Preamble:

The editorial for this issue consists of the transcript of Professor Emerita Margaret Harrison's keynote address at the recent JBI Colloquium in Singapore. Professor Harrison is a founding member and Senior Scientist with the Queen's Practice and Research in Nursing Group (PRN), an innovative academic-practice partnership to advance practice through research at the point-of-care. Professor Harrison's invited address consists of an erudite discussion on evidence-based healthcare, knowledge translation and the work of the Joanna Briggs Institute moving forward.

Dr Zachary Munn, Acting Editor-In-Chief

On this last day of the Singapore conference we have heard much about scaling new heights and challenging the status quo. Now In this section of the conference the focus is on strengthening and building capacity for healthcare including leadership, evidence-based health care policy, and evolving a culture of empowerment and practice development. This morning I have been asked to reflect on energizing global healthcare and the evidence for action - a tall order!!

Being Clear on Terms and Meaning

Global health has been described as the health of populations in a global context - one that transcends country borders and focuses on worldwide health improvement.1 Philosophically it is something we subscribe to, influential organizations such as WHO and the Joanna Briggs Institute promote - but has it come to mean everything yet nothing? Is it possible to energize healthcare globally through evidence use? What form does 'energizing' evidence take in a global context take?

To begin, what is considered evidence? Is it the same as knowledge - we have seen them used interchangeably. For this conversation we will assume they are different - evidence is explicit and factual while knowledge results from the integration of evidence with belief and context. Given this one might surmise that evidence could move comparatively easily while knowledge is rooted in people.2

Another aspect of 'evidence' important for this discussion and highlighted in recent literature is the notion of external and local evidence. Lomas3 describes it as scientific evidence and colloquial evidence. In this way ascribing to science a "sense of absolute truth" that can be categorized as context-free or context-sensitive. Colloquial evidence represents the context level i.e. experiential knowledge, societal values, resources, tradition. Others such as Andy Oxman3 argue that all evidence is context-sensitive.

Following through on the theme a little further, what does knowledge translation and 'evidence for action' entail? In a groundbreaking 2005 World Health Organization meeting on Bridging the Know-Do Gap - Knowledge Translation in Global Health, it was suggested that knowledge translation is "the synthesis, exchange and application of knowledge by relevant stakeholders to accelerate the benefits of global and local innovation in strengthening health systems and improving people's health." This was drawn from the Canadian Institutes of Health Research (CIHR), 2001 which was further refined at CIHR4more recently[horizontal ellipsis].'Knowledge translation (KT) is defined as a dynamic and iterative process that includes synthesis, dissemination, exchange, and ethically-sound application of knowledge to improve the health of Canadians, provide more effective health services and products, and strengthen the health care system.'

So let's recap:

* Global health relates to populations in a global context - i.e. all of our countries and beyond.

* Evidence is broadly understood to include both external and local i.e. contextual information.

* Knowledge translation includes synthesis, dissemination, exchange, and ethically-sound application of knowledge.

This leads us to questions about knowledge translation and use of evidence in practice and policy for global health improvements and what is best done internationally i.e. centrally, and what can only be carried out locally. In particular, ethically sound application in considering context and resources.

The World Health Organization and other international health bodies provide policy and leadership on global priorities and issues. It is well agreed that evidence ought to be an essential in policy-making, planning, and programs of healthcare. Adding to this, international entities such as the Cochrane Collaboration focus on amalgamating available international evidence rendering it more suitable for users. Others go further with a global approach. For example the Joanna Briggs Institute (JBI), provides theory and conceptual guidance on evidence and evidence use. Noteworthy is that JBI developed its model for evidence-based healthcare and its role in improving global health from their experience working with global partners in promoting and facilitating evidence-based healthcare across the world.5 This innovative, engaged approach with end-users is something we will come back to.

Returning to 'Evidence for action', we know there are several important elements, namely: 1) Synthesis: the rigorous synopses of all available international research on effectiveness as well as contextual evidence (feasibility, appropriateness, accessibility, meaningfulness); 2) capacity at the implementation level; 3) partnerships and an integrated-KT approach i.e. collaboration and engagement to work with end-users. Ultimately, good external global evidence should be viewed only as a starting point. Next it must be aligned with local knowledge.

Regarding synthesis and the external evidence, you will probably agree with me that there is now decent infrastructure in place to synthesize and disseminate the global research through international bodies like the Cochrane Library, the Joanna Briggs Institute and the Campbell Collaboration. Notwithstanding that there is always room for improvement in terms of synthesis methods and enhancements in translation for use (e.g. moving beyond technical reports and "more research is needed conclusions"), these bodies are in place with transparent rigorous processes, internet accessible, and recognized as good sources for synthesized evidence. Further, we have seen other advancements with the 'external evidence' part of the equation: development and testing of approaches to levels of study evidence; clinical translation into practice guideline recommendations; tools such as, GRADE (http://www.gradeworkinggroup.org/intro.htm) to level practice recommendations by incorporating values/tradeoffs with evidence; and methods to evaluate guideline development such as AGREE (http://www.agreetrust.org/).

But what about the other aspects needed for KT: capacity at the implementation level; partnerships and an integrated-KT approach i.e. collaboration and engagement to work with end-users. Good external global evidence is a starting point and makes sense to process centrally. What follows is the alignment with local knowledge and this is about the local environments, culture, and resources.

Countries all over the world are grappling with the challenge to implement 'best practices'. As a global community we have found that using best available evidence to improve health care processes and outcomes is typically a daunting task - one of 'trial and error' with little guaranteed success. As noted by Professor Alan Pearson, "it is complex and sometimes misunderstood and frequently maligned."5^{(pg. 214)} Why is this?

Working on implementation at ground-level I continue to wonder why we ever thought this was just going to be a matter of simply handing over good evidence to the field at a local setting level, let alone globally. Working with a number of guideline bodies in the early '90's developing clinical recommendations for guidelines there was an underlying assumption that this was the 'be all and end all' to attain best practices. Significant investments were made in my country and I am sure many of yours, in producing quality guidelines - the guideline factories proliferated and developed multiple guidelines on the same topic - think about Pressure Ulcers or Falls Prevention - dozens of guidelines!! But a guideline developed did not result in a guideline used. Why?

With the proliferation of guidelines from credible bodies such as the Royal College of Nursing, Agency Health Care Policy and Research, Scottish Intercollegiate Guidelines Network, the Registered Nurses Association of Ontario an awareness was created. This provided impetus for care settings to focus on care delivery supported by best available evidence and guidelines were an enabler. As knowledge tools, practice guidelines represent a major advance in transferring research evidence from many studies for use at the point-of-care. Best available evidence became accessible and packaged in a more useable form. Guidelines also served as a vehicle to improve consistency in the structure and process of care both within and across settings providing organizations with a 'script' as they undertook efforts to deliver evidence-driven care.

On the surface, this journey seems clear-cut: translating available evidence into practice recommendations, then integrating practice recommendations into service delivery, the result should be improved quality of care and health outcomes. The underlying assumption to this sequence being, when good evidence is embedded in a quality guideline, it will be fairly straightforward to move it into practice. It has taken more than a decade to figure out that guidelines are necessary but not sufficient.6

The process of taking the evidence into the complexity and chaos of real-world health settings presented multiple challenges. For one, thinking about effectiveness evidence, a quality randomized controlled trial (RCT) controls all the important contextual factors so it can never be a direct transfer to practice in various contexts. It would need to be implemented and studied organically to find the generalizable 'truths'.

Let's return to this notion of local, contextual evidence -practically speaking what does this entail? There is a logical flow of action, but it is neither linear nor tightly sequential. External evidence (from the literature) serves as foundation providing leverage in (re)designing the practice setting by discovering how to 'fit' and 'align' this evidence with local resources, populations and context. When we engage in generating local evidence this constructively achieves a number of things: it focuses all involved on the 'same page'; identifies important facilitating factors and barriers; provides empirical support for planning; and is, in itself, instrumental to implementation and sustaining change. A journey moving evidence into practice typically consists of three major phases of implementation activity:7

Phase I:Issue Identification/Clarification: think of it as problem deconstruction. Local experience and expertise raises awareness of the issue providing momentum for change. This Phase is characterized by the formation of a strategic alliance among providers within or across agencies and settings, possibly with researchers. Ideally the alliance will have clinical and management expertise and representation from an appropriate range of decision-making levels.

To begin, a critical review and quality assessment of the external evidence and/or practice guidelines would be undertaken to ascertain 'best available' evidence related to the care issue. Then, an assessment conducted locally determines the extent of the issue, the environment in which it occurs, and how care is currently delivered. Answering these questions develops the foundation for decision-making and planning for needed changes. The purpose here is to create a reliable, comprehensive and shared understanding of the issue and care needed to address it.

Phase II: Solution Building:Here the alliance works with the local information focusing on what implementation of a 'best practice' innovation would entail in their context. There is a proactive exchange to identify needed changes in the current practice and delivery of care.

Activity during this phase is population-based and may include: environmental scans to understand the current organization and delivery of care; knowledge, attitudes, and practice (KAP) surveys with local providers; gap analyses through practice audits; and barriers assessment to what might help or impede a reorganization based on external evidence. Some factors may be known but others are more difficult to tease out. The enquiry process provides the insights needed for key players to identify clinical, health services, and/or policy changes (small or large) to move forward with evidence-informed care.

Phase III: Implementation, Evaluation and Nurturing the Change: Now the focus is on the actual implementation of evidence e.g. a guideline, and an evaluation of the uptake and outcomes. Planning for implementation underpins both Phases I and II, and culminates in Phase III, where a process evaluation reveals important process-of-care information about delivering evidence recommendations (e.g., organization of teams to carry-out a comprehensive wound assessment). As well, experience with the feasibility, appropriateness, and sensitivity of outcomes may later be useful to establish quality monitoring. Nurturing change requires proactive work to promote sustainability. In Phase III, the alliance begins to understand the impact and benefit of their work by conducting process and outcome evaluations. This phase presents opportunity to assess potential long-term monitoring and outcome assessment for the setting.

I hope you can see from this rapid overview how the process is local, iterative and engaging. It can initiate and sustain a strategic alliance, providing a natural avenue for learning and appreciating the external evidence in relation to their local circumstances. In addition to data that is available locally from population and administrative sources, there is potential research throughout these phases to understand the population and health environment providing opportunity for further collaboration. I would argue this is not activity that can be globally defined.

If we return to our theme of activating evidence for global health, how can we Think Globally, Act Locally? What makes sense to centralize and share and what should be driven at a more local, regional level?

This brings me to the Joanna Briggs Institute - from its inception has been dedicated to both evidence synthesis and implementation to improve global health. Fundamentally the JBI approach to evidence synthesis is broad, encompassing questions of feasibility, acceptability, accessibility, meaningfulness as well as effectiveness. JBI was ahead of the curve of implementation science having this model and approach for nearly 20 years. With its worldwide collaboration and commercial partnership with Wolters-Kluwer Ovid Lippincott, JBI is perfectly positioned to fulfil both the external evidence requirements for knowledge translation i.e. rendering the many international studies in a more useable form through their broad-based approach to evidence. JBI by its very structure develops and builds support for the local evidence requirements. Our arrangement as JBI centers (in our memorandum of understanding), dictates a direct linkage with practice/policy partners to establish local priorities for synthesis and is foundational. By our nature, the work is ground-up, at the coalface of healthcare. The global element comes through the Institute and its library, its partnerships amongst centres, and between JBC and our valued commercial partner Wolter-Kluwers who are enabling greater global reach with more effective and efficient means through a business program focused on evidence-based practice and enhanced IT systems. Our scholarship is spread across dozens of universities and hundreds of health settings, creating further collaborations within and across regions.

Thinking about knowledge translation JBI has been a beacon light for global KT, let me give you just a few highlights:

* capacity building

* Providing fellowship opportunities for evidence synthesis, uptake and evaluation activities

* Delivering workshops around the world through the collaboration for rigorous synthesis methods of both qualitative, quantitative and mixed-methods research findings

* engaged scholarship and collaboration

* With KT-model and policy developments

* Supporting Nodes focused on large-scale synthesis on specific areas

* Progressing the science and scholarship in KT through methods advancement

* Engaging with our commercial partner to advance evidence-based practice through tools and on-line support that is widely available

* public engagement

* Fostering public engagement directly through the Institute and through the collaboration of JBI centers worldwide where we all fan out to our communities

* adaptation of evidence to a context

* maintaining a multi-level focus on frontline clinical questions and importantly also on health services/economic topics

* new tools and resources e.g. CAN-IMPLEMENT

* Advancing the use of evidence in non-English language contexts, valuing and supporting this activity through Translation Centers

JBI is unique and well positioned - we are on a large-scale level 'living' the mission To be the leader in producing, disseminating and providing a framework for the use of the best available research evidence to inform clinical decision-making to improve health outcomes globally.

As we think about this next couple of days when we convene as centers to discuss our future directions, let's focus on the KT phases of problem identification, solution building and implementation and evaluation and how we to strengthen our infrastructure to serve globally and continue to be user-driven locally.

Moving forward in 2014:

Capacity build, capacity build, capacity build - we need more people and centers focused on synthesis, continue and widen the fellowship opportunities. The reports from the last few years' fellows and the changes they made in practice are inspiring.

Continue supporting the advancement of methods for synthesizing all types of evidence - much of what JBI offers that is unique is related to the questions beyond effectiveness, these methods are in their infancy.

Consider the 3 phases of local implementation (issue identification, solution building and implementation/evaluation) and develop with our commercial partner more supports for generic tools to advance local evidence-uptake.

Build scientific, public and policy partnerships. Scientific to advance synthesis methods and implementation science approaches. Public and policy partnerships to remain relevant and cutting-edge.

JBI's iconic symbol of a pebble falling into a pool creating ripples of knowledge has never been more meaningful. We are creating thousands of lights worldwide through our collaboration in working ground-up, getting evidence into practice and practice into evidence!!

Thank you.

Margaret B. Harrison RN, PHD, Professor Emerita

School of Nursing Co-Director Queen's Joanna Briggs Collaboration, Queen's University, Kingston

References