In the healthcare field, knowledge transfer and exchange (KTE) has been identified as an integral practice for optimising learning and empowering decision making, whether it be from “lab bench to bed side” or “lab bench to sports bench.” This process involves finding creative and effective ways to “get the right information to the right people in the right format at the right time so as to influence decision-making.”1 Many models and strategies have been developed to facilitate this process for populations such as medical professionals, educators and athletic professionals.

This is especially challenging in sports medicine where there is so much interaction among a diverse group of specialties, including medical staff, coaches, athletic trainers and athletes. Moreover, management of the “invisible injury” concussion, specifically in sport, is a prime example where effective communication of optimal and current knowledge is key and can benefit from the practice of KTE.2 Concussion is an injury that is under reported and where misconceptions exist, reinforcing the importance of education in this area of injury.2 Although resources such as journal articles, educational videos, seminars and websites communicate knowledge about concussion, there is no evidence to indicate that these modalities are the most appropriate. Learning methodologies need to be identified and put into place for target audiences so that optimal communication and education can occur. This has become a mandate for many safety and injury prevention organisations.

Principles, theories and practices of KTE are applicable to all realms of life. This discussion paper will (a) examine the KTE literature as it applies to healthcare personnel such as physicians, physiotherapists and athletic trainers/therapists, and coaches and student athletes; (b) provide a comprehensive understanding of the needs of each target audience identified in relation to optimal learning; (c) apply the practice of KTE to sport concussion resources and (d) identify needs and, where possible, make recommendations for the improvement of concussion education resources and programmes based on the premise of KTE.

METHODS

Literature review

Databases Pubmed, Medline, Psych Info and Sport Discus were used in this literature review. The search was conducted using standardised terms such as “knowledge”, “knowledge transfer”, “concussion”, “mild traumatic brain injury”, “coach and athlete learning”, “teaching” and “optimal learning”. The literature search was restricted to articles published in the English language, but not restricted to any particular years.

An internet search was also conducted to gather information pertaining to KTE. Databases and reports from the following websites were searched: Ontario Neurotrauma Foundation (ONF), Institute for Work and Health, World Health Organization (WHO), Canadian Health Services Research Foundation (CHSRF) and the Centre for Health Economics and Policy Analysis (CHEPA). Altogether, 52 journal articles, 20 websites and 2 books were reviewed.

RESULTS

General principles of KTE

The implementation of knowledge transfer and the exchange of knowledge is essential as a means for improving the healthcare system.3 The transfer of knowledge is a process of moving knowledge that is research-based or ideas from area to area.4

The literature currently describes three knowledge transfer models: (a) producer-push model, which involves developers of the research knowledge planning and implementing strategies to push knowledge towards targeted audiences; (b) user-pull model, where knowledge users plan and implement strategies to pull knowledge developed by sources useful for their own decision making; and (c) exchange model, which involves building relationships between the researchers and those who use the knowledge to effectively allow for the exchange of information, ideas and experiences.5 The transfer and exchange of knowledge involves collaboration to engage in problem solving, where learning occurs through planning, disseminating and applying new or existing research in the decision making process.6 This process enhances evidence-based decision making; thereby, increasing the probability that the best possible decisions are being made, especially as it applies to health care.6 It is important to recognise that the processes and strategies put in place for effective KTE will always vary based on factors such as individuals and organisations.

According to the Institute for Work and Health’s guide, “From Research to Practice: A Knowledge Transfer Planning Guide,” there are five principles, which are described below, that should be considered to maximise the uptake of knowledge: (1) Who is the target audience? (2) What is the message being delivered? (3) Who is delivering the message? (4) How is the message being transferred? (5) What is the impact of the knowledge transfer?5

Who is the target audience?

When defining the target audience, it is important to be specific. Knowing the audiences’ values can help shape the message to their needs and be communicated to reflect their values. Involving the audience in the development, discussion and delivery process will help communicate the message more effectively.7

What is the message being delivered?

Messages should be specific and tailored to the needs of the target audience. They should be clear, concise, consistent, continuous and compelling.7 Knowing the behaviour that you want to change can help create the message to facilitate that change.

Who is delivering the message?

Messages should be delivered to an audience by a credible messenger. Communication should occur using a language that the audience is comfortable with and follows the audience’s agenda and not their own.7

How is the message being transferred?

When selecting the appropriate knowledge transfer method, the size and nature of the audience, budget and availability of resources should be considered.5

What is the impact of the knowledge transfer?

The role of evaluation is essential. Changes in knowledge, awareness or attitude that has assisted decision making and behaviour change should be assessed.5

Many factors need to be considered when developing strategies to facilitate education. Determining the appropriate knowledge transfer model and applying knowledge transfer principles are key to knowledge mobilisation, particularly in the area of sport concussion.

Knowledge transfer: the missing link for enhancing concussion education

Concussion is an invisible injury, which is under reported and diagnosed. Providing education to enhance recognition and reporting by athletes and coaches, and improve diagnoses by physicians, is key in facilitating treatment and return to play from this injury. There is overlap between groups of learners and methods, but key differences also exist. As it applies to all groups, enhancing concussion education is essential and there are studies which reinforce education as a necessity. The Concussion In Sport Group (Fédération Internationale de Football Association (FIFA), International Ice Hockey Federation (IIHF) and the International Olympic Committee (IOC)) identifies education as a key issue in comprehensive concussion management.2 8 According to this group, “as the ability to treat or reduce the effects of concussive injury after the event is minimal, education of athletes’ colleagues and the general public is a mainstay of progress in this field (p 53).”2 A growing body of literature reveals that enhanced concussion education and awareness impacts outcome.9^–11

Learning styles and preferences among target audiences

The methods in which individuals experience optimal learning vary and should be considered when developing effective concussion education strategies.

Enhancing knowledge transfer for healthcare professionals

Optimising physician learning

Improving the quality of how physicians practice enhances their accountability and knowledge acquisition is linked to this. It is suggested that “the pursuit of evidence-based healthcare (rather than medicine) implies a move beyond medicine towards individual level interventions…(p 33)”12 It is essential that focus be placed on effectively and properly organising and managing systems of care.12 Managing change, professionals, and the development and implementation of effective strategies is key, and optimising and enhancing physician learning should be part of the model of change.

Continuing medical education (CME) plays an important role in the ever changing healthcare system and, traditionally, physician learning is accomplished through CME. Improving performance and optimising patient healthcare outcomes is essential and although participating in CME may enhance physician knowledge, impact on practice and patient outcomes may be limited, demonstrating a lack of impact of CME.13 Individual learning preferences and adult learning methods should be considered and physicians should choose the educational strategy compatible with their learning method or style.14 15 The type of CME activities provided to enhance learning are variable and include: (1) educational materials (non-interactive printed produced information); (2) audit and feedback; (3) educational outreach (visits by educators); (4) opinion leaders; (5) conferences, seminars, workshops, small group sessions, traineeships and teleconferences; (6) patient-mediated interventions (for example, patient education materials) and (7) reminders.

Research has found that passive dissemination of educational materials as a standalone method of education are ineffective in enhancing physician knowledge.16 17 Similarly, traditional didactic lectures, where there is limited or no interaction between the audience and the presenter, has little impact on changing physician performance.5 13 17 18 Although knowledge, skill and attitude may be affected, the lectures do not solely change performance or improve patient care.13 18

Audit and feedback, which involves providing a summary of a physician’s clinical performance and/or recommendations for clinical care over a period of time (for example, average number of diagnostic tests ordered) has been shown to have variable effectiveness and a moderate impact on physician practice.5 16 17 The role of opinion leaders, who are nominated by colleagues, are healthcare professionals with extensive knowledge within a discipline/area of practice. Further clarity regarding the impact they may have on the practice of their peers is needed.16 Patient mediated interventions, also considered to be variable, involves “changing the performance of health care providers where specific information was sought or given to patients: for instance, direct mailings to patients (e.g. educational materials given to patients or placed in waiting rooms) (p 11–44)”.17

Academic detailing or education outreach is considered an effective strategy. This method uses a trained individual who meets with healthcare professionals in their practice settings to provide them with information with the intent of changing their performance.16 Interactive education sessions are also effective and allow participants to engage in discussions, applying knowledge and skills used in their practice setting. Reminder messages, a form of reinforcement, have also been found to be effective.5 16

The role of the theatre as a knowledge transfer tool for healthcare professionals has also been examined. Theatre can enhance healthcare practitioners level of understanding of complex issues that arise in medicine through facilitating verbal and non-verbal communication and their level of engagement in theatre on a cognitive and emotional level.19 Theatre can reinforce best-practices and experiences of healthcare professionals and insight in healthcare research. More research is required to examine the efficacy, disadvantages and the type of evaluations that should be conducted to assess theatre as a learning tool.19

Application to concussion

Adopting optimal physician education strategies is essential to managing a concussed athlete. Research suggests that every concussed athlete should be evaluated by a medical doctor.2 Physicians are essential in diagnosing, treating and managing concussion, and in working with athletes to establish return to play steps. They may even be key in pre-injury education, especially in the setting of “preseason medical evaluation”.2 Although sport medicine physicians receive focused education in concussion, wider education is needed in family practice, emergency medicine, neurology and neurosurgery settings.

Several education resources have been developed, which may positively affect physicians’ approach to concussion. Many safety and injury prevention groups have developed a variety of concussion education resources.

One example is booklets that provide overviews of concussion definitions, diagnosis, treatment and return to play guidelines. This information is often summarised as a concussion card. These types of tool are often free and downloadable from injury prevention and safety organisation websites. From a knowledge transfer perspective, passive dissemination of printed educational materials as a standalone method of education are ineffective in changing physician performance.16 Furthermore, the impact of using the internet as a learning resource for physicians is also unknown.

Knowledge transfer research has identified educational outreach, interactive education sessions and reminder messages as generally effective tools in optimising physician learning and changing physician performance. Knowledge of these types of education strategies should be taken into consideration when developing concussion education programmes and resources for this audience. Establishing concussion education sessions/seminars would be effective strategies to optimise physicians’ learning about concussion. Trained individuals in the area of sport concussion then speak to practitioners about concussion diagnosis, treatment and management. Although education sessions may not directly occur in the healthcare settings of the medical professionals attending, it is a forum for interaction as all members have an opportunity to interact and discuss with the speakers and each other. Furthermore, educations sessions provide a venue for physicians to apply and share what they currently know about sport concussion

In conjunction with the verbal and visual component of education sessions, printed education materials could be distributed to the audience. Although printed education materials are not effective resources as a standalone method for education, coupling these materials with education outreach and interaction can act as an additional form of reinforcement and strengthen the overall value of the education materials.

Incorporating concussion education as a component of medical school should also be considered. It has been identified that sport medicine education is deficient in US paediatric programmes with several medical programmes having no one in charge of the sports medicine curriculum.20 Lectures seem to be the primary teaching tool, as opposed to hands-on teaching, with many of the programmes not including formal teaching of concussion management. A standardised sports medicine curricula, with a focus on hands-on training for teaching paediatric residents sports medicine is needed.20 In Canada, the Canadian Academy of Sport Medicine (CASM) is committed to excellence in the practice of medicine as it applies to all aspects of physical activity. Concussion education and training is a component of the CASM programme and part of a rigorous qualifying examination (Diploma in Sport Medicine). Physicians interested in practicing sports medicine are trained to deal with the injury of concussion.

Enhancing learning opportunities for physiotherapists, athletic trainers and therapists

Physiotherapists frequently work with concussed athletes and can also benefit from using effective educational methods to enhance their knowledge and skills to practice physiotherapy. Learning extends beyond providing information and involves the ability of individuals in this field to construct knowledge.21 Physiotherapists need to be motivated and engaged, draw upon existing knowledge and learn in the situation in which knowledge is required.21 Research has shown that models for physiotherapy education are not well documented or evaluated.21

Problem-based learning (PBL) is a model used in the medical school community that emphasises and promotes learning through small groups and self-direction with the assistance of a facilitator.22 PBL involves (a) learning in small groups; (b) a change in faculty role from expert lecturer to facilitator of learning; (c) emphasis on student responsibility and self-directed learning and (d) a written problem as the stimulus for learning with students engaging in a problem-solving process as they learn and discuss problem related content (see table 1).23

The impact of evidence-based practice (EBP) as an educational programme for physiotherapists has also been examined.24 Through EBP physiotherapists are encouraged to provide the most effective health care and be responsible and accountable for the interventions they provide (see table 1).

Other approaches examined to facilitate learning in physiotherapy include socialisation and development pathways. Socialisation is a process of learning formal knowledge, skills and rules, as well as learning shared values, beliefs and ways of reasoning.25 Research has found that the foundation of learning, for the individual student, is adhered through interaction with others in situated physiotherapy practice.25 Identifying with a profession such as physiotherapy can occur through meaningful situated experiences. Learning involves two aspects: the content of what is being learned and the way in which learning occurs (see table 1).

Peer-assisted learning (PAL) has also been recognised as a valuable tool where students encounter mutual educational benefits as both teachers and learners.26 The role of PAL in the athletic training clinical setting has been examined.26 PAL has been defined as “the act or process of gaining knowledge, understanding or skill in athletic training-related tasks among students who are at either different or equivalent academic or experiential levels through instruction or experience (p 102).”26 See table 1.

Application to concussion

Physiotherapists, athletic trainers and therapists play an essential role in concussion management. Using and adopting optimal resources that meet their learning needs can facilitate with their onsite management of concussed athletes. The Sport Concussion Assessment Tool (SCAT) was developed for the use of medical doctors, physiotherapists or athletic therapists to facilitate with the sport concussion evaluation.2 Furthermore, several safety and injury prevention groups have established a variety of education resources existing in various formats ranging from education documents and concussion cards to establishing position statements specific to the management of sport-related concussion.27

Coaches and athletes: learning as a partnership

For athletic programmes to function well, several components need to come together. One component of this is the level of preparation shown by coaches. There are increasing demands being placed upon coaches as they are expected to be knowledgeable and skilled at teaching their sport, understand and apply risk-management regulations, individualise their approaches to athletes, be effective communicators and survive challenges associated with interacting with parents.28

Learning and education challenges experienced in both the healthcare and education settings are also encroaching on the athletic environment. Challenges in learning are experienced by both coaches and athletes. Coaches play a key role in the development and success of athletic careers. Understanding and appreciating the broader concepts of the basis of coaching and how coaches impact the social development of athletes is essential.29 Coaches are key community leaders who positively influence an individual’s personal and athletic development.30 They are important to society and engage in a continuum of training and education to ensure that the needs of those that rely on them are met.

A great deal of work has been conducted regarding coach education. Research has found coaches learn through three forms of reflection: (a) reflection-in-action (during the action), (b) reflection-on-action (within the action, but not during the activity) and (c) retrospective reflection-on-action (outside of the action present).31 32 Further work on reflective practice indicated six different components within the coach learning/education process: (1) coaching issues (stimulus is provided to the coach for reflection); (2) role framing (coach may take a personal approach to coaching); (3) issue setting (identifying why a situation is being considered a coaching issue); (4) strategy generation (resources are used by the coach to create a strategy to deal with the issue); (5) experimentation (implementing the strategy) and (6) evaluation (examining if the strategy is effective). If the strategy is effective, then the coaches reflective process would stop; however, if the coaching issue remains unresolved, then the coach would continue with generating a more effective strategy for dealing with the issue until it is resolved.31 32 Reflection provides a framework to connect education, theory and practice.33 Through reflection, coaches become more aware of their behaviours.

In conjunction with the reflection process, coaches also need to recognise athletes as learners.34 Many coaches have not considered the relationship between the instructional approach of the coach and how it is perceived by athletes. This reinforces the point that coaching has often focused more on the technical, tactical and bio-scientific aspects of sport performance, rather than the educational function of the coach. Coaches also need to reflect on their approach, which would allow them to analyse and understand why certain coaching practices/approaches are productive or non-productive.34 Speaking with other coaches is also valuable as it allows for discussion, debate and sharing ideas with colleagues.

In conjunction with the learning component are the needs of coaches to help make their job easier. There are a lack of resources and a need to be innovative. Sport administrators are seeking education programmes that can meet the needs of today’s sporting environment and one way to do this is through online learning.28 Coaching programmes need to be (a) user friendly (easily accessible at their own convenience with no barriers), (b) up to date in their content (paper curriculum can be outdated by the time coaches receive it) and (c) administrative friendly (programmes are often not cost effective from a training perspective).28 The online Montana model effectively addresses these coaching needs by providing coaches with access to materials which traditionally have not been available.28 The web-based coaching curriculum consists of 10 chapters that include topics such as injury prevention, risk management, nutrition, and social and psychological aspects of sport. Each chapter consists of materials, website links and new articles related to topics of interest. This model is undergoing refinement in the areas of testing and reporting systems and an expansion of available material.28

Application to concussion

Coaches play an important and integral role in the education and safety of athletes as it pertains to concussion. Research looking at players’ understanding of concussion and return to play guidelines found that players predominantly obtained their concussion information from coaches/teachers followed by medical personnel and then other players.35 Furthermore, players identified that the responsibility for assessing concussion rested primarily on the player or the coach rather than with a doctor.

Although athletes rely on coaches for their concussion information, there is some cause for concern. Research has shown that there are concussion misunderstandings among youth coaches.36 A survey developed to assess concussion knowledge of youth coaches found that those with previous coaching experience and education were able to correctly identify and recognise signs and symptoms of concussion.36 Findings highlighted misconceptions such as the requirement of loss of consciousness to occur as part of a concussion, not removing an athlete from play with a suspected concussion and allowing athletes to return to play while symptomatic.36 Although this study showed that a majority of the coaches correctly responded to the concussion questions, it is apparent that continued education is needed.

Greater efforts are required in the concussion education of players by coaches, and as coaches are informed of concussion, its diagnosis, management and return to play guidelines, information should be transmitted to players more extensively.35

There are a variety of concussion education materials that are readily available to assist coaches. Materials, such as education booklets, concussion cards, clipboard stickers and CDs provide recommendations to coaches. Many resources are free and downloadable from the internet. In using the internet as a coach resource, it is important not to overlook individual learning characteristics and preferences of instructional features.

From a coach perspective, educational sessions provide coaches with the opportunity to learn from concussion experts. Furthermore, it provides a forum for coaches to apply what they have learned about concussion, both pre and post the teaching event, discuss it with the speakers and peers in the audience during a discussion period.

Developing optimal concussion education resources that effectively enhance coaches’ knowledge can increase concussion reporting, facilitating a decrease in the number of symptomatic athletes playing sport, ultimately reducing the chances of re-injury.36

Student-athlete learning

It is important to recognise athletes as learners. It has been argued that both students and teachers experience a motivational effect when the focus has shifted from the subject matter to be learned to the learner.37 In the sport environment, the coach is the teacher and the athlete is the student. In establishing effective methods for teaching and facilitating learning, there has been an increased interest in the role of multiple intelligences and how it affects learning and achievements.

The theory of multiple intelligences proposes that each individual possesses distinct areas of skills to different degrees.38 39 The theory is comprised of seven areas of intelligence: (1) linguistic (verbal or written communication to express what is on one’s mind); (2) logical-mathematical (logic focus, order and problem solving); (3) spatial (learning through visualisation involving sensitivity to colour, line, shape, form and space); (4) musical (thinking in music and perceiving and expressing various forms of music); (5) bodily-kinaesthetic (learning through bodily sensations to express ideas and feelings, including specific skills such as coordination, balance, dexterity, strength, flexibility and speed); (6) intrapersonal (focusing on one’s inner-self and knowledge) and (7) interpersonal (understanding and relating to others, and learning through collaboration).

Much research pertaining to the theory of multiple intelligences has been focused on the original seven multiple intelligences. The theory suggests that children have strengths and weaknesses in different areas, indicating that they have different intellectual profiles and require different use of intelligences.40 Research has found that teaching educators and students about multiple intelligences theory in an elementary school setting can positively impact students.41 Students become more self-directed, gain self-confidence, understand the abilities of themselves and others, and identify their strengths and work on their weaknesses.41 42 As for educators, they learn to appreciate a wider variety of student strengths.41

This theory has created interest regarding diversifying teaching strategies, creating balanced programming, and tailoring student learning by matching teaching instruction to specific learning styles; however, it has been criticised for being too broad for planning curriculum and is inadequately supported by evidence.43

Application to concussion

The amount of knowledge and education athletes have around the topic of concussion can greatly influence the choices that are made concerning their health. Common reasons for why athletes do not report their concussion includes not thinking the injury is serious enough to warrant medical attention, their motivation to not be withheld from participation and their lack of knowledge regarding the signs of concussion.10

Knowledge transfer resources

Initiatives to educate young athletes about concussion need to be put into place. Several multimedia approaches have been established to deliver concussion knowledge to this audience (see table 2).

The role of e-learning through the use of internet technology is gaining prominence in education and is recognised as having the ability to change performance, knowledge and skill acquisition.44 It has been shown to be a valuable supplement to traditional approaches to education and has the potential to improve learning quality, access to training and education, and enhance the cost effectiveness of education.45 The internet is a good example of a multimedia modality used in concussion education. Currently, many education resources exist on the internet. These resources could potentially expand beyond the printable education booklet or concussion card to incorporate internet-based approaches to learning. Distance learning, blended learning and flexible learning are all approaches that could enhance the concussion e-learning process (see table 2).46

Television is another example of a multimedia resource that can be used to educate athletes. Although television has been associated with some negative factors from a learning perspective, it also can act as a socialising agent and a learning tool. Television can be used as a substitute for teachers on a temporary basis, it can be used to compliment teaching and learning resources that are not available and/or it can provide programming that occurs over the community, national and international stations, providing general information education (see table 2).47

Video gaming is another example of a multimedia approach that may have educational benefits for athletes and has become a popular medium for education. Although video games have been linked to inactivity, asocial and violent behaviour, they do have an educative value.48 49 Research suggests that video games help to re-define education and intrigue students so that they will spend time engaging in independent learning.49

Video games often require players to master skill sets, including strategic and analytical thinking, problem solving, planning and execution of strategies, decision making, adapting to change and team building.50 In the school setting, educational games can be used to target specific, positive, learning outcomes. Despite the positive outcomes, there are barriers that exist that are impeding the implementation of video games as an educational tool (see table 2).

Use of video games in enhancing concussion knowledge has been investigated. A video game was developed in which the educational aspect of concussion was implicitly embedded.51 The game was developed to convey information about concussion symptomatology for the minor ice hockey population. Information pertaining to the players’ experience with concussion history, video gaming habits and involvement with hockey, as well as their input on video game attributes such as difficulty level, enjoyment and instruction clarity was collected.51 Results indicated that participants found the game interesting and that knowledge of concussion symptomatology was enhanced.

Peer support may also help to facilitate athlete education. From a rehabilitation perspective, social support in the athletic setting plays a critical role in the rehabilitation of injury.52 Support groups for injured athletes provide a forum for them to come together “to voice their concerns, share ideas about coping, learn vital performance enhancement strategies and realise that they are not alone. The goal is that athletes will support one another both mentally and physically by helping each other deal with the elements of rehabilitation and not participating in their sport (p 520).”52

The impact of concussion support groups has been assessed.53 Benefits such as improved mood, reduced anger, confusion and frustration were seen and this facilitates recovery for concussed athletes. More research on the value of peer-support groups for concussed athletes is needed. Using tools such as case studies and discussion sessions, for example, may not only engage athletes in learning about concussion but allow them to tap into peer support, which could facilitate and provide them ownership in their rehabilitation process if they are injured.

SUMMARY AND RECOMMENDATIONS

It is evident that different target audiences have distinct learning needs. It is apparent that education outreach, engaging in interactive education sessions and receiving reminder messages are optimal not for only enhancing physician learning but on impacting physician performance. It is also clear that traditional methods of learning such as didactic lectures and the distribution of printed educational materials, although they may enhance knowledge, do not change performance. From a coach perspective, research supports the reflective process as a learning modality for coaches. Providing coaches with the proper tools can facilitate their reflection process and how they deal with specific coaching issues such as concussion. Student athletes also have preferred methods for learning.

From a resource perspective, research associated with video gaming, internet and television all support the facilitation of learning. However, it is important to recognise that resources and approaches used to facilitate learning should be based on the needs of the target audiences and their preferred method and style of learning.

A variety of concussion education resources exist for various target audiences and in various formats. Although the content of these resources may be clear, concise and up to date, the impact and use they have on influencing the knowledge, attitude and behaviours of those who deal with concussion requires further investigation. In order to effectively assess the impact and efficacy of concussion education resources, an evaluation of resources needs to occur in controlled research studies.

As part of the improvement, update and development of concussion education resources, the knowledge transfer principles should be consulted to ensure that education design is optimal. The knowledge transfer process may be the missing link needed to strengthen and enhance concussion knowledge and education.