The effect of a translating research into practice (TRIP)--cancer intervention on cancer pain management in older adults in hospice

Initiatives Targeting Health Care Professionals: A Systematic Review of Knowledge Translation Pain Assessment and Management Studies Focusing on Older Adults

OBJECTIVES

Pain is often undertreated in older adult populations due to factors, such as insufficient continuing education and health care resources. Initiatives to increase knowledge about pain assessment and management are crucial for the incorporation of research evidence into practice. Knowledge translation (KT) studies on pain management for older adults and relevant knowledge users have been conducted; however, the wide variety of KT program formats and outcomes underscores a need to evaluate and systematically report on the relevant literature.

MATERIALS AND METHODS

Using a systematic review methodology, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, PsycInfo, and Web of Science databases were searched from inception to June 2023. Pain-related KT programs targeted towards older adults, their informal caregivers, and health care professionals were examined. Initiatives focusing on health care professionals are the focus of this review. Initiatives focusing on older adults are reported in a companion article.

RESULTS

From an initial 21,669 search results, 172 studies met our inclusion criteria. These studies varied widely in focus and delivery format but the majority were associated with significant risk of bias. In this report, we are focusing on 124 studies targeting health care professionals; 48 studies involving initiatives targeting older adults are reported in a companion article. Moreover, most programs were classified as knowledge mobilization studies without an implementation component. Across all studies, knowledge user satisfaction with the initiative and the suitability of the material presented were most commonly assessed. Patient outcomes, however, were underemphasized in the literature.

CONCLUSION

Patient and clinical outcomes must be a focus of future research to fully conceptualize the success of KT programs for older adult individuals. Without implementation plans, disseminated knowledge does not tend to translate effectively into practice.

A Systematic Approach to Evidence-Based Design for Measurable Health and Wellness Outcomes: Curating and Translating Evidence to Practice

OBJECTIVES

Evaluating evidence from peer-review literature for use in evidence-based design is often challenging for the design disciplines, requiring access to the peer-reviewed literature, expertise in evaluating methods and findings, and translating the results into actionable design and operational recommendations.

PURPOSE

The purpose of this methods paper is to elucidate the process for systematic evaluation of research to translate evidence into practical application to improve design for occupant health and wellness.

BACKGROUND

Researchers have found strong connections in environmental design influence on health and wellness that have proven to be substantiative in the effort to improve health and well-being. Design has the capacity to encourage healthy choices and decisions within the built environment. Translation of evidence into applied design solutions may improve public health.

METHODS

A protocol is presented that culminates in the translation of evidence into design recommendations focused on improving occupant health. The protocol includes preparation for the literature search and review, search strategy, study selection, data analysis, and development of the literature review.

RESULTS

After evaluation of the evidence is completed, there were several positive findings in the example that stakeholders could utilize to improve the health of building occupants with programs and design to support nutrition, physical activity, and circadian entrainment.

CONCLUSIONS

There are a variety of software tools and processes to utilize in the curation of evidence to improve the built environment with relevant design recommendations and operational considerations affecting the personal, social, and economic health of our society.

Translation of Evidence-Based Interventions Into Oncology Care Settings: An Integrative Review

BACKGROUND

Adoption of evidence remains slow, leading to variations in practices and quality of care. Examining evidence-based interventions implemented within oncology settings can guide knowledge translation efforts.

OBJECTIVE

This integrative review aimed to (1) identify topics implemented for oncology-related evidence-based practice (EBP) change; (2) describe frameworks, guidelines, and implementation strategies used to guide change; and (3) evaluate project quality.

METHODS

PubMed and CINAHL were searched to identify published practice change projects. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines were followed. Fifty articles met the inclusion criteria. Data were extracted; content analysis was conducted. The Quality Improvement Minimum Quality Criteria Set guided quality assessment.

RESULTS

Topics included infection control/prevention (n = 18), pain/palliative care (n = 13), psychosocial assessment (n = 11), and medication adherence (n = 8). Among the projects, Plan, Do, Study, Act (n = 8) and Lean Six Sigma (n = 6) frameworks were used most. Thirty-six projects identified guidelines that directed interventions. Multiple implementation strategies were reported in all articles with planning, education, and restructuring the most common. Reach, sustainability, and ability to be replicated were identified as quality gaps across projects.

CONCLUSION

The EBP topics that emerged are consistent with the oncology nursing priorities, including facilitating integration of EBP into practice. The studies identified used national guidelines and implementation strategies to move evidence into practice. Heterogeneity in measurement made synthesis of findings difficult across studies, although individual studies showed improvement in patient outcomes.

IMPLICATIONS FOR PRACTICE

Development of an interprofessional oncology consortium could facilitate a standardized approach to implementation of high-priority topics that target improved patient outcomes, harmonize measures, and accelerate translation of evidence into practice.

Evaluation of Quality Improvement Initiatives to Improve and Sustain Advance Care Planning Completion and Documentation

Despite the established benefit of advance care planning (ACP), achieving and sustaining high rates of ACP completion continue to be a challenge in many health care settings. A palliative care champions committee has targeted improving the ACP process through quality improvement initiatives at an academic medical center. To understand the impact of multiyear efforts to improve ACP, surveys of registered nurses, care coordinators, and medical assistants from inpatient and outpatient settings were conducted in 2013 and 2017 to explore comfort level with ACP, barriers preventing completion of ACP in daily practice, and suggestions for overcoming these barriers. The findings suggest strategies to further integrate ACP through interdisciplinary teams, including outpatient staff education, inpatient and outpatient quality improvement initiatives, and dedicated staff for ACP.

Racial Differences in Pain Management for Patients Receiving Hospice Care

OBJECTIVES

To investigate racial differences in implementation of 11 evidence-based cancer pain management strategies in a matched sample of patients in hospice.

SAMPLE & SETTING

32 African American and 32 Caucasian American older adults (aged 65 years or older) with cancer pain receiving hospice care in the midwestern United States.

METHODS & VARIABLES

Matched cohort secondary data analysis of postintervention data in a cluster randomized controlled trial was used. Main outcomes are the summative and individual Cancer Pain Practice Index scores.

RESULTS

There were few statistically significant or clinically meaningful differences in implementation of individual best practices for pain management by race. Assessment of primary pain characteristics and management of opioid-induced constipation with a bowel regimen was significantly lower in African Americans than in Caucasian Americans.

IMPLICATIONS FOR NURSING

African American older adults receiving hospice care at the end of life received pain management that was, overall, comparable to matched Caucasian American older adults. Hospice and oncology nurses play a critical role in effective pain management and should continue to implement evidence-based guidelines for pain management into daily practice. Diffusing the hospice model and principles of pain and symptom management into other settings and specialty care areas may reduce widespread pain disparities.

Are the MORECare guidelines on reporting of attrition in palliative care research populations appropriate? A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Palliative care trials have higher rates of attrition. The MORECare guidance recommends applying classifications of attrition to report attrition to help interpret trial results. The guidance separates attrition into three categories: attrition due to death, illness or at random. The aim of our study is to apply the MORECare classifications on reported attrition rates in trials.

METHODS

A systematic review was conducted and attrition classifications retrospectively applied. Four databases, EMBASE; Medline, CINHAL and PsychINFO, were searched for randomised controlled trials of palliative care populations from 01.01.2010 to 08.10.2016. This systematic review is part of a larger review looking at recruitment to randomised controlled trials in palliative care, from January 1990 to early October 2016. We ran random-effect models with and without moderators and descriptive statistics to calculate rates of missing data.

RESULTS

One hundred nineteen trials showed a total attrition of 29% (95% CI 28 to 30%). We applied the MORECare classifications of attrition to the 91 papers that contained sufficient information. The main reason for attrition was attrition due to death with a weighted mean of 31.6% (SD 27.4) of attrition cases. Attrition due to illness was cited as the reason for 17.6% (SD 24.5) of participants. In 50.8% (SD 26.5) of cases, the attrition was at random. We did not observe significant differences in missing data between total attrition in non-cancer patients (26%; 95% CI 18-34%) and cancer patients (24%; 95% CI 20-29%). There was significantly more missing data in outpatients (29%; 95% CI 22-36%) than inpatients (16%; 95% CI 10-23%). We noted increased attrition in trials with longer durations.

CONCLUSION

Reporting the cause of attrition is useful in helping to understand trial results. Prospective reporting using the MORECare classifications should improve our understanding of future trials.

Systematic review of the use of process evaluations in knowledge translation research

BACKGROUND

Experimental designs for evaluating knowledge translation (KT) interventions can provide strong estimates of effectiveness but offer limited insight into how the intervention worked. Consequently, process evaluations have been used to explore the causal mechanisms at work; however, there are limited standards to guide this work. This study synthesizes current evidence of KT process evaluations to provide future methodological recommendations.

METHODS

Peer-reviewed search strategies were developed by a health research librarian. Studies had to be in English, published since 1996, and were not excluded based on design. Studies had to (1) be a process evaluation of a KT intervention study in primary health, (2) be a primary research study, and (3) include a licensed healthcare professional delivering or receiving the intervention. A two-step, two-person hybrid screening approach was used for study inclusion with inter-rater reliability ranging from 94 to 95%. Data on study design, data collection, theoretical influences, and approaches used to evaluate the KT intervention, analysis, and outcomes were extracted by two reviewers. Methodological quality was assessed with the Mixed Methods Appraisal Tool (MMAT).

RESULTS

Of the 20,968 articles screened, 226 studies fit our inclusion criteria. The majority of process evaluations used qualitative forms of data collection (43.4%) and individual interviews as the predominant data collection method. 72.1% of studies evaluated barriers and/or facilitators to implementation. 59.7% of process evaluations were stand-alone evaluations. The timing of data collection varied widely with post-intervention data collection being the most frequent (46.0%). Only 38.1% of the studies were informed by theory. Furthermore, 38.9% of studies had MMAT scores of 50 or less indicating poor methodological quality.

CONCLUSIONS

There is widespread acceptance that the generalizability of quantitative trials of KT interventions would be significantly enhanced through complementary process evaluations. However, this systematic review found that process evaluations are of mixed quality and lack theoretical guidance. Most process evaluation data collection occurred post-intervention undermining the ability to evaluate the process of implementation. Strong science and methodological guidance is needed to underpin and guide the design and execution of process evaluations in KT science.

REGISTRATION

This study is not registered with PROSPERO.

Inpatient Health Care Utilization in Children With Hemophilia Before and After the Joint Outcome Study Publication

The "Joint Outcomes Study" (JOS) demonstrated improved joint outcomes for patients receiving primary prophylaxis versus on-demand therapy. The impact of primary prophylaxis on inpatient health care utilization is not well-defined. To evaluate changes in hospitalization care of children with hemophilia before and after the 2007 JOS publication, this study utilized the Pediatric Health Information System (PHIS) to evaluate admissions for patients with hemophilia A or B (age, 2 to 7) admitted between January 2002 and 2006 (pre-JOS) and January 2010 and 2014 (post-JOS). Discharge diagnosis codes and clinical transaction classifications were used to differentiate bleeding episodes, infections, bypass agent use, length of stay, and intensive care unit (ICU) management. Overall, admissions for bleeding episodes did not change (26.5% of admissions pre-JOS vs. 23.6% post-JOS, P=0.10). However, admissions for suspected infections increased (3.0% of admissions pre-JOS vs. 7.2% post-JOS, P<0.01) while confirmed infections remained stable. Meanwhile, ICU utilization decreased (7.8% of admissions pre-JOS vs. 4.9% post-JOS, P<0.01). The necessity for ICU care in children with hemophilia has decreased since publication of the JOS. However, expanded adoption of primary prophylaxis is associated with more hospitalizations for suspected systemic infections, likely due to utilization of central venous catheters to deliver clotting factor concentrates.

Analyzing Analgesic Medications in Community-Dwelling Older Adults

Objectives

Analyzing medication data for research purposes is complex, and methods are rarely described in the literature. Our objective was to describe methods of quantifying opioid and nonopioid analgesics and to compare the utility of five different analgesic coding methods when analyzing relationships between pain, analgesic use, and clinical outcomes. In this study, we used physical function as the outcome variable for its clinical relevance and its relationship to pain in older adults.

Design

Secondary analyses of baseline cross-sectional data from the Advanced Cognitive Training Interventions for Vital Elders (ACTIVE) study.

Setting

Community settings in six regions of the United States.

Subjects

A total of 2,802 community-residing adults older than age 65 years.

Methods

A medication audit was conducted. Analgesics were coded as any pain medication, counts (total analgesics, number of opioids and nonopioids), equianalgesics (oral morphine equivalents, oral acetaminophen equivalents), and dose categories. Adjuvant medications used to treat pain (e.g., tricyclic antidepressants and anticonvulsants) and low-dose aspirin typically used for cardiovascular conditions were excluded from these analyses. To examine the utility of these various approaches, a series of hierarchical regression models were conducted with pain and analgesics as predictors and physical functioning as the dependent variable.

Results

Eighty-one point nine percent of participants reported experiencing recent pain, but 26% reported analgesic use. Nonopioids were the most common drug class used. Models revealed that pain was significantly associated with worse physical function (β = -0.45, P = 0.001), after controlling for demographic and analgesic variables. Two basic drug coding methods (e.g., any pain medication, number of pain medications) were equivalent in their explanatory power (β = -0.12, P = 0.001) and were slightly stronger predictors of function than the more complex coding procedures.

Conclusions

Analgesic medications are important variables to consider in community-based studies of older adults. We illustrate several methods of quantifying analgesic medications for research purposes. In this community-based sample, we found no advantage of complex equianalgesic coding methods over simple counts in predicting physical functioning. The results may differ depending on the research question or clinical outcome studied. Thus, methods of analyzing analgesic drug data warrant further research.

Nonpharmacologic Pain Interventions: A Review of Evidence-Based Practices for Reducing Chronic Cancer Pain

BACKGROUND

Pain is a common issue for patients with cancer and can be challenging to manage effectively. Healthcare professionals need to be knowledgeable about evidence-based nonpharmacologic interventions.
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OBJECTIVES

This systematic review critically appraises the strength and quality of the empirical evidence for nonpharmacologic interventions in reducing chronic cancer pain.
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METHODS

Intervention studies were critically appraised and summarized by an Oncology Nursing Society Putting Evidence Into Practice team of RNs, advanced practice nurses, and nurse scientists. A level of evidence and a practice recommendation was assigned to each intervention.
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FINDINGS

Based on evidence, recommended interventions to reduce chronic cancer pain are celiac plexus block for pain related to pancreatic and abdominal cancers and radiation therapy for bone pain. Although psychoeducational interventions are considered likely to be effective, the effective components of these interventions and their dose and duration need to be determined through additional research.

Advancing the pain management in older adults agenda forward through the development of key research and education priorities: A Canadian perspective

Background: The undermanagement of pain in older adults has been identified as a problem worldwide. Aims: The purpose of this research is to identify priority areas in education and research for future development with the aim of improving pain management in older persons. In addition, barriers to addressing these priorities are identified. Methods: This mixed methods study, based on a modified Delphi approach, included three distinct components: (1) a qualitative component using focus groups with key informants or experts in the field of pain management in older adults (n = 17), (2) a scoping review of the literature, and (3) a survey of ranked responses completed by the same key informants who attended the focus groups. Thematic analysis was used to identify the initial list of issues and descriptive statistics were used for ranking them. Results: A number of concerns related to both education and research were frequently endorsed by participants. For education, they identified the need for more content in both undergraduate and continuing education programs related to documenting about pain; assessing pain, and learning about the complexities of pain. Research priorities included the need to explore successful practice models; costs of untreated pain; effects of mobility on pain; and patient preferences for pain management. Key barriers to addressing these barriers included lack of staff time and resources and unfamiliarity with pain assessment tools. Conclusion: These findings highlight priority issues related to pain management in older adults from a nationwide perspective.

Workforce characteristics and interventions associated with high-quality care and support to older people with cancer: a systematic review

OBJECTIVES

To provide an overview of the evidence base on the effectiveness of workforce interventions for improving the outcomes for older people with cancer, as well as analysing key features of the workforce associated with those improvements.

DESIGN

Systematic review.

METHODS

Relevant databases were searched for primary research, published in English, reporting on older people and cancer and the outcomes of interventions to improve workforce knowledge, attitudes or skills; involving a change in workforce composition and/or skill mix; and/or requiring significant workforce reconfiguration or new roles. Studies were also sought on associations between the composition and characteristics of the cancer care workforce and older people's outcomes. A narrative synthesis was conducted and supported by tabulation of key study data.

RESULTS

Studies (n=24) included 4555 patients aged 60+ from targeted cancer screening to end of life care. Interventions were diverse and two-thirds of the studies were assessed as low quality. Only two studies directly targeted workforce knowledge and skills and only two studies addressed the nature of workforce features related to improved outcomes. Interventions focused on discrete groups of older people with specific needs offering guidance or psychological support were more effective than those broadly targeting survival outcomes. Advanced Practice Nursing roles, voluntary support roles and the involvement of geriatric teams provided some evidence of effectiveness.

CONCLUSIONS

An array of workforce interventions focus on improving outcomes for older people with cancer but these are diverse and thinly spread across the cancer journey. Higher quality and larger scale research that focuses on workforce features is now needed to guide developments in this field, and review findings indicate that interventions targeted at specific subgroups of older people with complex needs, and that involve input from advanced practice nurses, geriatric teams and trained volunteers appear most promising.

Implementation of a Psychoeducational Program for Cancer Survivors and Family Caregivers at a Cancer Support Community Affiliate: A Pilot Effectiveness Study

BACKGROUND

Psychoeducational interventions, tested for efficacy in randomized clinical trials, are seldom implemented in clinical practice where cancer survivors and their family caregivers can benefit from them.

OBJECTIVE

This study examined the effectiveness of the FOCUS Program on cancer survivors' and their family caregivers' outcomes when implemented at a Cancer Support Community (CSC) affiliate by agency social workers. Study aims were to (1) test effects of the program on survivor and caregiver outcomes as a unit and (2) determine program feasibility in terms of enrollment, retention, intervention fidelity, and satisfaction.

METHODS

A preintervention and postintervention pilot effectiveness study was conducted with 34 cancer survivor-caregiver dyads (ie, pairs). The FOCUS Program, originally delivered by nurses in dyads' homes, was modified to a small-group format and delivered by CSC social workers. The primary outcome was quality of life (QOL). Intermediary outcomes were benefits of illness/caregiving, communication, support, and self-efficacy. Analyses included repeated-measures analysis of variance.

RESULTS

Dyads had significant improvements in total QOL; physical, emotional, and functional QOL; benefits of illness; and self-efficacy. Effect sizes were similar to prior randomized clinical trial findings. Although dyads were difficult to recruit (enrollment, 60%), both retention (92%) and intervention fidelity (94%) were high.

CONCLUSIONS

It was possible to implement the FOCUS Program at a CSC affiliate by agency staff, obtain positive intervention effects, and maintain intervention fidelity.

IMPLICATIONS FOR PRACTICE

Researchers and clinicians need to collaborate to implement more evidence-based interventions in practice settings for cancer survivors and their family caregivers.

The contribution of distance learning to the knowledge of nursing lecturers regarding assessment of chronic wounds

OBJECTIVE:

to identify the contribution made by a refresher course on the assessment of chronic wounds, offered through the Moodle virtual learning environment (VLE), to the knowledge relating to this issue of nursing lecturers and nurses linked to higher education.

METHOD:

a prospective, quasi-experimental study, with data collection before and after the educational intervention. The study was undertaken in three stages using the Moodle VLE. The sample was made up of 28 participants who answered the pre-test on the knowledge, devised in accordance with international guidelines on chronic wounds. Afterwards, the refresher course was offered (intervention) and was accessed in accordance with individuals' schedules, during the established time period. At the end of the course, 26 participants answered the post-test. Those who did not participate in the post-tests were excluded from the study, as it is pairwise analysis of the sample.

RESULT:

the participants obtained, on average, 55.5% of correct answers in the pre-test on their knowledge, and 73.4% in the post-test, this difference being statistically significant. There was a negative correlation between the time of experience in lecturing and the performance in the test on their knowledge.

CONCLUSION:

the participation in the online refresher course contributed to improving the lecturers' performance in the test on their knowledge, in relation to the recommendations for assessing chronic wounds, based in scientific evidence.

Evaluation of Evidence-based Nursing Pain Management Practice

It is important to ensure that cancer pain management is based on the best evidence. Nursing evidence-based pain management can be examined through an evaluation of pain documentation. The aim of this study was to modify and test an evaluation tool for nursing cancer pain documentation, and describe the frequency and quality of nursing pain documentation in one oncology unit via the electronic medical system. A descriptive cross-sectional design was used for this study at an oncology unit of an academic medical center in the Pacific Northwest. Medical records were examined for 37 adults hospitalized during April and May 2013. Nursing pain documentations (N = 230) were reviewed using an evaluation tool modified from the Cancer Pain Practice Index to consist of 13 evidence-based pain management indicators, including pain assessment, care plan, pharmacologic and nonpharmacologic interventions, monitoring and treatment of analgesic side effects, communication with physicians, and patient education. Individual nursing documentation was assigned a score ranging from 0 (worst possible) to 13 (best possible), to reflect the delivery of evidence-based pain management. The participating nurses documented 90% of the recommended evidence-based pain management indicators. Documentation was suboptimal for pain reassessment, pharmacologic interventions, and bowel regimen. The study results provide implications for enhancing electronic medical record design and highlight a need for future research to understand the reasons for suboptimal nursing documentation of cancer pain management. For the future use of the data evaluation tool, we recommend additional modifications according to study settings.

Implementation of a nursing home quality improvement project to reduce resident pain: a qualitative case study

This article describes the experiences of staff members working within nursing homes that successfully implemented a quality improvement project aimed at reducing resident pain. Interviews were conducted with 24 nursing home employees from within 8 facilities participating in the quality improvement project. Findings were organized using the Consolidated Framework for Implementation Research. Interdisciplinary communication, supportive leadership, training, and nursing assistant participation facilitated implementation. Increased documentation, resistance to change, and difficulty measuring outcomes were perceived challenges.

Evidence-based practice beliefs and behaviors of nurses providing cancer pain management: a mixed-methods approach

PURPOSE/OBJECTIVES

To describe evidence-based practice (EBP) beliefs and behaviors of nurses who provide cancer pain management.

DESIGN

Descriptive, cross-sectional with a mixed-methods approach.

SETTING

Two inpatient oncology units in the Pacific Northwest.

SAMPLE

40 RNs.


METHODS

Data collected by interviews and web-based surveys.

MAIN RESEARCH VARIABLES

EBP beliefs, EBP implementation, evidence-based pain management.

FINDINGS

Nurses agreed with the positive aspects of EBP and their implementation ability, although implementation level was low. They were satisfied with their pain management practices. Oncology nursing certification was associated with innovativeness, and innovativeness was associated with EBP beliefs. Themes identified were (a) limited definition of EBP, (b) varied evidence-based pain management decision making, (c) limited identification of evidence-based pain management practices, and (d) integration of nonpharmacologic interventions into patient care.

CONCLUSIONS

Nurses' low level of EBP implementation in the context of pain management was explained by their trust that standards of care and medical orders were evidence-based.

IMPLICATIONS FOR NURSING

Nurses' EBP beliefs and behaviors should be considered when developing strategies for sustaining evidence-based pain management practices. Implementation of the EBP process by nurses may not be realistic in the inpatient setting; therefore, hospital pain management policies need to be evidence-based and reinforced with nurses.

A protocol for a systematic review of the use of process evaluations in knowledge translation research

BACKGROUND

Experimental designs for evaluating knowledge translation (KT) interventions for professional behavior change can provide strong estimates of intervention effectiveness but offer limited insight how the intervention worked or not. Furthermore, trials provide little insight into the ways through which interventions lead to behavior change and how they are moderated by different facilitators and barriers. As a result, the ability to generalize the findings from one study to a different context, organization, or clinical problem is severely compromised. Consequently, researchers have started to explore the causal mechanisms in complementary studies (process evaluations) alongside experimental designs for evaluating KT interventions. This study focuses on improving process evaluations by synthesizing current evidence on process evaluations conducted alongside experimental designs for evaluating KT interventions.

METHODS/DESIGN

A medical research librarian will develop and implement search strategies designed to identify evidence that is relevant to process evaluations in health research. Studies will not be excluded based on design. Included studies must contain a process evaluation component aimed at understanding or evaluating a KT intervention targeting professional behavior change. Two reviewers will perform study selection, quality assessment, and data extraction using standard forms. Disagreements will be resolved through discussion or third party adjudication. Data to be collected include study design, details about data collection approaches and types, theoretical influences, approaches to evaluate intervention dose delivered, intervention dose received, intervention fidelity, intervention reach, data analysis, and study outcomes. This study is not registered with PROSPERO.

DISCUSSION

There is widespread acceptance that the generalizability of quantitative trials of KT interventions would be significantly enhanced to other contexts, health professional groups, and clinical conditions through complementary process evaluations alongside trials. This systematic review will serve as a 'state of the science' on methodological approaches to process evaluations and will allow us to: 1) take stock of current research approaches and 2) develop concrete recommendations for knowledge users (e.g., quality consultants and health services researchers) designing future KT process evaluations.