Introduction

Integrating health research evidence into decision-making, health care practices, and policies is critical for optimizing health outcomes and societal benefit from public investment in academic health research [1, 2]. Academic traditions have long-emphasized scholarly outputs associated with the production of evidence [3–5] despite proposals to expand concepts of scholarship [6, 7]. Such outputs include peer-reviewed publications, book chapters, patents, and academic conference presentations [8, 9]. These traditional outputs remain a cornerstone of academic activity [10–12], but have minimal impact on health care practices [13, 14], policies [15], and communities [16–18].

Efforts to bring academic health research and healthcare systems together use numerous terms, such as knowledge mobilization or knowledge translation [19, 20]. In Canada, the term Knowledge Translation (KT) was widely adopted following the publication of a definition in 2000 by the national health research funding agency, the Canadian Institutes of Health Research (CIHR). This definition, which has been adopted by multiple organizations globally [21, 22], describes KT as:

“a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically-sound application of knowledge to improve health, provide more effective health services and products and strengthen the health care system. This process takes place within a complex system of interactions between academic researchers and knowledge users which may vary in intensity, complexity and level of engagement depending on the nature of the research and the findings as well as the needs of the particular knowledge user.” [23]

The components of KT are defined in Table 1, column A. A knowledge user is defined as “an individual who is likely to be able to use the knowledge generated through research to make informed decisions about health policies, programs or practices” [23]. The activities involved in KT can have transformative impact beyond traditional academic boundaries because of their focus on meeting the needs of knowledge users [24, 25], but require moving beyond longstanding academic traditions towards a fundamental “re-imagining” of academic health research [26, 27]. The 2012 San Francisco Declaration on Research Assessment (DORA), with more than 20000 signatories from 148 countries, offers a glimpse of this re-imagining by calling for outputs beyond research article production and impact factors [28].

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Table 1. Components of knowledge translation.

https://doi.org/10.1371/journal.pone.0276586.t001

KT can only reach transformative potential if it is actively practiced. One of many factors that may influence engagement in KT is the role of recognition for KT efforts in performance and advancement considerations in the academic system, particularly regarding academic tenure and promotion [29–31]. Academic tenure refers to a permanent appointment of university-based faculty [32]. It is considered primarily a safeguard of academic freedom, as it allows faculty the liberty to engage in research, teaching, and service without undue consequences for employment [33]. It has a major practical benefit of long-term job security. Academic promotion is a related concept that refers to advancement of faculty rank, which typically includes assistant professor, associate professor, and full professor [27]. Several studies, including research we have conducted on Canadian health researcher experiences practicing KT [34], have identified the lack of recognition in tenure and promotion considerations as a barrier to engaging in KT [31, 35–39].

In Canada, universities individually develop Tenure and Promotion (T&P) policies. These T&P policies typically include criterion standards and/ or process guidelines for application and evaluation [40], and are often structured through formalized agreements between faculty unions or associations (where they exist) and institutions. While some of these policies and documents may apply to an entire institution, focused policies or supplements may exist at the unit level. While we are aware of cases of KT activity being incorporated in T&P policies [3, 4, 8], no comprehensive analysis has explored how academic institutions account for KT in academic recognition. Existing studies have examined components of KT in Canada and internationally [41, 42]. These include a 2021 analysis of dissemination activities in faculties of medicine at fifteen research-intensive universities in Canada that found an emphasis on traditional indicators. T&P consideration of activities aligning with the concept of exchange have also been examined, most recently in 2019 by Alperin et al. [43], who analyzed 864 T&P documents from all disciplines at 129 Canadian and American universities for the extent of ‘publicness’ in promotion considerations. They found that 64% of institutions included at least one mention of public and or community engagement in research and scholarship.

Although these are useful contributions, we note: i) the clear evidence gap with respect to the study of synthesis and application (two major components of KT) considerations in T&P; and ii) the absence of consideration for the many health science disciplines which extend beyond medicine. We argue that a comprehensive and critical examination of KT considerations is important for identifying strengths and opportunities in current approaches to T&P in academic health sciences. In turn, this can help clarify policies and guidance for engaging, reporting, and evaluating KT practice in academic health sciences. As a first step, institutional T&P documentation is important and can provide some information about how KT is formally recognized in academic health sciences. At a surface (manifest) level, the specific terms, descriptions, and examples explicitly described in T&P policies may provide guidance both to faculty members when applying for T&P, and to reviewers when evaluating applications. On a more subtle, or latent level, the discourses of these documents are not mere guidelines. They set a tone and operationalize cultural norms and expectations. They codify and reinforce assumptions about what is valued and upheld as a standard of ‘excellence’, and as such, are structural drivers of the relationship between health research and society. Collectively, both manifest and latent content reflect underlying values of an academic institution by illustrating the ‘true’ picture of organizational expectations and practices [44], and accordingly may influence researcher behavior.

With this in mind, our study was guided by two research questions: How are KT activities included and described in Canadian academic health sciences institutional T&P documentation? How do KT activities included in institutional T&P documentation reflect academic institutional values and expectations for undertaking KT?

Methods

Results

Search findings, document and cluster characteristics

Search results are provided in Fig 1. We identified 104 health sciences academic units across 18 of the 19 institutions (S2 Appendix). One institution did not have any health sciences academic units. We acquired 138 documents pertaining to 100 health sciences academic units from 17 institutions. Of these, 131 documents were acquired from the online search and seven were obtained from email inquiries. We were not able to acquire any documents for one institution that had four health sciences units. 13 of the 17 institutions had unionized agreements with faculty (i.e. collective agreements). Of the 138 acquired documents, we identified 89 that were unique and contained information about T&P. We identified 48 document clusters used by one or more health sciences academic units, with a range of 1–9 documents per cluster.

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Fig 1. Document search flowchart.

https://doi.org/10.1371/journal.pone.0276586.g001

Characteristics of the document clusters are provided in Table 2. Most document clusters (n = 34, 71%) included guidelines. The version dates of these documents ranged from April 1980 to June 2020. All document clusters included at least one document produced between 2010–2020, and 12 included at least one document produced before 2010 (25%). Most document clusters (n = 33, 69%) had both institution-level and unit-level documents.

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Table 2. Document cluster characteristics (n = 48).

https://doi.org/10.1371/journal.pone.0276586.t002

Manifest KT content

We identified 1057 text segments related to KT (range 0–103 segments/document cluster). Most of the segments were categorized as dissemination (n = 858, 81% of text segments) followed by application (n = 79, 7%), synthesis (n = 69, 6%), exchange (n = 32, 3%), and 19 instances of a non-specific KT category (2%). Dissemination was represented in 47 document clusters (98%), application was represented in 39 document clusters (81%), synthesis was represented in 28 document clusters (58%), and exchange was represented in just 20 document clusters (42%). Most document clusters included mention of three (n = 17, 35%) or four (n = 15, 31%) KT categories, while one (2%) did not have any KT categories identified.

We identified 65 unique KT activities (range 0–60 activities/ document cluster, S3 Appendix). Most of the KT activities fell into the dissemination category (n = 42, 64.6% of unique activities), followed by application (n = 8, 12.3%), synthesis (n = 8, 12.3%) and exchange (n = 7, 10.8%). The 10 most-commonly identified KT activities, nine of which are categorized as dissemination activities, are presented in Fig 2.

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Fig 2. Ten most-commonly identified KT activities.

https://doi.org/10.1371/journal.pone.0276586.g002

Discussion

Our analysis of 89 T&P institutional documents pertaining to 48 document clusters representing 100 health sciences academic units from 17 Canadian academic institutions demonstrated several key findings. First, we identified a clear emphasis on dissemination activities (over 80% of coded text segments and included in 47 of 48 document clusters). The most frequent dissemination activities represented traditional academic outputs (books, peer-reviewed publications, and academic conference presentations) with far less on activities targeted at knowledge users. Just over 15% of coded activities reflected any other KT category (application, exchange, or synthesis). This disproportionate distribution provides important signals as to what T&P documents codify as valued outputs in Canadian academic health sciences.

Second, the variation we identified in the nature and extent of KT recognition across document clusters was striking. The most comprehensive recognition of KT we found included nine documents in one cluster, which included reference to dozens of unique KT activities in all four categories. In contrast, some document clusters only included one document, and in a few cases the only document was an institution-level collective agreement, in which we found no mention of KT. Overall, the lack of explicit KT recognition and clarity we identified has implications for providing guidance to T&P applicants and reviewers. Our findings could be supplemented in future research with faculty members and T&P decision-makers to more fulsomely examine how KT activities are implicitly considered in academic advancement decision-making.

While our study was the first to examine T&P considerations from the lens of KT, our work partially replicates existing findings that showed an emphasis on traditional T&P criteria in 15 Canadian research-intensive faculties of medicine [42]. Given the partial overlap in sampling between their analysis and our present study, this shared finding is understandable. However, their criteria were limited to dissemination activities whereas our analysis examines the full scope of KT. The unique contribution of our analysis lies in our consideration of application and synthesis activities in academic work and their role in T&P considerations. We note that despite general enthusiasm for evolved concepts of scholarship and adoption by some health sciences disciplines through structures such as clinical accreditation [53], formal adoption of these concepts in Canadian academic health sciences advancement structures has been sub-optimal.

The primarily implicit recognition of KT activities in Canadian health sciences institutional T&P documents suggests that Canadian universities currently do not formally encourage an explicit and comprehensive approach to KT. Implicit recognition, in combination with the lack of clarity and guidance, may perpetuate limited KT practices. The focus on dissemination activities emphasizes a limited subset of KT practices that are least likely to have societal impacts. We note that many of the noted dissemination activities do address non-academic audiences (such as broadcast, print, or social media), reflecting some recognition of efforts to move beyond peer audiences. However, some of the dissemination activities reflect smaller, time-limited, discrete tasks (such as a conference presentation, or abstract publication), whereas other KT activities noted as a single line item in consideration for T&P may represent comprehensive bodies of work that can require years to complete and significant resource investments (e.g. systematic reviews, clinical practice guidelines). The continued emphasis on a limited range of dissemination activities reflects a habitual emphasis on traditional outcomes that have been encultured as long-standing expectations of faculty, a finding also identified by others [43].

It is not clear from these documents whether the vague KT considerations in Canadian T&P documents reflect a lack of understanding of KT, a deliberate attempt to be inclusive (letting any and all activities be considered in T&P processes), or a deliberate effort to not value the role of KT in scholarship. The lack of specificity does permit a degree of flexibility–while not necessarily encouraging explicit KT work, faculty are equally not discouraged from doing it. Despite the potential advantages of flexibility inherent in T&P documentation, the overwhelming emphasis on dissemination and traditional academic outputs may serve to disincentivize and devalue more intensive yet potentially impactful KT work. What these documents do suggest is a general low priority for comprehensive KT in academic health sciences that collectively reinforce and perpetuate the question: what is valued by academic institutions?

We acknowledge several limitations of our approach. Our sample was restricted to primarily research-intensive Canadian academic institutions, so the findings may not be generalizable to universities that are not research intensive. Our document search was restricted to publicly-available documents or those which institutions chose to share with us; as such we cannot verify if these represent all of the relevant documents for each health sciences academic unit. We did not validate the document cluster groupings with institutions. We recognize that our analysis only focused on official documentation, and additional guidance about inclusion of KT activities may be provided through oral communication or in other formats (e.g., presentations) to which we did not have access. We can only comment on written documentation, which does not mean T&P decisions strictly follow these guidelines, therefore findings will not be conclusive about KT recognition in overall T&P processes. Lastly, we acknowledge the challenges associated with evolving conceptualizations of KT which are inherently linked with applying contemporary thinking retrospectively.

In conclusion, our analysis showed vague considerations of KT in Canadian academic health sciences institutional T&P documents, supporting previous research highlighting concerns about the recognition of KT work as a barrier to its practice [29–31, 34, 39]. Having noted the importance of these documents as structural drivers of the relationship between research and society, when left vague, they reinforce status quo. We recommend that academic institutions consider and address the value of KT activities, and where appropriate, align documentation policies and procedures to reflect these values. Development of tools for supporting KT, such as institutional KT strategic plans (e.g. [54]), along with specific guidance for applicants and reviewers, may help to address both structural and individual barriers limiting academic KT work. Without further resources and supports, the application KT activities will be left to individual academics developing their T&P applications and/ or reviewers. Furthermore, we call on the innovative spirit of health researchers to continue to challenge traditional views of scholarship and embrace the diverse practices inherent in the work of KT to have meaningful impact within and beyond academic boundaries. To ensure this analysis reaches academic decision makers, we will share the findings and key recommendations with all participating institutions and associated units, develop a social media strategy, and disseminate to relevant target audiences (i.e. U15 Group of Canadian Research Universities, Canadian Association of Research Administrators, Universities Canada). We will share the findings with our networks and leadership tables that leverage the distributed networks we are connected to, with an invitation to generate dialogue about implications of these findings.

Supporting information