Increasing systemic capacity to respond
 to child and adolescent mental health
 needs using reciprocal knowledge transfer
 with parents
 Susan Croom Newcastle and North Tyneside NHS Mental Health Trust, Northumberland, UK and Susan Procter
 Adult Nursing Department, City Community and Health Sciences, City University, London, UK
 Background: Knowledge is recognized as a crucial organizational resource, which it
 has been suggested, increases in value through use. However, tensions exist between
 applying generalized scientific and academic knowledge to practice and incorporating
 local, experiential and tacit understanding in our knowledge base for practice.
 Knowledge management and transfer are frequently advocated as the means to
 increase service capacity within existing resource levels. In the NHS knowledge
 management and transfer tends to adopt a social constructivist approach, which
 favours the application of scientific evidence to practice, consequently the tacit and
 experiential knowledge of practitioners and service users is often excluded from
 formal knowledge-transfer processes. Aim: This paper describes a systematic process
 that was used to formalize tacit nursing knowledge in child and adolescent mental
 health (CAMH) and link it into the pre-existing scientific and academic literature.
 Method: The paper goes on to describe how this process was modified and trans-
 ferred to work with parents of children referred to CAMH services. Findings: The paper
 illustrates the differing strands of pre-existing scientific and academic knowledge
 valued by nurses and parents. It highlights how involving service users in identifying
 scientific and academic knowledge that they find useful can focus attention on strands
 of pre-existing knowledge previously overlooked by professionals and service provi-
 ders and thus enhance the value of this knowledge as an organizational resource.
 The paper also demonstrates how the tacit and experiential knowledge of nurses and
 services users can be transformed into more formalized knowledge, which can then be
 incorporated into organizational knowledge-transfer processes.
 Key words: child and adolescent mental health; knowledge management and
 transfer; parents and service users; practice knowledge; systemic capacity
 Received: October 2006; accepted: November 2007
 Introduction
 Knowledge is increasingly recognized as a critical
 organizational resource (Stewart, 2002; Davenport
 and Prusak, 1998), which is unique as it increases
 in value through use (Probst et al., 2000). In the
 UK, as in other health care systems, a range of
 policy initiatives have been introduced that set
 practice and service delivery guidelines based on
 the best available evidence. These include in the
 UK the introduction of National Service Frame-
 works (NSFs) for a range of conditions and the
 establishment of the National Institute for Health
 Address for correspondence: Professor Susan Procter, Adult
 Nursing Department, City Community and Health Sciences,
 City University, Philpot Street, London E1 2EA, UK. Email:
 s.procter@city.ac.uk
 r 2008 Cambridge University Press
 Primary Health Care Research & Development 2008; 9: 49?63
 doi: 10.1017/S1463423607000503
and Clinical Effectiveness (NICE). In the US,
 the Agency for Health Care Research and
 Quality and in Australia the National Institute for
 Clinical Studies have been established to promote
 evidence-based practice.
 Evidence-based guidelines are usually derived
 from knowledge obtained using scientific methods
 and codify explicit expert knowledge (Cochrane,
 1972; Sackett and Rosenberg, 1995). Knowledge,
 however, encompasses more than formal codified
 and scientifically derived evidence, it also encom-
 passes tacit understanding (Baumard, 1999) that
 is ?engrained in the analytical and conceptual
 understandings of individuals (the ??know what??
 knowledge) and also embodied in their practical
 skills and expertise (their ??know how??)? (Bate
 and Robert, 2002). The WHO (2006, p. 1) dis-
 cusses how: ?Bridging the know?do gap is one of
 the most important challenges for public health in
 this century. It poses the greatest opportunity for
 strengthening health systems and ultimately
 achieving equity in global health. Knowledge
 translation is emerging as a paradigm towards
 closing that gap? [our italics]. The WHO (2006)
 acknowledges that despite a range of innovative
 examples of knowledge transfer, there is no
 comprehensive platform for understanding how
 knowledge (ie, what we know) can be effectively
 utilized (ie, what we do) to promote optimum
 health within a given set of resources and cir-
 cumstances. The WHO argues that developing
 this platform will require that relevant parties
 engage in awareness building, joint learning and
 improved methodologies for knowledge synthesis
 and exchange. This paper describes a methodol-
 ogy designed to support reciprocal knowledge
 transfer between health policy, scientific and
 academic knowledge and nursing and parental
 practice knowledge in child and adolescent
 mental health (CAMH).
 Background
 Sociological discussions of the knowledge base
 for professional practice focus on an abstract and
 theoretical critique of professional knowledge
 and power (Johnson, 1995; Turner, 1995) and its
 impact on service users. The use of codified
 knowledge derived from rational, scientific and
 systematic analysis is seen as fundamental in
 distinguishing professional knowledge from lay
 or everyday knowledge, professionals are dis-
 tinguished by their access to and authority to use
 this knowledge in practice. Early practice debates,
 however, highlighted the limitations of traditional
 academic approaches in providing knowledge
 to inform practice, arguing academic knowledge
 was too abstract and generalized to be of much
 practical value in helping practitioners address
 specific everyday practice problems and situations
 (Agyris, 1993; Schon, 1983, 1987). This position is
 disputed in health care by proponents of evidence-
 based medicine who highlight the benefits of
 applying rigorously tested interventions and
 knowledge derived using scientific methods to
 practice (Sackett and Rosenberg, 1995; Muir Gray,
 1997; Centre for Reviews and Dissemination,
 2001).
 The tensions that exist between generalized
 scientific and academic knowledge as a basis for
 professional practice, and the impact of local
 experiential and tacit knowledge on that practice,
 give rise to debates about how effectiveness is
 conceived, achieved and maintained in everyday
 practice contexts (Reed and Biott, 1995; Ryecroft-
 Malone et al., 2004; Rolfe, 2000; Maturana, 1991).
 This has led Bate and Robert (2002) to comment
 (in a review of the application to the NHS, of
 lessons learnt about knowledge management in
 the private sector) that ?while the NHS has been
 vigorously promoting evidence-based medicine
 and the use of explicit, expert knowledge in
 clinical practice, the private sector has been
 moving in the opposite direction, stressing the
 value of intuitive, tacit knowledge? found in the
 heads of employees.
 As a result of this debate, increasing recogni-
 tion is being given to the oversimplified under-
 standing of knowledge for practice that occurs
 when practice is split up, for academic purposes,
 into discrete strands, themes, systems, or method-
 ological perspectives that are tested and theorized
 in isolation from each other (Miller and Crabtree,
 2000; Kemmis and McTaggart, 2000). More
 recently, the full complexity of identifying the
 knowledge base for practice has been mapped out
 by Pawson et al. (2004) who state:
 The problem is one of complexity. The
 health interventions in question are not
 singular schemes or finite treatments but
 50 Susan Croom and Susan Procter
 Primary Health Care Research & Development 2008; 9: 49?63
concern the design, implementation, man-
 agement and regulation of entire services.
 These services have a multiplicity of goals,
 many of them relating to the fulfilment of
 long-term ambitions. By the same token, the
 evidence base for health service decision
 making is also gargantuan. In getting to grips
 with so many activities of so many actors, the
 seeker of evidence has to call on the entire
 repertoire of social science and health
 services research. A review may thus involve
 a dissection of experimental and quasi-
 experimental trials, process and develop-
 mental evaluations, ethnographic and action
 research, documentary and content analysis,
 surveys and opinion polls. Even this for-
 midable list overlooks the pearls of wisdom
 to be found in the grey literature, including
 administrative records, annual reports, legis-
 lative materials, conceptual critique, personal
 testimony and so on.
 (Pawson et al., 2004, p. iii)
 But even this powerful statement of the pro-
 blem of deriving knowledge for practice over-
 looks a crucial aspect of the knowledge transfer
 debate and that is the skills, knowledge (both
 explicit and tacit) and analytical and conceptual
 understandings of the service users themselves.
 The importance of engaging with service users
 as active research participants is increasingly
 advocated (Khanlou and Peter, 2005; INVOLVE).
 However, the inclusion of service users in the
 literature on knowledge creation and transfer is in
 its infancy and forms a key focus for this paper.
 One way of addressing the problem created by
 tacit knowledge in professional practice is to
 convert tacit knowledge to explicit knowledge
 through a process of dialogue and the codification
 of tacit understanding into explicit transferable
 knowledge (Bate and Robert, 2002). According
 to Bate and Robert (2002), this process of
 knowledge creation improves its ?fluidity? or
 ?transferability? across organizational boundaries.
 This paper considers how these processes, which
 have been developed to support knowledge
 transfer within and between organizations, can be
 adapted and used to involve service users in a
 process of knowledge creation that codifies their
 tacit expertise, enabling it to transfer into both
 practice and policy contexts.
 Translating CAMH research and policy
 into action
 Standard nine of the NSF for Children Young
 People and Maternity Services (DoH and DfES,
 2004) recognizes the need to improve mental
 health services for children and adolescents
 through multi-agency working and an evidence-
 based approach to practice and service provision.
 Achieving this requires a fundamental shift in
 thinking about health and social service provision
 in order to develop services that are designed
 and delivered around the needs of children and
 families (DoH and DfES, 2004). The messages
 in the NSF are very similar to those enshrined
 in earlier CAMH policy documents (Health
 Advisory Service, 1995; Audit Commission, 1999;
 Mental Health Foundation, 1999). The lack of
 progress in implementing policy and evidence in
 practice, indicated by repeated national policy
 objectives over an extended period, suggest a
 major difficulty in policy implementation in this
 area. An analysis of these documents highlights
 a number of areas where problems are seen to
 persist over several decades despite repeated
 efforts on the part of policy makers, researchers
 and professionals to address them. These are
 given in Box 1.
 While the problems listed in Box 1 are well
 known to CAMH practitioners, researchers and
 policy makers and have been discussed exten-
 sively in the literature (Cunningham et al., 1996;
 Webster-Stratton, 1998), the know?do gap applies,
 as little attempt is made to acknowledge, theorize
 or address these challenges in practice and
 service delivery (doing) strategies. Instead CAMH
 services tend to adhere to socially constructed
 models for knowledge transfer and management
 as described by Bate and Robert (2002) and
 McAdam and Reid (2001). Socially constructed
 models of knowledge management and transfer
 are considered to be appropriate for under-
 standing knowledge transfer in organizational
 settings as they ?assume a wide definition of
 knowledge and represent knowledge as being
 intrinsically linked to the social and learning
 processes within the organisation? (McAdam and
 Reid, 2001).
 However, a focus on knowledge creation and
 transfer derived from organizational and profes-
 sional understandings of problems and solutions
 rather than population experience is unlikely to
 Reciprocal knowledge transfer in CAMH 51
 Primary Health Care Research & Development 2008; 9: 49?63
address the challenges to meeting the needs of
 the CAMH population highlighted in Box 1.
 Excluding service users from knowledge creation
 and transfer processes means that the knowledge
 found useful and therefore valued by service
 users goes unrecognized in policy, practice and
 service development strategies. At the same time,
 the social constructivist models of knowledge
 creation and transfer found in the NHS perpe-
 tuate the knowledge and experience of pro-
 fessionals, along with the limitations of this
 knowledge base in addressing key problems, often
 leading to repetitive cycles of initiatives as
 demonstrated in the above policy documents.
 This paper describes how findings from a nur-
 sing study (Croom et al., 2000) were tested, in a
 subsequent study, for their relevance with parents
 of children in receipt of CAMH services (Croom
 and Procter, 2005). The paper describes the
 methodological challenges and solutions adopted
 in developing reciprocal knowledge transfer
 between nurses and clients. Separate approval for
 each study was obtained from the local research
 ethics committee.
 Background to the Nursing Study
 The nursing study used action research with
 experienced nurses working in a regional, resi-
 dential CAMH unit (Croom et al., 2000). The
 nurses identified that a critical practice problem
 for them in providing 24-h care was how to help
 children to develop a sense of ?control?, which
 enabled them to cope with everyday frustrations
 without either becoming a danger to themselves
 or to others or interfering with their capacity to
 meet their social, emotional and developmental
 goals. This focus was supported by the literature
 (Caspi et al., 1995; Wenar, 1982; Cunningham
 et al., 1995). The nursing study began with a
 concept analysis of control, which was used to
 structure a wide body of literature that identified
 the essential elements of the concept (Cutcliffe
 and McKenna, 2005). The defining attributes of
 the concept analysis were attachment, informa-
 tion processing and the use of a pause to engage
 feedback and emotional regulation.
 The literature associated with these attributes
 was then examined by the nurses using critical
 incidents of practice situations they encoun-
 tered in the CAMH unit. Through this process
 Box 1
 1. In the area of CAMH there are high needs
 with a prevalence of at least 10% (Office of
 National Statistics, 2005) and finite resources.
 The importance of optimizing current
 resources by maximizing universal (services
 available to all) targeted (services aimed at
 those known to be at risk of developing
 CAMH problems) and specialist services
 (for those suffering from diagnosed CAMH
 disorders) has been a consistent feature of
 CAMH policy in the UK (Health Advisory
 Service, 1995; Audit Commission, 1999; DoH
 and DfES, 2004). Policy in the UK has
 consistently recognized that CAMH needs
 cannot be met by clinical services alone, yet
 the majority of expenditure in CAMH is still
 linked to clinical models of care (Pawson
 et al., 2004; Knapp et al., 1999).
 2. CAMH researchers have recognized the
 know?do gap in CAMHs. Evidence derived
 from experiments using randomized con-
 trolled trials is found not to be as effective
 when actually applied in practice (Henggeler
 et al., 1995; Pawson et al., 2004). This becomes
 particularly acute when attempting to make
 evidence-based approaches to practice acces-
 sible and acceptable to the most vulnerable
 clients (Cunningham et al., 1995). This high-
 lights the need to develop a knowledge-based
 rather than just evidence-based approach to
 CAMH practice.
 3. The sociological critiques of professional
 power and control over knowledge form a
 central issue in understanding the impact of
 knowledge transfer activities on the effective-
 ness of service delivery and the implementa-
 tion of policy objectives. CAMH services are
 currently dominated by professionals who are
 ascribed power through legitimated knowl-
 edge, derived predominantly from scientific
 research using experimental methods that
 control for variation in individual user atti-
 tudes and beliefs (Prillitinsky, 2001). This sets
 up didactic programmes that create an
 unequal power relationship between profes-
 sionals and parents, making reciprocal knowl-
 edge transfer, fundamental to family-centred
 practice, difficult to achieve.
 52 Susan Croom and Susan Procter
 Primary Health Care Research & Development 2008; 9: 49?63
additional attributes of ambivalence, reciprocal
 emotional arousal, peer relationships between
 children and the child?s help-seeking behaviour
 were identified as critical components of practice
 knowledge required to help a child develop a
 sense of control appropriate to their develop-
 mental age. The literature associated with these
 attributes was examined by the nurses as a means
 of integrating theoretical and empirical-based
 evidence with practice knowledge (Croom et al.,
 2000). The subsequent study with parents used
 participant action research (Khanlou and Peter
 2005) and critical social theory (Fontana, 2004) to
 explore with parents attending a parenting group,
 the relevance of the findings from the nursing
 study to the parents? everyday 24-h situation
 looking after children referred to the CAMH
 Unit.
 Developing theoretical link between the
 transfer and development of knowledge in
 the nursing study and the parental study
 A key finding that emerged from the nursing
 study was that the nurses found engaging in the
 reciprocal exchange of knowledge between pub-
 lished evidence and practice was valuable in both
 developing and clarifying their practice and to
 codifying their experiential knowledge, making
 it accessible to other members of the multi-
 disciplinary team. Together the experiential and
 the published knowledge provided a framework
 of practice, which was useful in the nurses? prac-
 tice context (Croom et al., 2000). However, this
 raised questions about the relevance and useful-
 ness of this framework to the parents to whom
 these children were discharged. Could access to
 this knowledge help them in looking after their
 child with challenging behaviours at home?
 This concern gave rise to the following analy-
 tical research questions, which formed the aims
 for the subsequent study with parents:
 > To identify whether the nursing knowledge
 and skills were useful and relevant to parents
 of children with behaviour problems, in the
 context of their 24-h everyday care of these
 children in their community.
 > What other knowledge and skills could be
 learned from parents who could continue to
 contribute to a cumulative knowledge base on
 the 24-h management of children with beha-
 viour problems and which might be useful to
 nurses and other professionals caring for these
 children.
 > To identify the potential impact on the capacity
 of CAMH systems to respond to children with
 challenging behaviours if their parents become
 participants in creating and developing knowl-
 edge and skills, rather than just being recipients
 of professional knowledge and skills.
 The parental study was undertaken as part of a
 series of parenting groups offered to parents as an
 additional service (Croom and Procter, 2005).
 Parents, therefore, contributed to the data col-
 lection whilst also receiving a service. At the
 outset of the study, a decision was taken to target
 parents of children most at risk of developing
 CAMH problems. Earlier literature had identified
 that these parents would have experience of the
 concept in their everyday parenting practice
 (Cunningham et al., 1995; Rae-Grant et al., 1989)
 but their attendance at parenting groups was
 sporadic with a high drop-out rate (Pugh and
 Smith, 1996).
 The decision to focus on marginalized parents
 emphasized the importance of addressing the
 potential power differential between the group
 facilitators and the parents, identified in Box 1
 as a key service delivery challenge. The issue
 of professional power was therefore central to
 the study, not as a known theoretical problem
 (Turner, 1995; Gabe et al., 1994; Johnson, 1995)
 but as a practice problem about which some-
 thing had to be done within the methodological
 approach taken by the research.
 This problem was addressed through the
 application of the principles of critical social
 theory. These principles were introduced as they
 explicitly incorporated the notion of practice
 change, in this case the parental practice change
 necessary to demonstrate the impact of the
 service on the users. This was achieved by getting
 both the researcher and the participants to focus
 on ?what could be rather than what is? (Thomas,
 1993; Fontana, 2004) and through this process to
 identify the tacit assumptions and beliefs of the
 participants (both parents and facilitators), which
 may be experienced as oppressive. Critical social
 theory was thus used to develop emancipa-
 tory practice knowledge, ie, knowledge that is
 Reciprocal knowledge transfer in CAMH 53
 Primary Health Care Research & Development 2008; 9: 49?63
emancipatory in the practice situation. Emanci-
 patory knowledge can be described as ?that which
 attempts to reconcile and transcend the opposi-
 tion between technical and practical knowledge.
 Emancipatory knowledge helps us to understand
 how social relationships are distorted and
 manipulated by relations of power and privilege.
 It also aims at creating the conditions under
 which irrationality, domination and oppression
 can be overcome and transformed through
 deliberative collective action? (McLaren, 1989)
 Thus, in this study, the parents were explicitly
 supported, as a group, to interrogate any potential
 tacit assumptions, at an individual, professional
 and societal level, which could possibly act to
 oppress them.
 From a methodological perspective, the main
 challenge to the parental study was how to use
 the findings from the nursing study to inform the
 parenting study without distorting or silencing
 the parents? authentic experiences of childrearing.
 The findings from the nursing study were framed
 in terms associated with in-patient nursing prac-
 tice. The parenting study required these findings
 to be transferred into a community context to
 provide a practice framework for the parenting
 groups. In order to achieve this, the findings from
 the nursing study were codified into four over-
 arching propositions (Figure 1), which repre-
 sented the concept analysis and key skill areas
 identified by the nurses. The propositions were
 used to frame the parenting groups. In order to
 test these propositions with parents, it was
 necessary to clearly explicate the nursing knowl-
 edge and skills underpinning each of them. This
 gave rise to sets of sub-propositions, which are
 given in Figure 2. The next section of the paper
 describes how the sub-propositions were derived
 and used to explore the reciprocal transfer of
 knowledge with parents.
 Attachment theory: its role and contribution
 to nursing care
 The nursing study illustrated that, provided
 the nurses could give the children alternative
 nurturing opportunities in which to develop a
 trusting attachment relationship, the children
 could use this relationship as a platform to help
 them develop control and strategies to cope with
 everyday limits and frustrations. This finding
 is supported by Clarke and Clarke (2000) and
 Rae-Grant et al. (1989) who identify the capacity
 for children to overcome their early adverse
 experiences, if they are provided with significantly
 better compensatory circumstances. These find-
 ings became a major motivating factor for the
 nurses in the first study as they indicated that
 their interventions could help these children
 progress towards health.
 Figure 1 Overarching propositions derived from nursing research (Croom et al., 2000)
 54 Susan Croom and Susan Procter
 Primary Health Care Research & Development 2008; 9: 49?63
Research, which highlighted that attach-
 ment relationships involve a reciprocal process
 (Schaffer, 1977; Stern, 1985; Sroufe, 1996), was
 important in enabling the nurses to understand
 the two-way nature of their relationships with the
 children in which they mutually influenced each
 others feelings and behaviours. The findings from
 the nursing research on attachment led to the
 formulation of two sub-propositions (Figure 2:
 1.1 and 1.2).
 Ambivalence
 In their reflections on attachment, the nurses
 described how the children could engender pow-
 erful emotions in them through the process of
 reciprocal emotional arousal. Nurses indicated
 that this was because they had previously felt
 guilty as nurses/carers for ?not liking every child
 equally? and that they felt particularly guilty
 if they experienced negative feelings towards
 a child.
 Figure 2 Sub-propositions tested in study with parents
 Reciprocal knowledge transfer in CAMH 55
 Primary Health Care Research & Development 2008; 9: 49?63
The literature was explored to check whether
 it could help nurses further negotiate a route
 through the moral complexity of this aspect of
 their practice. The work of Christine and Correia
 (1987) on maternal ambivalence helped the nur-
 ses to recognize how acknowledging any feelings
 of frustration or irritation about a child to another
 professional actually galvanized them into enga-
 ging in some positive interaction with the child.
 This finding highlighted the potential need to
 explore the literature on experiences of ambiva-
 lent feelings with parents. Sub-propositions 1.3
 and 1.4 (Figure 2) were formulated from this
 finding.
 Information processing
 The information processing model of Crick and
 Dodge (1994), identified during the concept ana-
 lysis, helped the nurses to articulate their tacit
 knowledge that children with challenging beha-
 viours often had a sustained distorted view of
 reality in which they felt everybody was against
 them. This helped the nurses to explicate how
 they intuitively used the opportunities across 24-h
 care to support the children to challenge their
 hostile attributions of social interactions and to
 explore alternative interpretations, which could
 stimulate them to formulate more prosocial goals
 in social interactions.
 The use of a pause to engage feedback
 Another perspective on control, identified
 through the concept analysis, was that of systems
 theory as developed in cybernetics. In systems
 theory control is modelled as a flow of informa-
 tion through systems with a feedback loop to
 detect error. Pauses and checks are included in
 the system to inform the feedback loop and to
 indicate whether adjustments are needed and, if
 so, in which direction (Dorf, 1967; George, 1967).
 Gaining a basic understanding of these models
 helped the nurses to appreciate the fact that
 children needed to be able to ?pause? or stop in
 order to gauge their level of emotional arousal
 and take preventative action before it over-
 whelms them. Nurses felt that they intuitively
 knew they had to support children to stop and
 think, but had not articulated this or integrated
 this tacit knowledge into systematic care plans,
 which could be shared with other professionals
 and carers. The findings from the research on
 information processing and systems theory led to
 the formulation of sub-proposition 1.5 (Figure 2).
 Help-seeking behaviour
 In addition to the literature identified in the
 concept analysis, nurses also identified skills and
 knowledge derived from their own practice
 experiences. Nurses possessed a tacit recognition
 of how difficult it can be for children with beha-
 viour problems to proactively seek help. Through
 discussion and reflection on critical incidents, the
 nurses identified how a feature of the relationship
 they built with a child was the ability to intuitively
 tune into the child?s non-verbal signals that they
 needed help, eg, a child may stand close to a nurse
 in order to indicate a need for help. On further
 reflection, the nurses recognized that as the child
 learned to trust that the nurse would be emo-
 tionally and physically there for them if they
 sought help, the child was more able to move
 on to verbal requests. The nurses found that
 systematically observing the child?s progress
 from non-verbal to verbal signals for help repre-
 sented significant therapeutic progress, which
 they had not previously recognized (Croom et al.,
 2000). They also found that describing this
 in multi-disciplinary groups enabled them to
 become better advocates for the child and
 to optimize the data arising from their 24-h
 observations. This formed the basis for the sub-
 proposition 1.6 (Figure 2).
 Peer relationships
 Reflection on and analysis of the nurses? prac-
 tice experiences highlighted the importance of the
 child?s peer relationships. Nurses identified that
 to promote peer relationship skills, they have to
 integrate a sophisticated understanding of how
 much the child was able to engage in a reciprocal
 trusting relationship, how much they were able to
 take on board information in order to negotiate
 or compromise, especially when emotionally
 aroused, and how competent they were in social
 interactions and with social skills. Nurses identi-
 fied that this required high levels of supervision of
 the young people and their peer interactions
 in order to make judgements on when adult
 56 Susan Croom and Susan Procter
 Primary Health Care Research & Development 2008; 9: 49?63
intervention was necessary and when the young
 people could be supported to use their own social
 skills with minimum promoting. A final sub-
 proposition 1.7 (Figure 2) was therefore developed.
 Parenting study
 In order to critically explore the reciprocal
 knowledge transfer process, the above proposi-
 tions were tested out with parents in the parent-
 ing study using critical incidents and critical social
 theory embedded in a participatory action
 research cycle (see Figure 3). In addition, any
 other knowledge or literature (known to the
 facilitators or identified using electronic searches
 during the course of the study) that appeared to
 be relevant to solving the parents problems and
 making sense of their experiences was shared
 with parents. This represents the use of ?just-in-
 time? knowledge transfer (Canadian Research
 Transfer Network, 2002). Here the facilitators/
 researchers use techniques of knowledge broker-
 age to inform participants of key information,
 which is introduced to help them make sense of
 their current situation. This balanced the use of
 knowledge valued by professionals and codified
 in the nursing framework by identifying, using
 and therefore increasing the value of different
 evidence which the parents identified as useful.
 Parents were therefore able to increase the range
 of formal knowledge used in the local system
 of health care delivery, increasing the value of
 knowledge that had previously been neglected by
 professionals.
 A total of eight cohorts of parents were
 engaged over a series of eight consecutive groups.
 Each group had 12?14 sessions. The minimum
 number attending a group session was one and
 the maximum was five. Twenty-five parents (all
 female) out of an initial 75 invited to attend,
 attended at least 75% of the sessions, including
 the first and last session. Data were collected
 from the 25 parents who attended at least 75% of
 the sessions.
 Inclusion criteria were derived using the Pearce
 (1993) criteria for identifying CAMH problems.
 These include:
 > behaviour problems which result in the child
 being able to cope with everyday frustrations
 and stresses in a way which inhibits their social
 and emotional development to a level that
 required referral to a CAMH service;
 > that these problems had lasted for at least a
 month and caused significant distress to the
 family on a daily basis.
 In addition, purposeful sampling was used to
 identify parents in socio-economically deprived
 areas of the city as these parents are most likely
 to drop out of parenting groups and therefore
 provide a way of discovering how transferable
 the knowledge is to the most vulnerable clients.
 Table 1 illustrates the socio-economic and edu-
 cational vulnerability of these parents; it indicates
 that the parents who participated match the
 characteristics of those identified in research
 (Cunningham et al., 1995) to be the least likely to
 access services.
 Findings
 In the course of the research, the parents brought
 along a range of issues and critical incidents
 related to the challenging behaviours of their
 child. The group then explored how they could be
 understood, eg, one parent described an incident
 in which a child kicked his sister when he was
 asked to come for his meal. The parent?s initial
 interpretation of the situation was that the child
 was deliberately winding her and his sister up.
 The introduction of the action component of the
 research, ie, the nursing practice framework and
 additional literature on temperament (Turecki
 and Tonner, 2000), helped the parents in the
 group to consider alternative interpretations/
 understandings of the child?s behaviour. This
 enabled them to consider that the child may have
 genuine difficulties with changing activities
 because of his innate temperament. Strategies to
 cope with this, identified in the nursing practice
 framework, were shared with the parents, for
 example that he be given a transitional warning
 prior to changing any activity (Turecki and
 Tonner, 2000). The parents unanimously found
 that access to knowledge on temperament was
 useful. Combining this with the knowledge from
 the nursing study on attachment helped them to
 ?tune into? their children?s individual tempera-
 mental profile and to recognize that their children
 were often being judged according to a narrow set
 Reciprocal knowledge transfer in CAMH 57
 Primary Health Care Research & Development 2008; 9: 49?63
Figure 3 Diagram to illustrate how data was analysed through reflective action cycles
 58 Susan Croom and Susan Procter
 Primary Health Care Research & Development 2008; 9: 49?63
of constructed behavioural norms. This knowl-
 edge enabled some of the parents to challenge
 their previously tacit assumption that children
 who did not conform to society?s norms were
 deliberately naughty.
 However, despite all of the parents having had
 significant multi-agency service contact prior to
 the referral to CAMH services, none of the
 parents had previously been introduced to knowl-
 edge on temperament. Using critical theory, the
 parents were supported to reflect on what ?could
 be? rather than ?what is?. This helped parents to
 identify some tacitly oppressive assumptions in
 the local systems of care, for example that parents
 of children who had difficulties conforming to
 constructed norms at school (such as all children
 should be able to sit quietly for 35-min periods)
 were failing in being able to socialize their child
 to appropriate behaviours. This sense of failure
 was universal across the cohorts and led to
 increasing social isolation and guilt. Using
 knowledge on temperament helped parents to
 interrogate these assumptions. However, some of
 the parents found that this knowledge transfer
 was useful but not sufficient to change their
 parenting practice. A number of reasons for this
 were identified.
 At an individual level, parents found that they
 could only apply the knowledge about effectively
 tuning into their children when they themselves
 were feeling calm and supported. They identified
 a number of stressors such as neighbourhood
 harassment, socio-economic factors, social isola-
 tion and depression that inhibited this process.
 At a systemic level, the parents identified that
 although the literature on temperament was
 available in academic and professional journals it
 did not form part of the local knowledge system
 informing schools or GP practices. Some of the
 parents were able to successfully share knowledge
 about temperament with their child?s school-
 teacher and use this understanding to transform a
 previously hostile relationship with the teacher
 into a shared partnership to support the child.
 Other parents, however, found profound profes-
 sional resistance from schools to knowledge
 transfer from parents about temperament. At a
 service delivery level, there did not seem to be
 sufficient resources to sustain taking the indivi-
 dual approach to children designed to promote a
 fit between the child?s temperamental needs and
 his/her environment as recommended in the NSF.
 Evidence suggests that lack of fit creates insensi-
 tive responses to a child with a challenging tem-
 perament and increases their risk of school and
 social exclusion (Churchill, 2003; Chess and
 Thomas, 1999).
 Overall the findings from the analysis indicated
 that the knowledge transferred from the pub-
 lished literature and the nursing practice frame-
 work was useful but not sufficient in developing
 parental practice solutions and developing
 Table 1 Social characteristics of parents invited to participate in the research and those who participated
 Social Characteristics of
 Parents invited and those
 who became active research
 participants
 Parents
 invited to
 participate
 Parents, from
 75 invited who
 agreed to
 attend
 Parents, from 50, who
 agreed to attend, who
 only attended first
 session of group, but did
 not attend subsequent
 sessions
 Parents who became
 active research
 participants and
 attended 75% of
 sessions (n 5 25)
 Gender 75 female 50 all female 20 female 25 female
 Owner occupied house 1 1 0 1
 Council/rented
 accommodation
 74 49 20 24
 Educational qualifications
 beyond 16
 1 1 0 1
 National Vocational
 Qualification
 1 1 0 1
 Single parents 74 44 20 24
 Married 1 1 0 1
 Living on social assistance 74 49 20 24
 Employed 1 1 0 1
 Reciprocal knowledge transfer in CAMH 59
 Primary Health Care Research & Development 2008; 9: 49?63
parental capacity to respond to their child?s needs.
 The following factors were identified as limiting
 parental responses:
 > Lack of material resources.
 > Tacit oppression in system.
 > Failure to disseminate the findings of research,
 which the parents found relevant to their
 situation, across the system to include schools,
 leisure facilities and social services.
 > Lack of group consciousness among parents
 of these children and lack of awareness of
 inappropriate attribution of behaviours as
 naughty rather than arising from temperament,
 the awareness of which enabled some of the
 parents to address these problems with sig-
 nificant carers such as teachers and grand-
 parents.
 However, although some parents did learn to
 challenge systems, they identified that changes
 needed to take place at a service delivery (doing)
 level if their capacity as parents to meet the needs
 of these children is to be developed.
 Development of a methodology for
 reciprocal knowledge transfer between
 carers and professionals
 This section will identify the practice and
 methodological tensions to engaging in recip-
 rocal knowledge transfer not only with fellow
 professionals but also with parents who were
 simultaneously clients of a CAMH system, and
 the solutions to these tensions adopted in this
 research.
 The first challenge was how to access experi-
 ential knowledge of professionals who have
 developed expertise, which was taken for granted
 and intuitive. The solution developed in the
 nursing study was to use published knowledge,
 structured using a concept analysis, as a tool to
 interrogate practice experiences and facilitate the
 articulation of tacit taken-for-granted experiential
 knowledge (Croom et al., 2000). In extending this
 method to parents, the emerging nursing knowl-
 edge and skills were converted into propositions
 (described above) that were then used with
 parents to critically interrogate their parenting
 experiences and to identify the parameters of the
 transfer of nursing knowledge useful in their
 parenting context.
 A second challenge was how to access authentic
 experiential data which are grounded in real-life
 experiences and therefore provide the medium for
 testing out the relevance of codified formal knowl-
 edge to practice/real-life situations. Critical incident
 technique allows participants to focus in on their
 own experiences and use narratives of their every-
 day practice and experience. Themes emerging
 from the analysis of these data can help to identify
 critical skills (Flanagan, 1954; Norman et al., 1992).
 This method used with nurses was found to be
 transferable to parents.
 A third challenge was how to engage vuln-
 erable hard-to-reach parents in research. The
 solution adopted here was to deliver services
 simultaneously with research and so attempt to
 engage in reciprocal knowledge transfer in situ by
 offering a service that could meet clients? needs
 whilst simultaneously giving them a research
 voice that could support them to be creators and
 not just users of services.
 A fourth challenge was the acknowledged ten-
 dency of vulnerable groups to echo the voice of
 the most powerful (Gaventa and Cornwall, 2001).
 The parents, who were also clients of a CAMH
 service, could feel vulnerable/oppressed by pro-
 fessional researchers and hence say what they felt
 the researchers wanted to hear. The solution used
 in this study was to develop parenting research
 groups that lasted 12 weeks in order to allow
 the development of group cohesiveness and
 consciousness. In addition, the application of a
 critical theory (Fontana, 2004) perspective facil-
 itated an exploration of any tacit or overt
 oppression within the current evidence base and/
 or the interactions with the researchers. Con-
 verting the professional practice knowledge base
 to a series of propositions meant that each pro-
 position could be inductively analysed with the
 parents according to whether the knowledge
 underpinning the proposition was valuable when
 applied to the parents? actual parenting experi-
 ences. The length of the groups enabled comple-
 tion of a series of action cycles in which parents
 could test out and reinforce their experiences
 with each other and not just with researcher/
 practitioners.
 A fifth methodological challenge was how to
 delineate research data from the plethora of
 60 Susan Croom and Susan Procter
 Primary Health Care Research & Development 2008; 9: 49?63
practice data that emerges in a group over
 12 weeks. The solution adopted was to use pur-
 poseful sampling of data using completed action
 research cycles (see Figure 4). Therefore only
 data appertaining to completed cycles of action
 were included in the analysis of the parenting
 study.
 A sixth methodological and ethical challenge
 was how to ensure parents received a quality
 service as well as participating in research. The
 solution adopted was to provide access to a wide
 range of knowledge in addition to the nursing
 knowledge according to issues which parents
 raised through their ongoing experiences.
 Conclusion
 This paper has described how a body of practice
 knowledge can be built and how established
 scientific and academic knowledge can be used and
 modified in particular contexts to meet parti-
 cular needs. It demonstrates how ?just-in-time?
 knowledge-transfer techniques (Canadian Research
 Transfer Network, 2002) can be embedded within
 more systematic and evidence-based approaches
 to action research. This enables knowledge
 valued by service users to be incorporated into
 the knowledge systems informing professional
 practice.
 From both a practice and research perspec-
 tive, the issue of sustaining support for parents
 was important and represents a further system
 challenge. Despite the approach taken, only 25
 of the 75 parents referred to the service were
 able to sustain the programme, reflecting similar
 problems of accessing hard-to-reach groups
 identified in previous CAMH studies (Pugh and
 Smith, 1996).
 Current health contexts are characterized
 by high needs and finite resources and policy
 requirements to incorporate user views and
 participation. However, the service delivery
 challenges given in Box 1, and inherent oppres-
 sion identified by service users in this study are
 rarely acknowledged. This paper demonstrates
 that elements of the social constructionist per-
 spective on knowledge transfer advocated by
 Bate and Robert (2002) and McAdam and
 Reid (2001) can be used to facilitate knowledge
 transfer between service organizations and users.
 Of particular value were the codification of tacit
 user knowledge and the transfer of knowledge
 valued by service users into the practice system.
 Figure 4 Action research cycle
 Reciprocal knowledge transfer in CAMH 61
 Primary Health Care Research & Development 2008; 9: 49?63
However, if the social constructionist approach is
 to address the challenges of optimizing service
 delivery identified in Box 1 it must move beyond
 discussions of organizational knowledge man-
 agement and recognize the crucial importance of
 including service users in the creation and con-
 struction of knowledge for practice. The recipro-
 cal transfer of knowledge described in this paper
 describes one example of how this can be
 achieved and may go some way to addressing the
 ?know?do? gap (WHO, 2006).
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