Organisationally embedded evidence: how surgical knowledge-in-practice was constructed from research findings

The recent literature on knowledge management emphasises the crucial role of social networks in negotiating what comes to be accepted as "knowledge" in a given milieu. Various models have been suggested to explain how both codified and tacit knowledge are iteratively negotiated among "communities of practice" as they construct- or "combine" - many sources of relevant information in an act of collective sensemaking and enaction. The processes described contrast markedly with the simplistic and rationalist approach to "research implementation" advocated by most proponents of evidence-based healthcare. Our paper reanalyses case-study data from an evaluation that was carried out of an attempt in the 1990s to influence surgeons in their use of the insertion of grommets for glue ear. We present a detailed account of the processes by which knowledge from the research world was introduced into clinical policy and practice. We develop a model that reflects the essentially contingent social and organisational determinants of the ways that knowledge became accepted and used in a given local environment. Key elements of the process were the nature of the scientific evidence, and the motives and interests both of those in the higher echelons of the health service in promoting it, and of the local protagonists who were negotiating a guideline for the management of the condition. We use our model to analyse how these elements impacted upon the formulation and reformulation of the research evidence as key actors attributed meaning and action to the research findings in the context of their work.