The Joanna Briggs Institute clinical fellowship program: a gateway opportunity for evidence-based quality improvement and organizational culture change

Abstract

Practising health professionals trained and prepared for best practice lead the provision of high quality, evidence-based healthcare (EBHC), as many researchers have consistently demonstrated.1–5 Nurses in particular have a high level of knowledge and acceptance of EBHC, high uptake of EBHC principals in undergraduate and postgraduate nursing programs, and increasing integration of evidence in nurse-led quality improvement initiatives.6–9 There have been many benefits to the uptake of EBHC, not just in terms of practice improvement, but also in understanding individual and organizational barriers and facilitators and indeed the process of change itself.10–13 However, nurses are not always professionally enabled to contribute to EBHC initiatives.14,15 While EBHC has supported nurses to make substantive contributions to professional nursing knowledge and practice, there are still gaps. A lack of autonomy in the strategic and cultural domains of healthcare organization and delivery is problematic.16 Without mechanisms to address these systemic, organizational issues, the promise and potential contribution of nursing will not be fully realized. The Joanna Briggs Institute (JBI) was established as an international research institute in 1996 with a vision for a world in which the best available evidence is used to inform policy and practice to improve health in communities globally.17 While many associate JBI with systematic reviews of the best available evidence, that is only one element of their work. JBI is also involved with knowledge transfer and knowledge implementation as the JBI Model (Fig. 1) illustrates.Figure 1: The Joanna Briggs Institute model of evidence-based healthcare.The JBI Evidence-Based Clinical Fellowship Program (EBCFP) focuses on implementation and was designed for busy healthcare practitioners, managers, and administrators, who have an interest in implementing best practice, but may not have familiarity with the suite of skills needed to lead and sustain practice change.18,19 The program is delivered over 6 months; participants attend an intensive 1-week workshop that provides foundational knowledge on change management, leadership, implementation, and evaluation. Following the workshop, participants return to their clinical institution, where they conduct a rapid cycle small test of change following a Model of EBHC.14 After they have collected baseline data, and implemented their change based on best practice, participants return for a second intensive residency, in which they work in small groups to analyse and evaluate their data and work on dissemination. This constructionist approach enables participants to situate and ground their learning in their own clinical experience, expertise, and interests, all of which facilitate the translation of research into practice. Programs such as the EBCFP are designed to help improve the safety and quality of care provided in health facilities; and facilitate the development of clinical autonomy in the strategic and cultural domains of healthcare organization and delivery. This is a complex process that crosses systems, resources, infrastructure, and policy and process requirements, and requires situated contextual know-how and operational leadership necessary for patient and family care. Instituting a change based on best practice needs to utilize a programmatic, standardized approach that promotes the use of systems and infrastructure to address issues of policy or practice at the organizational level. This in turn, contributes to the promotion of key indicators (such as hand hygiene or surgical patient management) aligned with national or international accreditation and benchmark standards. The achievement of such key indicators is by necessity a multidisciplinary endeavour. Graham et al.20 and Steel-Moses21 argue that embarking on a trajectory for a substantive strategic goal requires a whole of organization investment. It involves a mission driven investment that recognizes the value of nurses and their contribution to clinical leadership and policy and practice improvement. Graham advocates for the use of a process similar to that described in the knowledge to action model for leveraging change processes based upon a call to action that includes a situational analysis and total organizational engagement for implementation of EBHC.20 The need for a roadmap and steps in planning aligns well with the work of Steele-Moses,21 who also advocate for a gap analysis to inform the scope of work, effective planning, inclusivity of top down support for clinical practice transformation, and adequate resourcing of the planning phase.21 Adequate resourcing includes finance, staff time, integration with relevant committees, and regular high-level program activity review.21 JBI Clinical Fellows work with other clinicians, administrators and managers as required to scope the problem and develop a plan for implementing best practice to address the compliance gaps found in the baseline audit. The implementation phase is a facilitated project that starts with the identification of potential barriers to best practice, moves to solution building where strategies to overcome the barriers are developed, and the resources needed to implement are identified. As per the JBI Model, the facilitation of change is step two in the implementation of best practice and is where most of the fellowship time is allocated. Implementation continues through an evaluation cycle that provides measurable data on care processes and patient outcomes that were identified as important during the context analysis. The JBI suite of best evidence programs, tools, and resources facilitate the implementation of change based on best practice, and surveys consistently demonstrate that clinicians possess both the knowledge and motivation to participate and indeed lead such programs of work. By bridging the evidence to practice gap, and enabling organizations to up-skill and equip their clinical staff with specific skills, knowledge and resources, the JBI programs can be considered gateway programs for practice change. Investing in nurses and the practising professions as clinical leaders, innovators, and drivers of healthcare quality is well supported by high-quality systematic reviews. Creating a collective organizational culture of improvement, as well as the tangible individual benefits of the JBI EBCFP include honing important project management skills, instilling a sense of empowerment and mastery, and increasing capacity for clinical leadership by the clinicians and carers who are equipped with the knowledge, skills and resources to lead evidence-based practice change. Investing in staff for EBHC is something we can all support. Acknowledgements Conflicts of interest The authors report no conflicts of interest.

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