From Research Evidence to “Evidence by Proxy”? Organizational Enactment of Evidence‐Based Health Care in Four High‐Income Countries

• Published date: 01 September 2019
• Author: Roman Kislov,Alison Kitson,Gill Harvey,Janet Kelly,Anna Ehrenberg,Wendy Gifford,Paul Wilson,Lena Pettersson,Greta Cummings,Lars Wallin
• DOI: http://doi.org/10.1111/puar.13056
• Date: 01 September 2019

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Abstract: Drawing on multiple qualitative case studies of evidence-based health care conducted in Sweden, Canada,

Australia, and the United Kingdom, the authors systematically explore the composition, circulation, and role of

codified knowledge deployed in the organizational enactment of evidence-based practice. The article describes the

“chain of codified knowledge,” which reflects the institutionalization of evidence-based practice as organizational

business as usual, and shows that it is dominated by performance standards, policies and procedures, and locally

collected (improvement and audit) data. These interconnected forms of “evidence by proxy,” which are informed

by research partly or indirectly, enable simplification, selective reinforcement, and contextualization of scientific

knowledge. The analysis reveals the dual effects of this codification dynamic on evidence-based practice and highlights

the influence of macro-level ideological, historical, and technological factors on the composition and circulation of

codified knowledge in the organizational enactment of evidence-based health care in different countries.

Evidence for Practice

• The evidence-based policy and practice movement encourages the incorporation of evidence from research

into decision making.

• Its implementation at the organizational level involves an increasing role for “evidence by proxy,” such as

performance standards, organizational policies, and local data.

• Different forms of evidence by proxy are interconnected, simplifying scientific knowledge, reinforcing some

of its elements, and making it applicable to the local context.

• Frontline practitioners tend to rely on evidence by proxy, which is created, circulated, and analyzed by

specialists.

• The composition and circulation of different forms of evidence by proxy differ across countries.

The evidence-based policy and practice

movement encourages decision makers at

different levels to be concerned with “what

works,” on the assumption that increased use of

research evidence will lead to better outcomes in terms

of effectiveness, accountability, and sustainability

(Hall and Van Ryzin 2018; Head 2016; Newman,

Cherney, and Head 2016; Nutley, Walter, and Davies

2007). In the context of health care, this paradigm-

shifting doctrine is based on the premise that clinical

practice should integrate professional experience

with the best available scientific evidence about

the effectiveness of the interventions used (Ferlie et

al. 2009; Rousseau and Gunia 2016; Sackett et al.

1996). Research directly informs clinical guidelines,

providing actionable recommendations for practice

that are developed using rigorous, systematic,

and transparent processes to summarize the best

available evidence (Harrison 1998; Knaapen 2013;

Timmermans and Kolker 2004).

Research has shown, however, that the uptake of

clinical guidelines by health-care practitioners

remains low as codified “know-what” research

evidence has to compete with multiple forms of

tacit “know-how” knowledge and skills (Gabbay

and le May 2011; McCaughan et al. 2005). At

the same time, we know from organization and

management theory that the institutionalization

of new approaches in day-to-day organizational

practices always involves a complex interplay of tacit

and codified knowledge (Kislov et al. 2014; Tsoukas

and Vladimirou 2001). As evidence-based practice

has been widely embraced by health care systems and

organizations (Dopson et al. 2003), this study aims

to look beyond guidelines, exploring the role of other

forms of codified knowledge—that is, knowledge

that is formal, systematic, and expressible in text or

numbers, making it easy to store, transfer, and use

across space and time (Turner et al. 2014)—in the

enactment of evidence-based practice.

Roman Kislov

Paul Wilson

University of Manchester

Greta Cummings

University of Alberta

Anna Ehrenberg

Dalarna University

Wendy Gifford

University of Ottawa

Janet Kelly

University of Adelaide

Alison Kitson

Flinders University

From Research Evidence to “Evidence by Proxy”?

Organizational Enactment of Evidence-Based Health Care in

Four High-Income Countries

Lena Pettersson

Dalarna University

Lars Wallin

Dalarna University, Karolinska

Institute, and Sahlgrenska Academy

Gill Harvey

University of Adelaide

Anna Ehrenberg is professor of

nursing and head of research in health and

welfare in the School of Education, Health

and Social Studies, Dalarna University,

Sweden. Her research is in the area of

implementation of evidence-based practice,

patient safety, and nursing informatics to

support nursing knowledge in assessments

of patient care needs and clinical decision

making.

Greta Cummings is dean of the

Faculty of Nursing, University of Alberta,

Canada. She leads the CLEAR (Connecting

Leadership Education and Research)

Outcomes Research Program, focusing on

leadership practices of health-care decision

makers to achieve better health outcomes

in the health-care system and for providers

and patients. She has published more than

200 papers and was a 2014 Highly Cited

Researcher in Social Sciences (Thomson

Reuters) for papers arising from her

leadership research.

Paul Wilson is senior research fellow

in the Alliance Manchester Business

School, University of Manchester, United

Kingdom. His research interests are focused

on evidence-informed decision making

in health policy and practice and the

development and evaluation of methods

to increase the uptake of research-based

knowledge in health systems. He is the

co-editor-in-chief of

Implementation

Science

.

Research Article

Roman Kislov is senior research fellow

in the Alliance Manchester Business School,

University of Manchester, United Kingdom.

He conducts qualitative research on the

processes and practices of knowledge

mobilization, with a particular interest

in communities of practice, intermediary

roles, organizational learning, and

implementation of change. Before joining

academia, he worked as a doctor for a gold

mining company in Central Asia, combining

clinical work with a managerial post.

E-mail: roman.kislov@manchester.ac.uk

Public Administration Review,

Vol. 79, Iss. 5, pp. 684–698. © 2019 The

Authors. Public Administration Review

published by Wiley Periodicals, Inc. on behalf of

The American Society for Public Administration.

DOI: 10.1111/puar.13056.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited

and is not used for commercial purposes.