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The JBI Model of

Evidence-based
Healthcare: A model
reconsidered

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Background
According to Pearson, Jordan and Munn (2012) there are a number of models
that attempt to represent the components of evidence-based healthcare “to
facilitate understanding, analysis, improvement, and/or the replacement of the
process as it is currently conceived, purported and practiced”.
The JBI Model of Evidence Based Healthcare (referred to hereafter as ‘the
Model’) was first published in 2005 (Figure 1) and has become an important
marker of the Institute’s unique and distinctive conceptualisation of evidence
based healthcare and how it is operationalised. This developmental framework
for evidence-based practice situated healthcare evidence, in its broadest sense,
and its role and use within complex healthcare settings. It conceptualised
evidence-based practice as “clinical decision-making that considers the best
available evidence; the context in which the care is delivered; client preference;
and the professional judgement of the health professional” (Pearson et al 2005,
p209).

Figure 1: The JBI Model circa 2005


The Model further depicts four major components of evidence-based healthcare
as being evidence generation, evidence synthesis, evidence transfer and evidence
utilisation, with each modelled to incorporate their essential elements.
In 2011 Pearson, Weeks and Stern explored the relationship between the JBI
Model and translation science, which incorporated an in depth analysis of each of
the component parts of the Model. A further paper quickly followed this in 2012
that sought to clarify the relationship between evidence-based healthcare and
translation science (Pearson, Jordan and Munn 2012). The paper asserts that
three translational gaps (identified as the gap between knowledge need and
discovery; discovery and clinical application; and clinical application and policy
and practice) could be complimented by elements of the JBI Model and help to
model the relationship between the translation science cycle and the pragmatic
evidence-based healthcare cycle. It concluded that integration of translational
gaps with a model of evidence-based healthcare clarifies and re-conceptualises

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the complexity of improving health outcomes through translating knowledge
into action.

Justification for change


The JBI Model is now a decade old and it is interesting to note that the discursive
statements utilised within it (and the structures and colour frameworks) went
on to become the scaffolding for other organisational documents and discourse
that followed (Jordan, 2011). Indeed the work programs of the Institute and the
Joanna Briggs Collaboration and JBI tools and resources all utilise 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 organisation.
In the years since its inception there have been significant shifts in both the
internal and external discourse around evidence-based healthcare 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 relook at the model and its component parts
to see whether they remain relevant and a true and accurate reflection of where
the movement is today in 2015. It is an opportunity to better align the
construction of the organisational discourse, the vision and mission with the
Model and vice versa.

Structure and design notes


It is important to acknowledge the corporate investment in this Model. Having
been in circulation for ten years, the Model is now broadly associated with JBI
and thus the intent is not to dilute that, but rather to enhance and strengthen it.
Understanding that the Model has become a fundamental framework for how JBI
and the JBC is organised some minor structural and design alterations have been
made, but with the integrity of the original in mind at all times.
Colour theory is complex, however, in their most basic format they provide a
logical structure for colour. This reconceptualisation was utilised as an
opportunity to create colour harmony within the structure of the Model and
colours now follow the colours of the visible spectrum in the correct sequence.
From a design perspective, additional colours (or blurring colours) would only
create an imbalance in the visual experience and confuse the concept rather than
simplify the information being delivered. Additionally, the outer sections (3 for
each wedge) are a paler version of the internal wedge colour so that they act to
support the importance of the inner wedges.
The inner circle (pebble of knowledge) has remained largely untouched from a
design perspective and the colour has been maintained in line with the pebble
that sits within the JBI logo. The “inner wedges” provide the Institute’s
conceptualisation of the steps involved in the process of achieving an evidence-
based approach to clinical decision-making while the “outer wedges”
operationalise the component parts of the model and articulate how they might
be actioned in a pragmatic way.

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With respect to the design elements of the Model some subtle modifications have
also been made. Red is used for the central “pebble” circle and therefore the
wedge that is now called evidence implementation has been changed from red to
orange so as not to imply a stronger relationship between these two elements
than the others.
The flow, indicated by the arrows, has the large arrow flowing clockwise; the
smaller arrows for the “feedback cycle” are slightly smaller. It was important to
acknowledge that this is not a clean, linear process and that it may, at times, be
bi-directional. The rationale for this decision was to ensure that there was
directional clarity. Making the arrows the same size would imply there was
some confusion regarding the preferred direction (Figure 2).

Figure 2: The new JBI model

The “Pebble of Knowledge”


The central component of the JBI Model (the “pebble” – aka the “pebble of
knowledge” as per the JBI logo) is designed to focus the Institute’s
conceptualisation of evidence-based healthcare. In the original model evidence-
based practice is a process whereby clinical decision-making “considers the best
available evidence; the context in which the care is delivered; client preference;
and the professional judgement of the health professional” (Pearson et al 2005,
p209).

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Pearson and colleagues (2005) define evidence as “the basis of belief; the
substantiation or confirmation that is needed in order to believe that something
is true” (p210). For health professionals to be able to establish the utility of a
broad range of interventions and procedures a broad conceptualisation of
evidence is required. While evidence of effectiveness is acknowledged as being
of value, other types of evidence are considered equally important as they are
designed to answer different clinical questions.
This unique articulation of what constitutes evidence and its ability to inform
practice was a first in the field at the time of the original publication in 2005.
The FAME scale and this broad conceptualisation of evidence is frequently cited
and clearly resonates with those seeking to conduct research that is relevant to
point of care decision making.
The centre of the Model demonstrates that, encompassing:
 Feasibility (the extent to which an activity or intervention is practical or
viable in a particular context or situation)
 Appropriateness (the extent to which an intervention or activity fits
with a particular context or situation)
 Meaningfulness (the extent to which an intervention or activity is
positively experienced by an individual or group)
 Effectiveness (the extent to which an intervention achieves the intended
result or outcome)
Given the significant impact that this conceptualisation has on every other
component of the Model it has been moved to the centre pebble. The FAME scale
is not only a reflection of the different types of research that are undertaken by
health researchers but it also drives the conduct of different types of reviews, the
generation of derivative products and resources and their implementation in
practice.
When making clinical decisions, health professionals are concerned with
whether their approach is Feasible, Appropriate, Meaningful and Effective. We
therefore define evidence-based healthcare as clinical decision-making that
considers the feasibility, appropriateness, meaningfulness and effectiveness of
healthcare practices. The feasibility, appropriateness, meaningfulness and
effectiveness of healthcare practices may be informed by the best available
evidence, the context in which the care is delivered, the individual patient, and
the professional judgment and expertise of the health professional.

Global Health
As the original model paper states: “the achievement of improved global health is
conceptualised as both the goal and endpoint of any or all of the model
components and the raison d’etre and driver of evidence-based healthcare”
(Pearson et al 2005, p209). This assumption remains an important element of
our conceptualisation of evidence-based practice and hence this wedge of the
Model has been moved to the top/centre of the model.

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Sustainable Impact
Often evidence implementation activities succeed in making a change to
healthcare practices. Unfortunately, due to resourcing issues and the ever-
changing nature of health services these changes may only be temporary. To
truly address and improve healthcare, any positive improvements need to be
lasting. Sustainable impact can only be achieved where there is collective
conceptual clarity around the motivation and perceived benefits of an evidence-
based approach to healthcare decision-making and the strategies for
operationalising it. It is likely that sustainability thresholds will be reached given
the changeable nature of the healthcare environment. However, it is our belief
that, if research questions are derived from the knowledge needs of the
community and a collaborative approach that accounts for local application is
utilised then sustained impact is a far more likely outcome.

Engagement
To successfully address the significant issues we face in delivering evidence-
based healthcare, engagement and collaboration is essential across all involved
stakeholders and groups. This ranges from local collaborations between health
services and academia, clinicians and patients, to international collaboration
between governments, research units, and health organisations. The Institute
has, since its inception, forged local and global partnerships to ensure that
activities were “context driven by individuals and groups who understood their
very specific healthcare environments and the forces that would work both for
and against them” (Pearson in Jordan, Donnelly and Pittman, 2006).

Knowledge need
“Gathering knowledge of what people need, what resources are available, and
what limits constrain their choices” is vital to an evidence-based approach to the
delivery of healthcare (Jordan and Pearson, 2013). JBI has long asserted the
need for evidence-based healthcare to address the knowledge requirements of
the community (that is, clinicians, patients/consumers, governments and other
organisations). It is these explicit questions or concerns that are also
encompassed in this wedge of the Model. Indeed, a significant gap associated
with the translation of research into action has been the gap from knowledge
need to discovery. As Pearson, Jordan and Munn (2011) suggest, “within this gap
there can be an integrated approach to topic selection, where there is active
collaboration between those conducting research and the end users of research.”

Evidence generation
It is important to note that the generation of new knowledge may occur through
either primary or secondary research. Systematic reviews are equally important
as primary research in this area and can also identify important gaps in what is
known about a particular field, intervention or practice (hence the importance of
the two way arrows). With that in mind, it is essential to acknowledge that
knowledge is not only about effectiveness.
The evidence generation wedge of the Model identifies, as in the original,
discourse (or narrative), experience and research as legitimate means of
knowledge generation. What has been removed from the wedge is the FAME

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scale, given its relevance across the entire Model and the shift to having it central
to the conceptualisation of evidence-based healthcare.

Research
It is broadly accepted now that evidence can take many forms and, in the real
world of practice and policy making, decision makers are influenced by a variety
of understandings and sources of evidence that flow over the situation: habits
and tradition, experience, expertise, reasoning, trial and error and research and
many others (Pearson, Weeks and Stern, 2011). Of course, in the first instance,
“the results of well-designed research studies grounded in any methodological
position are seen to be more credible as evidence than anecdotes or personal
opinion” (Pearson et al 2005). However, research does not always exist for
every intervention, practice or procedure. In these instances clinicians are still
required to make choices about the care provided and so must look elsewhere
for evidence/knowledge to inform their decision-making.

Discourse
Discourse can be defined as a written communication or debate based on
personal anecdote or experience. The term is conceptually broad and has wide
applicability across all settings. Alvesson and Karreman (2000) conceptualise
two types of discourse, namely ‘little d’ and ‘big D’ discourse. ‘little d’ discourse
refers to talk and text in local social interaction and ‘big D’ discourse (or
Discourse) refers to culturally “standardized ways of referring to/constituting a
certain type of phenomenon” (p. 1134). This is as opposed to “communication,
which is defined as the means by which messages are imparted, transmitted or
conveyed (Jordan 2011). Within the context of evidence-based healthcare and
the JBI Model, discourse is viewed as incorporating both big D and little d
discourse and as “operating or taking effect through communicative functions –
communications activities or tactics are the symbolic interactions through which
discourses are revealed” (Jordan 2011).

Experience
Drawing on the conceptualisations in the healthcare wedge and the component
that relates to knowledge need, JBI positions experience (and expertise) as able
to inform both primary research; secondary analysis in the form of systematic
reviews (and the role of expert advisory panels); and implementation programs.
Thus experience and expertise is acknowledged as a vital form of evidence
within this framework. This also incorporates patient preferences and/or values.
The process of identifying what type of evidence is required to answer a
particular question and what type of evidence is available (research, experience
or discourse) are fundamental to the movement of evidence into practice. While
the gold standard is still recognised by many as being the randomised controlled
trial, the importance and significance of other sources of evidence continues to
gather growing respect, particularly among direct care providers. Due weight
must, of course, continue to be afforded to research evidence, clinical wisdom
and patient preferences and values.

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Evidence synthesis
The original Model defined evidence synthesis as “the evaluation or analysis of
research evidence and opinion on a specific topic to aid in decision making in
healthcare” and was conceptualised as having three main components (theory,
methodology and systematic review of evidence). In this current
reconceptualisation, although the definition of evidence synthesis remains true
and accurate, we would argue that a significant component of synthesis (i.e.
‘collation’) is missing. We also propose that a more meaningful representation of
the three main pragmatic components of the wedge for JBI is in fact systematic
reviews, evidence summaries and clinical guidelines.

Systematic Reviews
The core of evidence synthesis efforts remains the systematic review, which is in
and of itself a form of research (secondary research). Systematic review
methodology is rapidly evolving with the types of reviews being conducted
ranging from traditional reviews of effects to reviews of qualitative research,
economic and cost effectiveness research, prognosis, diagnosis, umbrella,
scoping just to name a few. The scope for reviews is immense, making their
applicability and relevance to practice even stronger.

Evidence Summaries
However, smaller scale evidence summaries or rapid reviews have also emerged
as a streamlined approach to synthesising evidence in a timely manner. While
systematic reviews are still considered the gold standard in knowledge synthesis
they are not without their limitations. As Khangura (2012) and colleagues
identify, systematic reviews typically take anywhere between 6 months and 2
years to complete and often focus on a narrow clinical question. They suggest
that evidence summaries offer something new and potentially valuable to the
syntheses repertoire in a way that better addresses the needs of policy makers,
decision makers, stakeholders and other knowledge users.
Clinical Guidelines
Clinical guidelines are sources of summarised information on specific practices
related to patient care to guide health professionals in their clinical decision-
making. They may, or may not, be based on the results of a systematic review of
the international evidence. The shift of clinical guidelines from transfer, as in the
original Model, to synthesis, has been made due to the passive nature of these
publications. We acknowledge, however, they might be considered ‘borderline’
synthesis/transfer as such have ensured they are positioned directly next to the
transfer wedge.

Evidence transfer
Evidence transfer is defined as “the act of transferring knowledge to individual
health professionals, health facilities and health systems globally by means of
journals, other publications, electronic media, education and training and
decision support systems” (Pearson et al 2005, p213). However, we take the
position that the production of additional ‘derivative products’ from systematic
reviews remains a largely passive activity and as such would seek to redefine the
term transfer to mean a coactive, participatory process to advance access to and

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uptake of evidence in local contexts. In adjusting this definition we intend to
reframe transfer as a potential causal phenomenon (i.e. a factor that enables,
facilitates and supports evidence implementation). In this way, it moves transfer
beyond a single interaction to one that extends beyond that of a “publication”.
In the original model the component parts included systems, information and
education. In this iteration we propose that evidence transfer incorporates
active dissemination, education and clinical integration. Pearson, Weeks and
Stern (2011) articulate the fundamental components of this process as being:
 Development of understandable and actionable messages;
 Accommodation of the context of the target audiences information needs;
and
 Delivery of messages in cost effective ways (including information
technology, print material, meetings, workshops and training programs.

Active Dissemination
Fundamental to the process of evidence-based decision-making is the ability of
those at the point of care to access synthesised research evidence. Active
dissemination (rather than passive) is therefore an important component part of
this wedge of the JBI Model. This is largely a communicative function aimed at
spreading knowledge/evidence on a large scale within and across geographic
locations, practice settings and other networks of end users (RTI International,
2013). As indicated in a systematic review commissioned by the Agency for
Healthcare Research and Quality (AHRQ) Effective Healthcare Program (RTI
International 2013) multicomponent, blended communication style
dissemination strategies are more effective at enhancing clinician behaviour,
particularly for guideline adherence. Active dissemination involves active
methods to spread information (such as email and social media), formats to
encourage motivation/uptake (such as infographics, decision aids or icon
arrays), and knowledge spreaders (such as champions or thought leaders).
Passive dissemination is of course still important, but this model highlights the
importance of active methods of dissemination in evidence-based healthcare.

Education Programs
Equally, educational programs have been identified as consistently effective
strategies for evidence transfer. This might include education regarding the
evidence related to a particular intervention, it could involve continuing
professional development (CPD) or broader programs at award and non-award
levels that take participants through the rationale for evidence-based
approaches to clinical decision-making, methods for evidence synthesis or
pragmatic strategies for implementation.

Systems Integration
Systems integration might involve the inclusion of an evidence base in clinical
decision support systems, but it may also involve the embedding of evidence in
broader systems, policies and procedures.

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Evidence implementation
The first and most obvious change to this component of the model is the change
from utilisation to implementation. While scholars in the disciplines of public
and community health and social science have for some years studied
behavioural change with respect to the implementation of evidence, it remains a
relatively young area of scientific investigation. The phrases implementation
and utilisation have both been commonly referred to in the extant literature,
however implementation seemingly better reflects this activity within the
context of the JBI Model. Evidence implementation in the context of the JBI
Model is defined as a purposeful and enabling set of activities designed to engage
key stakeholders with research evidence to inform decision-making and
generate sustained improvement in the quality of healthcare delivery.
Within this wedge the original Model incorporated the components of
embedding system organisational change, practice change and the evaluation of
impact on system/process/outcome. We propose that a more appropriate
reflection of the components of evidence implementation includes a situational
analysis, the facilitation of practice change and evaluation of process and
outcome.
The Centre for Reviews and Dissemination (CRD) posit that evidence indicates a
need for the following steps to be pursued in programs designed to implement
evidence (NHS CRD, 1999):
 A ‘diagnostic analysis’ to identify factors likely to influence the proposed
change. Choice of dissemination and implementation interventions
should be guided by the diagnostic analysis and informed by knowledge
of relevant research (context analysis)
 Multi-faceted interventions targeting different barriers to change are
more likely to be effective than single interventions (facilitation of
practice change)
 Any systematic approach to changing professional practice should include
plans to monitor and evaluate, and to maintain and reinforce any change
(evaluation of process and outcome)
While we accept the above summation, the evidence relating to multifaceted
interventions is not conclusive. Hence, we would argue that local champions,
opinions leaders or clinicians who facilitate practice change (whether through
audit and feedback or other programs) are essential for successful
implementation of evidence.
Approximately nine models for evidence implementation dominate the
healthcare literature and the success of these models is dependent on how well
they account for the complex, multi-dimensional nature of the healthcare
environment – systems thinking. Discovering better ways to ensure patients
receive the care they need is not easy and poses formidable methodological
challenges. The overlap with the quality improvement field and its parent field
of complexity theory are considerable.
Drawing on existing models and theories about change management and
knowledge translation, the evidence implementation wedge of the JBI Model

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seeks to ensure that this process is one that is cognisant of local culture and
context, that builds capacity and supports and reinforces existing infrastructure
in a sustainable fashion.

Overarching principles: culture, capacity, collaboration and communication


The complex and inimitable healthcare environment means that there is no
single, linear approach that will work every time to move evidence into policy
and practice. Indeed evidence will not always be feasible, appropriate,
meaningful or effective in a given context. As such, we propose that the
overarching principles of this process are culture, capacity, collaboration and
communication. In this way, issues relating to stakeholder engagement, the
localisation of knowledge, responsiveness to local knowledge requirements and
sustainability are acknowledged.
Invariably, discourse and communication are fundamental to the translational
agenda. However, communication is something that Manojlovich and colleagues
(2015) see as being only implied in the JBI Model, rather than being explicit.
Given the recognition that evidence translation (on the whole) is a largely
discursive activity that takes place within a global context, a transparent and
flexible approach is advocated that utilises a broad array of communicative
activities to promote collective understanding, identity and mutually beneficial
goals and objectives.
It is important that this Model is not seen to be reductive in character or to
ignore, in any way, the importance of social, cultural and historical
organisational and individual influences on clinical decision making. There must
be understanding of the ‘sameness’ and uniqueness’ of the actors participating in
the process of moving evidence into policy and practice and the need, to a certain
extent, to openly acknowledge it as an on-going, organic, evolutionary process
that requires constructive, coactive partnership across sectors, groups and
individuals.

Conclusion
The Model has been an important part of the Institute’s development, both from
a scientific and organisational perspective. It has provided a framework for the
Institute’s academic endeavours as much as an organisational construct for
operations at both a local and international level. Given the changing
international discourse relating to evidence and its translation into policy and
practice over the course of the last decade it was opportune to revisit the Model
and assess its ongoing applicability in its current form. Some
changes/alterations have been made for consideration in the hope that it
repositions the Institute theoretically and pragmatically.

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How to cite: Jordan Z, Lockwood C, Aromataris E, Munn Z. The updated JBI
model for evidence-based healthcare. The Joanna Briggs Institute. 2016

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