K. D., & Barr, P. S. (1999). The effect of mood on individuals’ use of structured decision protocols. Organization Science,10(2), 181–198.
Engeström, Y. (1987). Learning by expanding: An activity-theoretical approach to developmental research. Helsinki: Orienta-Konsultit Oy.
Eva, K. W. (2008). On the limits of systematicity. Medical Education,42(9), 852–853. https://doi.org/10.1111/j.1365-2923.2008.03140.x.
Fenwick, T., Edwards, R., & Sawchuk, P. (2011). Emerging approaches in educational research: Tracing the sociomaterial in education. New York: Routledge.
Fleming-Dutra, K. E., Hersh, A. L., Shapiro, D. J., Bartoces, M., Enns, E. A., File, T. M., Jr., et al. (2016). Prevalence of inappropriate antibiotic prescriptions among US ambulatory care visits, 2010–2011. Journal of the American Medical Association,315(17), 1864–1873. https://doi.org/10.1001/jama.2016.4151.
Francis, J. J., O’Connor, D., & Curran, J. (2012). Theories of behaviour change synthesised into a set of theoretical groupings: Introducing a thematic series on the theoretical domains framework. Implementation Science,7(1), 35. https://doi.org/10.1186/1748-5908-7-35.
Gasper, K., & Clore, G. L. (2002). Attending to the big picture: Mood and global versus local processing of visual information. Psychological Science,13(1), 34–40. https://doi.org/10.1111/1467-9280.00406.
Gillet, N., Vallerand, R. J., Amoura, S., & Baldes, B. (2010). Influence of coaches’ autonomy support on athletes’ motivation and sport performance: A test of the hierarchical model of intrinsic and extrinsic motivation. Psychology of Sport and Exercise,11(2), 155–161. https://doi.org/10.1016/j.psychsport.2009.10.004.
Ginsburg, S., Bernabeo, E., & Holmboe, E. (2014). Doing what might be “wrong”: Understanding internists’ responses to professional challenges. Academic Medicine,89(4), 664–670. https://doi.org/10.1097/ACM.0000000000000163.
Gollwitzer, P. M. (1993). Goal achievement: The role of intentions. European Review of Social Psychology,4(1), 141–185. https://doi.org/10.1080/14792779343000059.
Grant, M. J., & Booth, A. (2009). A typology of reviews: An analysis of 14 review types and associated methodologies. Health Information and Libraries Journal,26(2), 91–108. https://doi.org/10.1111/j.1471-1842.2009.00848.x.
Grimshaw, J. M., Eccles, M. P., Walker, A. E., & Thomas, R. E. (2002). Changing physicians’ behavior: What works and thoughts on getting more things to work. Journal of Continuing Education in the Health Professions,22(4), 237–243. https://doi.org/10.1002/chp.1340220408.
Kahlke, R., Bates, J., & Nimmon, L. (2018). When I say … sociocultural learning theory. Medical Education. https://doi.org/10.1111/medu.13626.
Kennedy, T., Regehr, G., Rosenfield, J., Roberts, W., & Lingard, L. (2004). Exploring the gap between knowledge and behaviour: A qualitative study of clinician action following an educational intervention. Academic Medicine,79(5), 386–393.
Kotabe, H. P., & Hofmann, W. (2015). On integrating the components of self-control. Perspectives on Psychological Science,10(5), 618–638. https://doi.org/10.1177/1745691615593382.
Kuhl, J. (1987). Action control: The maintenance of motivational status. In F. Halisch & J. Kuhl (Eds.), Motivation, intention, and volition (pp. 279–291). Berlin: Springer.
Kuhl, J., & Beckmann, J. (1985). Introduction and overview. In J. Kuhl & J. Beckmann (Eds.), Action control: From cognition to behaviour (pp. 1–8). New York: Springer.
Kulier, R., Gee, H., & Khan, K. S. (2008). Five steps from evidence to effect: Exercising clinical freedom to implement research findings. BJOG: An International Journal of Obstetrics & Gynaecology,115(10), 1197–1202. https://doi.org/10.1111/j.1471-0528.2008.01821.x.
Lave, J., & Wenger, E. (1991). Situated learning: Legitimate peripheral participation. Cambridge: Cambridge University Press.
Légaré, F., Freitas, A., Thompson-Leduc, P., Borduas, F., Luconi, F., Boucher, A., et al. (2015). The majority of accredited continuing professional development activities do not target clinical behavior change. Academic Medicine,90(2), 197–202. https://doi.org/10.1097/ACM.0000000000000543.
Légaré, F., O’Connor, A. M., Graham, I. D., Saucier, D., Côté, L., Blais, J., et al. (2006). Primary health care professionals’ views on barriers and facilitators to the implementation of the Ottawa decision support framework in practice. Patient Education and Counseling,63(3), 380–390. https://doi.org/10.1016/j.pec.2006.04.011.
Maes, S., & Karoly, P. (2005). Self-regulation assessment and intervention in physical health and illness: A review. Applied Psychology,54(2), 267–299.
Martin, L. L., & Clore, G. L. (2013). Theories of mood and cognition: A user’s guidebook. Mahwah: Psychology Press.
Martin, K. O., & Mazmanian, P. E. (1991). Anticipated and encountered barriers to change in CME: Tools for planning and evaluation. Journal of Continuing Education in the Health Professions,11(4), 301–318. https://doi.org/10.1002/chp.4750110405.
May, C. R., Mair, F., Finch, T., MacFarlane, A., Dowrick, C., Treweek, S., et al. (2009). Development of a theory of implementation and integration: Normalization Process Theory. Implementation Science,4(1), 1–9. https://doi.org/10.1186/1748-5908-4-29.
Mazmanian, P. E., Ratcliff Daffron, S., Johnson, R. E., Davis, D. E., & Kantrowitz, M. P. (1998). Information about barriers to planned change: A randomized controlled trial involving continuing medical education lectures and commitment to change. Academic Medicine,73(8), 882–886.
McConnell, M. M., & Shore, D. I. (2011). Upbeat and happy: Arousal as an important factor in studying attention. Cognition and Emotion,25(7), 1184–1195. https://doi.org/10.1080/02699931.2010.524396.
Meeker, D., Knight, T. K., Friedberg, M. W., Linder, J. A., Goldstein, N. J., Fox, C. R., et al. (2014). Nudging guideline-concordant antibiotic prescribing: A randomized clinical trial. JAMA Internal Medicine,174(3), 425–431. https://doi.org/10.1001/jamainternmed.2013.14191.
Meeker, D., Linder, J. A., Fox, C. R., Friedberg, M. W., Persell, S. D., Goldstein, N. J., et al. (2016). Effect of behavioral interventions on inappropriate antibiotic prescribing among primary care practices: A randomized clinical trial. Journal of the American Medical Association,315(6), 562–570. https://doi.org/10.1001/jama.2016.0275.
Michie, S., Johnston, M., Francis, J., Hardeman, W., & Eccles, M. (2008). From theory to intervention: Mapping theoretically derived behavioural determinants to behaviour change techniques. Applied Psychology,57(4), 660–680. https://doi.org/10.1111/j.1464-0597.2008.00341.x.
Nigg, J. T. (2017). Annual research review: On the relations among self-regulation, self-control, executive functioning, effortful control, cognitive control, impulsivity, risk-taking, and inhibition for developmental psychopathology. Journal of Child Psychology and Psychiatry,58(4), 361–383. https://doi.org/10.1111/jcpp.12675.
Norcini, J., Anderson, B., Bollela, V., Burch, V., Costa, M. J., Duvivier, R., et al. (2011). Criteria for good assessment: Consensus statement and recommendations from the Ottawa 2010 Conference. Medical Teacher,33(3), 206–214. https://doi.org/10.3109/0142159X.2011.551559.
Pham, M. T. (2007). Emotion and rationality: A critical review and interpretation of empirical evidence. Review of General Psychology,11(2), 155.
Redelmeier, D. A., & Shafir, E. (2015). Why even good physicians do not wash their hands. BMJ Quality and Safety,24(12), 744–747. https://doi.org/10.1136/bmjqs-2015-004319.
Rodrigues, T. A., Roque, F., Falcao, A., Figueiras, A., Herdeiro, M. T., Teixeira Rodrigues, A., et al. (2013). Understanding physician antibiotic prescribing behaviour: A systematic review of qualitative studies. International Journal of Antimicrobial Agents,41(3), 203–212. https://doi.org/10.1016/j.ijantimicag.2012.09.003.
Ryan, R. M., & Deci, E. L. (2000). Intrinsic and extrinsic motivations: Classic definitions and new directions. Contemporary Educational Psychology,25(1), 54–67. https://doi.org/10.1006/ceps.1999.1020.
Ryan, R. M., & Deci, L. E. (2017). Self-determination theory: Basic psychological needs in motivation. New York: Guilford Publications.
Vanlessen, N., De Raedt, R., Koster, E. H. W., & Pourtois, G. (2016). Happy heart, smiling eyes: A systematic review of positive mood effects on broadening of visuospatial attention. Neuroscience and Biobehavioral Reviews,68, 816–837. https://doi.org/10.1016/j.neubiorev.2016.07.001.
Vohs, K. D., Baumeister, R. F., Schmeichel, B. J., Twenge, J. M., Nelson, N. M., & Tice, D. M. (2014). Making choices impairs subsequent self-control: A limited-resource account of decision making, self-regulation, and active initiative. Motivation Science,1(S), 19–42. https://doi.org/10.1037/2333-8113.1.s.19.
Wenger, E. (1998). Communities of practice: Learning, meaning, and identity. Cambridge: Cambridge University Press.
Williams, G. C., Levesque, C., Zeldman, A., Wright, S., & Deci, E. L. (2003). Health care practitioners’ motivation for tobacco-dependence counseling. Health Education Research Theory and Practice,18(5), 538–553. https://doi.org/10.1093/her/cyf042.
Acknowledgements
The authors wish to thank colleagues at the Centre for Health Education Scholarship, University of British Columbia, who provided feedback on this work during its development.
Author information
Authors and Affiliations
Corresponding author
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Kahlke, R.M., McConnell, M.M., Wisener, K.M. et al. The disconnect between knowing and doing in health professions education and practice. Adv in Health Sci Educ 25, 227–240 (2020). https://doi.org/10.1007/s10459-019-09886-5
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10459-019-09886-5