Kaleidoscopic integration: Advancing the integration of incommensurable knowledge in healthcare guidelines

The integration of different types of knowledge in epistemically hierarchical settings remains one of the greatest challenges when developing standards for healthcare practices. In this article, we open up the notion of knowledge integration and empirically examine the various ways in which different types of knowledge interact and can be integrated. To allow us to focus on the diverse forms of knowledge as well as their interaction and integration, we combine Moreira's work on repertoires of evaluation with that of Dewulf and Bouwen on frame interactions. We examine the quest for knowledge integration by studying interactions in the case of the development of the COVID-19 vaccination guideline in the Netherlands, a prime example of the encounter of a wide range and diversity of knowledge that needs to be appraised and integrated into guideline recommendations. Drawing on ethnographic observations of more than 70 guideline development meetings between 2021 and 2022, we first map the different types of knowledge and reasonings used by the guideline developers and subsequently analyze their interactions. We identified eight knowledge interaction patterns, being disconnection, polarization, accommodation, incorporation, reconnection, reconciliation, passive juxtaposition, and kaleidoscopic integration. We hereby draw attention to the various possible knowledge interactions encompassed in the concept of "knowledge integration", especially to those in which integration is achieved while differences and incompatibilities are maintained. Finally, we discuss potential ways to facilitate fruitful knowledge interactions during collaborative work which include the ability to accept and sustain tensions between different types of knowledge and making more explicit use of frame or rather repertoire reflection.