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Redeveloping the JBI Model of Evidence Based Healthcare

Jordan, Zoe PhD; Lockwood, Craig PhD; Munn, Zachary PhD; Aromataris, Edoardo PhD

International Journal of Evidence-Based Healthcare: December 2018 - Volume 16 - Issue 4 - p 227–241
doi: 10.1097/XEB.0000000000000139
DISCUSSION PAPER
Open

Background: In 2005, Pearson et al. presented a developmental framework of evidence-based practice that sought to situate healthcare evidence and its role and use within the complexity of practice settings globally. A decade later, it was deemed timely to re-examine the Model and its component parts to determine whether they remain relevant and a true and accurate reflection of where the evidence-based movement is today.

Methods: A two-phase process was employed for this project. Phase 1 involved a citation analysis, conducted using the index citation of the original source article on the Joanna Briggs Institute (JBI) Model by Pearson et al. The databases searched were Web of Science and Google Scholar from year of publication (2005) to July 2015. Duplicates and articles in languages other than English were removed, and all results were imported and combined in an Excel spreadsheet for review, coding and interpretation. Phase 2 (model revision) occurred in two parts. Part 1 involved revision of the Model by an internal working group. This revised version of the Model was then subjected to a process of focus group discussion (Part 2) that engaged staff of the Joanna Briggs Collaboration during the 2015 annual general meeting. These data were recorded then transcribed for review and consideration.

Results: The citation analysis revealed that the Model was primarily utilized to conceptualize evidence and evidence-based healthcare, but that language used in relation to concepts within the Model was variable. Equally, the working group and focus group feedback confirmed that there was a need to ensure the language utilized in the Model was internationally appropriate and in line with current international trends. This feedback and analysis informed the revised version of the JBI Model.

Conclusion: Based on the citation analysis, working group and focus group feedback the new JBI Model for Evidence Based Healthcare attempts to utilize more internationally appropriate language to detail the intricacies of the relationships between systems and individuals across different settings and the need for contextual localization to enable policy makers and practitioners to make evidence-based decisions at the point of care.

Faculty of Health and Medical Sciences, The Joanna Briggs Institute, University of Adelaide, Adelaide, South Australia, Australia

Correspondence: Prof Zoe Jordan, PhD, Faculty of Health and Medical Sciences, The Joanna Briggs Institute, University of Adelaide, Adelaide, South Australia, Australia. E-mail: zoe.jordan@adelaide.edu.au

This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0

What is known about the topic?

  • The JBI Model is now more than a decade old
  • Evidence-based healthcare is complex, dynamic and evolving quickly
  • There are many frameworks aimed at representing this process
  • What does this article add?
  • An understanding of how the JBI Model has been perceived and utilized in the international literature
  • An understanding of how the JBI Model has been perceived and utilized by stakeholders internationally
  • A revised version of the JBI Model
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Background

The JBI Model of Evidence Based Healthcare was first published in 2005.1 The implications of the final presentation of the Model, as published in the original source article, were two-fold and related to both internal organizational dynamics as well as the broader conceptualization of evidence-based healthcare (EBHC). It was presented as a ‘developmental framework of evidence-based practice that builds and expands on work of leaders in the field of evidence-based healthcare; is contextualised; is inclusive of diverse forms of evidence; and incorporates understandings of knowledge transfer and utilisation’.1 According to the authors of the original article, the Model was developed to provide an overview of the complete cycle of EBHC, from the generation of knowledge through to its implementation in practice.

There are a considerable number of frameworks and models available today that have been designed to articulate the process of moving evidence into practice.2 These include the Knowledge to Action Framework,3 the PARIHS Framework,4 the Ottawa Model of Research Use,5 the Coordinated Implementation Model,6 the Stetler Model of Research Utilisation7 and the CIHR Model of Knowledge Translation8 and, of course, the JBI Model of Evidence Based Healthcare.1 These models, frameworks or theories can all be useful for guiding the movement of evidence, although it is unlikely that any one of these single theories or models will provide the complete picture for EBHC.2

However, in addition to the above, the Joanna Briggs Institute (JBI) Model and the discursive statements utilized within it (in addition to the structures and colour frameworks) also went on to become the scaffolding for other organizational documents and discourse that followed in JBI.9 Indeed, the work programmes of the Institute, the Joanna Briggs Collaboration and JBI tools and resources all utilize the language of the Model and the colour themes associated with each wedge. It has permeated and influenced the presentation of every aspect of the organization.

In the years since the inception of the JBI Model, there have been significant shifts in both the internal (i.e. within JBI) and external discourse around EBHC and the terminology associated with it. Even in its infancy, there were internal ‘disconnects’ between the language used to describe the Model and the language used to describe the activity of JBI and its international collaboration. As such it was considered timely to re-examine the Model and its component parts to see whether they remain relevant and a true and accurate reflection of where the evidence-based movement is today. This examination was used to rearticulate and further refine components of the Model.

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Aims and objectives

The aim of this project was to evaluate the ongoing relevance of the JBI Model of Evidence Based Healthcare and to ascertain whether updates were required.

Specifically, it sought to

  • Understand how the Model was perceived and utilized in the international literature.
  • Understand how the Model was perceived and utilized by stakeholders internationally.
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Methods

Phase 1: citation analysis

Publication and citation counting techniques have been used in the assessment of scientific activity for many decades, both as tools for librarians and to map scientific activity. Similar to other authors,10 we chose citation analysis to investigate how the JBI Model of Evidence Based Healthcare Model was perceived and used in the literature. The citation analysis was conducted using the index citation of the original source article by Pearson et al.1 The databases searched were Web of Science and Google Scholar from year of publication (2005) to July 2015. Duplicates and articles in languages other than English were removed and all results were imported and combined in an Excel spreadsheet for review and analysis.

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Inclusion/exclusion criteria

All identified citations were screened by title and abstract. Articles were only excluded if they were in languages other than English, if no citation could be identified or if the article was listed in the reference list but no in text citation could be identified. No additional exclusion criteria were applied as the authors’ interests were in gauging use cases broadly in the literature and did not want to limit on the basis of how or why the Model was cited.

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Data extraction

Data extracted included title, authors, publication year, where in the article the Model was referenced (i.e. background, methods, discussion), how many times the Model was referenced and other pertinent field notes and excerpts from the text relating to the Model. This was inputted to an Excel spreadsheet for analysis.

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Quality assessment

No quality assessment was applied to the articles as this exercise was aimed at identifying where and how the Model was cited, rather than the quality of the publication itself.

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Data analysis

The included articles were coded by publication type, attribution of use and emergent themes.

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Phase 2: model revision

Part 1 (working group review)

Participants

Following the citation analysis, the results were reviewed by a working group of senior researchers/academics in the JBI from across programme areas (synthesis, transfer, implementation, collaboration/communication) with significant experience in the field of EBHC.

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Method

The current process included multiple group unstructured face-to-face meetings during 2015. The meetings were not facilitated, but rather findings arose de novo through general discussion.

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Data analysis

One member of the working group acted as scribe and following each session worked with a graphic designer to make changes to the Model that were then reviewed and further clarified at subsequent meetings.

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Part 2 (focus group review)

Participants

Focus group discussions with the staff of Joanna Briggs Collaboration took place during the 2015 annual general meeting. This included approximately 70 participants experienced in EBHC and familiar with JBI and the JBI Model from around the globe (across Australia, Asia, America, Africa and Europe), representing approximately 20 language groups.

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Method

Participants were divided into groups of 10 with a JBI staff member allocated as facilitator and scribe. They were provided with a graphic of the revised version of the Model (generated by the working group) along with a discussion article detailing the changes that had been made and the rationale for change for consideration and were asked to discuss, in their groups, each of the component parts and to provide feedback related to the language and appearance of the Model and the specific changes that had been made. Their responses were recorded by scribes allocated per table and then transcribed for review.

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Data analysis

Transcribed content was transferred to an Excel spreadsheet for analysis. No a-priori codes were determined for this phase of the analysis, but rather an inductive approach was employed whereby emergent themes were identified.

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Results

Phase 1: citation analysis

The search identified a total of 290 citations of the original source article (239 in Google Scholar and 51 in Web of Science). SCOPUS was not searched as the International Journal of Evidence Based Healthcare (IJEBHC) was not indexed in SCOPUS until after the date of publication of the original article, and thus, no citations of the source article are captured. Of the 290 citations in Google Scholar and Web of Science, 56 were identified as duplicates and 79 were identified as non-English articles and removed, an additional 30 were excluded on the basis of not having any reference to the source article (either in the reference list or in the text) and a final two were excluded at full text review as the citation had no bearing on the original source article (one related to preoperative hair removal techniques and the other related to educational contexts). This left a final number of 123 references.11–133

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Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart

Figure

Figure

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Data analysis

Data analysis was both descriptive and thematic. Citations were coded using predetermined codes and then analysed for emergent themes.

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Descriptive data

Authorship: A total of 34 of the articles identified were authored by staff of the JBI. Of these, seven had Prof Alan Pearson as first author, who was also first author of the original source article. In addition, nine authors could be identified as JBI students and 19 as staff of Joanna Briggs Collaborating entities.

JBI publications: The identified articles were published in a range of journals and databases. However, it is important to note that, of these, 11 were published in the JBI Database of Systematic Reviews and Implementation Reports11–21 and 16 in the IJEBHC.22–37 These are both publications linked with the JBI.

Attribution of use: Table 1.

Table 1

Table 1

Publication type: Table 2.

Table 2

Table 2

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Thematic data

Two emergent themes were identified as follows:

  1. Conceptualizing EBHC
  2. Conceptualizing evidence

The results of these analyses are detailed below.

  1. Conceptualizing EBHC
  2. Where explicit reference to the JBI Model was identified, the content was largely descriptive in nature, explaining each segment. The Model was often used to conceptualize EBHC and the steps required to achieve it; however, this was not always achieved in a consistent manner. Within the context of outlining, the challenges surrounding evidence-based medicine in developing countries utilized the JBI Model to outline the steps required for evidence synthesis.134 Others refer to the JBI Model and the various stages of evidence implementation, ‘including evidence production, synthesis, knowledge transfer, and evidence utilisation’.55 Given these examples, it is evident that language is an issue in which various elements of the evidence-based process are referred to with considerable variation even when referring to the same Model.
    Equally, the idea that evidence does not stand alone in the decision-making process, but should be considered alongside client preferences, clinical judgement and context was a focus in many of the articles in which the Model was cited. Macdonald135 outlines the benefits of the JBI approach, as conceptualized in the Model, stating the value of recognising both ‘qualitative and quantitative evidence, a holistic understanding of the provision of healthcare, a systematic approach to evidence synthesis and a global presence’. It is the congruence between primary and secondary research and clinical practice that appears to resonate with health practitioners and researchers alike. As Macdonald135 states, the JBI approach ‘mirrors the nursing approach to client care, which is holistic and aims to balance both the scientific and humanistic characteristics of health’ and is important ‘not only for nurses and nursing but for all healthcare providers’.
  3. Conceptualizing evidence
  4. There was considerable reference to JBI Feasibility, Appropriateness, Meaningfulness and Effectiveness (JBI FAME), particularly in which authors sought to extend the understanding of what constitutes evidence. It is clear from the literature that this conceptualization of evidence (and the inclusion of research and other articles as they relate to the feasibility, appropriateness, meaningfulness and effectiveness of interventions) has resonated considerably with authors internationally. Not only was JBI FAME utilized to highlight the importance of considering a broader conceptualization of evidence but also to inform and guide the types of questions being asked about healthcare provision and thus the types of reviews being conducted. There is evidence that since the publication of the original model, these terms (and their synonyms) have permeated common understandings and interpretations of EBHC, which was not necessarily the case when the Model was published.136,137
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Phase 2: model revision

During Part 1 of the Model revision process, the working group considered the original Model (Fig. 1) in light of the results of the citation analysis and their collective experiences and understandings of where the EBHC movement had evolved to over the course of the last decade. Each segment of the Model was considered through an iterative process of discussion and debate until a unified position was agreed upon. The result was a revised Model (Figure in Appendix 1).

Figure 1

Figure 1

Focus group participants were presented with the revised version of the Model (Figure in Appendix 1) for their consideration and feedback. Based on this feedback, a further version of the Model was developed (Fig. 2). Results from the working group review and focus group discussion are presented below in the form of responses to each segment of the Model.

Figure 2

Figure 2

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Segment 1: centre ‘pebble of knowledge’

Revision 1 (working group changes): The central component of the JBI Model (the ‘pebble’ – aka the ‘pebble of knowledge’ as per the JBI logo) remained in Revision 1 of the Model. However, ‘evidence based’ was replaced with ‘evidence informed’ as the working group believed this to be a more accurate reflection of the evidence-based movement and how evidence should be considered in the context of clinical decision-making. In addition, FAME, which originally appeared as a component part of evidence generation, was moved to the centre pebble. FAME is the Institute's representation of the range of questions articulated by health professionals and the need for a broad view of what constitutes evidence to respond to these highly variable information needs.

Revision 2 (focus group feedback): Most feedback acknowledged that ‘informed’ might be a more semantically accurate term to reflect the Institute's activity; however, participants advocated strongly in favour of maintaining the term ‘based’, given the challenges around linguistic translation of the term ‘informed’ and the potential for confusion in the clinical community if the word was changed. There was also a desire to remain consistent with other international organizations such as the WHO, who continue to utilize the word ‘based’.

Most participants were positive about the shift of FAME to the central pebble and agreed that it was appropriate and relevant for JBI to do this and that it still reflected the important elements related to patient involvement, although it was important to ensure this was reflected both here and elsewhere in the Model.

Although no changes had been made, there was overwhelming feedback that evidence-based healthcare was far more appropriate than evidence-based practice, healthcare being a more inclusive term representative of the broader organizational imperative for best practice, including quality management and policy along with practice, as well as being more appropriately nuanced to the knowledge needs of educational settings, peak bodies, and professional societies and associations.

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Segment 2: global healthcare

Revision 1 (working group changes): In this revision, Global Health was changed to Healthcare, given some of the complexity around use of the term ‘global’ and the variation in understanding of the term.

Revision 2 (focus group feedback): Feedback was mixed regarding the right terminology to use to name this segment of the Model and no consensus was reached. Global Healthcare was formalized as the starting point for the Model on the basis that the Institute's mission is grounded in collaboration, with centres of excellence around the world contributing to inform knowledge needs for local problems with global relevance, and presents a timely reminder that evidence itself should also be sought globally.

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Segment 3: evidence generation

Revision 1 (working group changes): Given the move of FAME to the central pebble, the additional ‘middle’ layer of this segment was removed. The working group agreed that the terms research, experience and discourse remained valid for this segment.

Revision 2 (focus group feedback): There was consensus that evidence generation was the correct term to use to describe this segment of the Model. However, there was considerable discussion regarding its component parts. Specifically, there was consensus that ‘expertise’ was a more appropriate term than ‘experience’ and that each of the components required further clarification.

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Segment 4: evidence synthesis

Revision 1 (working group changes): The first revision of the Model saw the component parts of this segment change from Theory, Methodology and Systematic Review to Clinical Guidelines, Evidence Summaries and Systematic Reviews to better reflect the different ways in which evidence might be synthesized.

Revision 2 (focus group feedback): There was consensus that evidence synthesis was the correct term to use to describe this segment of the Model. There was also consensus that ‘clinical guidelines’ should be changed to just ‘guidelines’ in this segment to reflect the broad nature of health policy and practice. Although there was some reflection about whether guidelines fit better in synthesis or transfer, there were several comments in support of its positioning in synthesis at a ‘high level’.

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Segment 5: evidence transfer

Revision 1 (working group changes): In the first iteration of changes, the component parts of the Transfer segment of the Model were changed to include Education programs, Systems integration and Active dissemination (rather than just ‘information’).

Revision 2 (focus group feedback): There was consensus that evidence transfer was the correct term to use to describe this segment of the Model. There was a mixed response regarding the term ‘active dissemination’ with some suggesting the removal of ‘active’. Equally there were mixed responses to the titles in the other two component parts with suggestion to remove ‘programs’ from the education component and further explanation required for ‘systems integration’.

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Segment 6: evidence implementation

Revision 1 (working group changes): The working group changed Utilisation to Implementation to better reflect international language used to describe the field. The component parts were also changed to Situational analysis, Facilitation of practice change and Evaluation of process and outcome.

Revision 2 (focus group feedback): The change from ‘utilisation’ to ‘implementation’ to describe this segment of the Model was unanimously supported. There was a suggestion that ‘situational analysis’ may be outdated language and that ‘context analysis’ or ‘gap analysis’ might be more appropriate. It was generally agreed that ‘facilitation of change’ was an important component, but a suggestion to provide more information about what this might entail (i.e. skills development). There was further suggestion to move ‘sustainable impact’ to this segment and additional work to flesh out the science behind implementation in the accompanying article.

A ‘mapping’ table is provided below to summarize the main changes between the original version (Fig. 1) and final revised version (Fig. 1, noting that it was only a working draft; Appendix 1) (Table 3).

Table 3

Table 3

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Discussion

Generally, researchers and academics develop and utilize models to examine, explain or demonstrate ideas and phenomena. They are visual aids to assist in communicating complex processes, such as EBHC and translation science. Equally, there are a multitude of models in existence. This article sought to establish the use and revise the JBI Model and did so through a process of citation analysis and participants’ feedback.

The results of the work done as part of this project suggests that the JBI Model has been utilized, predominantly, as a tool to frame and describe EBHC broadly and to inform the conduct of systematic reviews and a small number of implementation projects. Although the requirement for implementation of evidence-based practice models is clear, ‘few guidelines exist for service providers about how to implement these models within the practical constraints of their organisational context’.138 This was an important consideration during the redevelopment process of the Model.

A significant body of research exists concerned with various aspects of communication across cultural and linguistic boundaries, which was also an important consideration in the redevelopment of the Model.139 Ollenschlager et al.140 state that, ‘Effective collaboration in evidence-based healthcare requires that methodological principles are common’. The focus group process utilized here highlighted the importance of language in addition to methodological principles in achieving an international approach to EBHC, with most feedback related to terminology and the use of various words or phrases to describe component parts of the Model.

There are very few ‘language universals’ and rather diversity can be found ‘at almost every level of linguistic organisation’.141 The Joanna Briggs Collaboration (JBC) includes centres from across approximately 40 countries, let alone the rest of the world's 6000–8000 other languages! Thus, the importance of finding terminology that can be translated with as much ease as possible is significant (and challenging!).

The focus group process was important for determining both the internal and external linguistic validity of the JBI Model. Internal linguistic validity, in this instance, relates to how language is utilized to promote unity across the JBC and shared understanding of the JBI approach to EBHC. In this sense, the Model has become a shared ‘object to think with’ facilitating the JBI/JBC's ability to ‘think together apart’ as part of the collaborative process.142 Given that the JBC now spans across five regions of the world, the cocreation of a common language around our collective understanding of how JBI conceptualizes EBHC is critical. It relates not only to how we function as an organization and our ability to work as a culturally agile and adept international team (building trust and rapport with our collaborators), but also our ability to move forward and to make an academic contribution to the evolution of EBHC and translation science.

External linguistic validity relates here to the ability of language constructs to enable effective communication with the broader healthcare community, particularly in countries where English is not the first language. Although the corporate language of JBI is English, it is important that there is facility for effective linguistic translation that will not inhibit meaning. There is always a risk that, during the translation process, the meaning or essence of the message is distorted or altered in some way. Responses from participants in the focus groups in relation to use of the term ‘informed’ instead of ‘based’ was particularly useful in this respect as the term ‘informed’ was deemed in some instances far more difficult to translate in a concise and meaningful way. This, from a knowledge transfer perspective, was vitally important feedback. In addition, some participants in the focus groups felt the move from ‘based’ to ‘informed’ would result in confusion in the clinical community, a concern that has also been expressed elsewhere and given these considerations the term ‘based’ was preferred.143

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Limitations

We recognize the limitations of using citation analysis (i.e. self-citing, authorship by JBI staff and collaborators and the fact that JBI has its own journal). However, the process was simply utilized to be indicative and to provide some insight into how the Model is generally perceived and utilized, if at all, to inform policy development and/or practice. Moreover, there are other articles that have included discussion of the JBI Model as a key feature of that publication, and although these were picked up in the current analysis it is possible that a further citation analysis of these key resources may have included additional and potentially different information regarding the use of the Model.144,145 However, we decided to use the original publication as the best and most relevant target source for this citation analysis. A significant limitation of this article is the exclusion of articles published in languages other than English, particularly as the JBI has many centres across the globe where English is not an official language.

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Conclusion

The citation analysis revealed that, despite being cited almost 200 times by academics, health professionals and policy makers, the Model itself was rarely used to inform or direct policy or practice. Equally, the focus group process confirmed that there was a need to ensure the language utilized in the Model was internationally appropriate and in line with current international trends in EBHC. As a result, a revised Model is proposed which clarifies the conceptual integration of evidence generation, synthesis, transfer and implementation, linking how these occur with the necessarily challenging dynamics that contribute to whether translation of evidence into policy and practice is successful.

Given that the JBI Model of Evidence Based Healthcare was published over a decade ago and has been heavily utilized as an organizational tool by the Institute, it was appropriate not only to conduct a citation analysis of its use internationally but also to consult with stakeholders regarding any proposed changes. The process was invaluable and has resulted in a revised Model that better reflects the process of EBHC as understood by JBI and the JBC. More information regarding the JBI Model can be found online (Appendix 2).

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Acknowledgements

The authors would like to thank members of the Joanna Briggs Collaboration Committee of Directors for providing their thoughts and feedback in relation to the JBI Model of Evidence Based Healthcare. The authors would also like to acknowledge the contribution of Sarah Silver for her assistance with the citation analysis.

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Declarations

Ethics approval and consent to participate: not applicable.

Consent for publication: not applicable.

Availability of data and material: not applicable.

Funding: not applicable.

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Authors contributions

Z.J. drafted the first full version of the article, C.L., Z.M. and E.A. provided feedback and comment on the article and all authors provided approval of the final version to be published.

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Conflicts of interest

The authors report no conflicts of interest.

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Appendix 1: First revision of JBI Model

Revised JBI Model of Evidence Informed Healthcare (Version 1). This version of the JBI Model was prepared by a Working Group of JBI and presented to members of the Joanna Briggs Collaboration Committee of Directors for feedback during the 2015 face-to-face meeting.

Figure

Figure

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Appendix 2: Supplementary materials

YouTube videos:

English: https://www.youtube.com/watch?v=Gjz5HUbE6sE

Spanish: https://www.youtube.com/watch?v=k_U26Pha_pQ

Chinese: https://www.youtube.com/watch?v=M38gxkaZago

Other resources: http://joannabriggs.org/jbi-approach.html

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Keywords:

conceptual model; evidence-based healthcare; knowledge translation

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