Implementing the best available evidence in day-to-day practice remains a challenge for many health care practitioners. Studies have shown that interventions known to be effective are not consistently provided to patients and that deviations from evidence-based recommendations are still common in different areas of practice (Cawich et al., 2014; Dotel, Gosbell, & Hofmeyr, 2015; Nabor, Buckley, & Lapitan, 2015). Barriers to evidence implementation have been widely reported in the literature and include lack of time, unsupportive organizational culture, practitioner and patient factors, limited access to resources and lack of skills in research and evidence-based practice (EBP) (Tacia, Biskupski, Pheley, & Lehto, 2015; Wallis, 2012).
To facilitate evidence implementation, health care practitioners require knowledge and skills to formulate clinical questions, search for research evidence, appraise the quality of evidence, and interpret research findings. Therefore, education is a necessary first step in changing practice behavior. Fellowships are a common means to provide practitioners with professional education and development, including training for research and EBP (Christenbery, Williamson, Sandlin, & Wells, 2016; Stutzman et al., 2016). Fellowship programs offer clinicians protected time and often provide access to resources and mentoring support (Meador, 2015; Short, McDonald, Turner, & Martis, 2010). They are also popular to clinicians because of the hands-on and interactive approach to training rather than a didactic delivery of lectures or demonstrations (Hines, Ramsbotham, & Coyer, 2015).
The Joanna Briggs Institute (JBI) offers a clinical fellowship program as part of its strategy to promote evidence-based health care. The program is offered to health practitioners, managers, educators, researchers, and policy makers who aim to develop skills around evidence implementation. The program establishes a strong network of policy and clinical leaders across the globe and provides ongoing support and motivation to this group. It is a 6-month program that includes 2 weeks of long intensive workshops and an implementation project in the participant's local institution. The Figure shows the process involved in the program; a complete description of this process is reported elsewhere (Stephenson et al., 2016). Briefly, the program starts with the establishment of partnership between the clinical fellow (i.e., participant in the program) and a JBI facilitator (i.e., a research staff), followed by a 5-day participant training at JBI on aspects of evidence implementation, health care quality improvement, audit, and feedback. After the training, clinical fellows return to their practice settings to undertake clinical audits and implementation initiatives. Following this, they return for a second 5-day intensive residency at JBI to develop a project report. During the course of the training, clinical fellows are provided access to an online audit tool, JBI PACES (Practical Application of Clinical Evidence System). The tool generates a graphical report of audit data and allows the fellows to compare their data against benchmarks or other organizations' averages.
Joanna Briggs Institute clinical fellowship program.
A key aspect of the JBI clinical fellowship program is facilitation. Facilitation is not specific to evidence implementation and has been applied in different fields, such as education, counseling, practice development, and health promotion. Kitson et al. defined facilitation as “a technique by which one person makes things easier for others” (Harvey & Kitson, 2016, p. 2). In the PARIHS (Promoting Action on Research Implementation in Health Services) framework, facilitation, evidence, and context have been identified as the three important elements for evidence implementation. In the context of the PARIHS framework, facilitation refers to the process of enabling the implementation of evidence into practice, achieved by an individual carrying out a specific role (i.e., facilitator) (Rycroft-Malone et al., 2013). Another group of implementation researchers described facilitation as “a goal-oriented, context-dependent social process for implementing new knowledge into practice or organizational routines” (Berta et al., 2015, p. 7). Findings from evaluation studies on facilitation suggested that facilitation that provides face-to-face communication and uses a range of enabling techniques can lead to positive changes in clinical and organizational practice (Baskerville, Liddy, & Hogg, 2012; Dogherty, Harrison, Graham, Vandyk, & Keeping-Burke, 2013; Wales, Kelly, Wilson, & Crisp, 2013). In the JBI clinical fellowship program, facilitation is aimed at enhancing skills in, and providing support to promote, evidence implementation.
This article provides practical tips for effective facilitation as applied in a clinical fellowship program aimed to promote evidence implementation. The majority of these tips are based on the authors' experiences and are supported by evidence from the literature.
Assigning a Qualified Facilitator
Prior to the commencement of an implementation project, JBI assigns a facilitator to the clinical fellow. The facilitator has a strong background in EBP and is an experienced health services researcher whose role is to support and assist the clinical fellow progress toward the achievement of their project aims and objectives. JBI facilitators have diverse backgrounds in quality improvement, project management and coordination, education provision, and information technology. This skills set is similar to the characteristics of good facilitators described in the literature and, in addition, should include interpersonal attributes and effective communication skills (Dogherty et al., 2013; Harvey & Kitson, 2015). Every JBI facilitator is also required to undergo training to become proficient with the use of the PACES program, which, as described above, is a tool to aid in the audit cycle. Training, whether formal or informal, enhances the quality of the facilitation provided to a clinical fellow or anyone who is involved in an implementation project (Hecht, Buhse, & Meyer, 2016; Kotecha et al., 2015).
Establishing a Genuine Relationship and Building Trust
The relationship between the JBI facilitator and clinical fellow is collaborative, and the aim of the partnership is to empower fellows to take responsibility for improving their clinical practice. The idea is for fellows to develop a strong sense of ownership of the project despite the support and assistance from facilitators. There is no power imbalance within the relationship, so both parties have equal input, which leads to a blending of expertise, with the facilitator having the implementation research knowledge and skills, whereas the clinical fellows have a better understanding of the clinical environment or the local context. This is in line with EBP research and initiatives that utilize an academic–clinical partnership framework to bridge the gap between research and clinical practice (Bvumbwe, 2016; Dale et al., 2016; Dobalian et al., 2014). Facilitators use their knowledge of the evidence base (from research) and experiences in implementation research to support and help clinical fellows throughout the implementation process rather than telling them what they need to change in clinical practice and why. They are neither prescriptive nor directive in their approach and strongly encourage clinical fellows to engage with them. Therefore, what develops is a relationship built on trust, which enhances the implementation process.
Setting Clear Roles and Responsibilities
Clearly articulating the role and responsibilities of the facilitator, as well as those of the implementation team, is important from a practical and operational perspective (Dogherty, Harrison, & Graham, 2010; Harvey & Kitson, 2015). The JBI facilitator sets the terms of reference for the partnership, which outlines their working arrangements, including roles and responsibilities. The facilitator makes the initial contact with the fellow and both will agree to an ongoing commitment to achieve the goals of the implementation project. At the outset, the facilitator queries about the topic or the area of clinical practice that requires examination and practice change. The facilitator assumes a support role while the clinical fellow acts as the change champion and implements the project. The Table summarizes the roles and responsibilities of the facilitator and the clinical fellow, as well as the activities where joint participation is required.
Roles and Responsibilities
Providing Ongoing Support and Mentoring
According to Harvey and Kitson (2015), the facilitator's role is particularly important when clinicians navigate through the complex change process, as they will require support and mentoring from individuals who are experienced in the how component of evidence implementation. The JBI facilitator provides an interactive, one-to-one mentorship to reinforce the learning acquired during the first week of the residency. This approach proved to be a time-efficient means for the fellows to access information tailored to their needs. Clinical fellows have seen this as a process by which they can seek advice or feedback, either on an ongoing or as-needed basis. Support is offered by means of providing literature resources or tools for facilitating practice change, interpreting research findings, problem solving, and ensuring that the project remains on task and is implemented as planned. The facilitator recognizes the pressure and sometimes the emotional toll experienced by fellows as they undertake the implementation project. As such, they also act as so-called shock absorbers and listen to fellows' frustrations and sentiments. This level of support maintains their momentum and motivation, particularly when they experience major barriers to project completion.
Stimulating Critical Thinking
Critical thinking is an integral component of evidence-based health care (Kim, Song, Sim, Ahn & Kim, 2015; Profetto-McGrath, 2005). It involves a process of reflection, evaluation, analysis, and interpretation that is oriented toward making judgments (Kim et al., 2015; Profetto-McGrath, 2005). Creating a condition that stimulates critical thinking is therefore a prerequisite for a successful implementation project. One of the first tasks of the clinical fellow is to determine and estimate the gap between current clinical practice and best practice from evidence-based recommendations. The JBI facilitator, on the basis of his or her knowledge of existing research, draws the clinical fellow's attention and thinking to key paradigms, questions, or potential challenges in their specific clinical area. The facilitator also probes and provides triggers to stimulate critical thinking. Throughout the implementation project, from describing the gap to interpreting the data and implementing actions or strategies, the facilitator encourages the fellow to reflect, evaluate information, problem solve, and make appropriate judgments.
Fostering Shared Decision Making and Relationship Building
A shared decision making and a collaborative process that truly integrates the perspectives and requirements of different stakeholders is key to a successful change process (Elf, Frost, Lindahl, & Wijk, 2015; Elwyn, Frosch, & Kobrin, 2016). An implementation project requires effective engagement and relationship building with a range of stakeholders, including (but not limited to) health care practitioners, managers, administrators, and consumers. The clinical fellows, at the start of their project, also organize a small team of people who will assist with conducting the practice improvement initiative. Buy-in from all stakeholders may not always be easy to achieve and can be a challenge for many clinical fellows. The JBI facilitator highlights to clinical fellows the importance of being strategic when inviting individuals to be part of their team. The facilitator also promotes the involvement of all stakeholders early in the process and encourages clinical fellows to maintain regular communication, seek their feedback and suggestions, and obtain their support for critical changes in clinical practice.
Communication and information sharing with stake-holders and staff is integral to any quality improvement initiative (Cooper et al., 2015; Crossland, Janamian & Jackson, 2014). Even with strong and committed leadership, a quality improvement project may fail as a result of ineffective communication (Hughes, 2008). To ensure regular communication, the JBI facilitator and clinical fellow set aside and protect a meeting time through all the phases of the project. Clinical fellows, after the initial 5-day intensive training, return to their practice settings to undertake clinical audits and implementation initiatives. This activity usually takes 3 to 4 months to complete and during this time, the facilitator maintains communication with the fellow by e-mails and teleconferences. Teleconferences are often reserved for more formal conversations about trouble shooting, problem solving, or discussing planned and unplanned strategies for changing practice behavior. E-mails are typically used to check the progress of the project and monitoring whether the process is occurring as planned.
An implementation project can sometimes be seen as a means to identify errors in a clinician's practice behavior rather than an opportunity to improve health services and outcomes. Clinicians should perceive the project as a valuable experience and a chance to promote innovation. This is one of the reasons why reporting back to the team on what has been achieved is crucial and should be considered as an important component of the project. The JBI facilitator provides fellows with tips on how to present the results in a positive way and ensure that credit is given to everyone who participated in the project. Acknowledging successes and celebrating achievements, no matter how small, may lead to more positive views about quality improvement initiatives and act as a catalyst for future projects (Staiger et al., 2016). A celebration means acknowledging that something positive occurred and achievements of the project would be easier to remember when marked with celebrations.
Encouraging Presentation at Scientific Conferences
Communicating the results of an EBP or implementation project to a wider audience is an important aspect of an evidence-based clinical fellowship program (Christenbery et al., 2016). JBI facilitators therefore encourage clinical fellows to present their implementation project in a scientific conference and assist with preparing the abstract for submission. Conference presentations allow clinical fellows to present their project and most up-to-date findings and receive feedback or comments from their peers, which can help with future quality improvement initiatives. It can also provide valuable information to interested individuals who wish to undertake similar projects in the future. Conferences are likely to be attended by professionals with similar interests, which provide clinical fellows with an opportunity to discuss their project and learn from other people's experiences. Establishing contacts with motivated professionals can also foster good relationships and promote future collaborations.
Supporting Publication in a Peer-Reviewed Journal
Publication in a peer-reviewed journal is another means by which clinical fellows can present their projects and disseminate their findings and is also an integral aspect of a clinical fellowship program (Christenbery et al., 2016). Publishing one's work offers a range of opportunities and benefits not only clinical fellows but also their organizations. These can include generating a credible evidence base for advocating policy change with local decision makers and international policy makers, enhancing the credibility of local organizations, promotion of dissemination and sharing of knowledge and experiences, and improving individual skills around scientific rigor (Zachariah et al., 2010). Publishing one's work can also contribute to self-esteem and career development (Zachariah et al., 2010). However, writing in a scientific style may not always be easy and can be challenging for some clinical fellows. To encourage fellows to publish their project, JBI facilitators offer a range of support, including selection of appropriate journals to which fellows could submit their implementation report, review of draft versions, and guidance on manuscript writing and formatting. When necessary, facilitators also assist with addressing comments received from peer reviewers.
Encouraging Active Engagement with Clinical Networks
Networking with people or groups outside one's organization can promote information sharing and future work collaborations. Clinical networks, which have been described as voluntary clinician groupings that aim to improve clinical care and service delivery, are increasingly being viewed as an important strategy for promoting EBP and improving models of health care (Haines et al., 2012). The JBI Clinical Fellows Alumni Group operates similarly to clinical networks and is composed of fellows who have successfully completed an evidence implementation project through the JBI Clinical Fellowship Program. The group aims to foster evidence-based health care through sustaining a connected community of clinical leaders devoted to translating evidence into action in health care. It promotes sharing of experiences and lessons learned in implementation of best practices. JBI facilitators strongly encourage clinical fellows to stay connected with other fellows and maintain their links with JBI as they continue their work on improving the quality of health care.
Assessing the Process, Outcomes, and Participants' Experiences
Evaluating the facilitation process and determining whether the outcomes of facilitation have been achieved is a valuable activity to undertake, either formally or informally. Formal assessments can take the form of a survey or structured interviews, and informal assessment can include speaking to fellows or listening to their project reporting. Exploring clinical fellows' experiences of the clinical fellowship program in general and the facilitation process in particular can enhance the quality of the program. At the conclusion of the fellowship program, JBI facilitators query about what learnings have occurred, review how the facilitation process worked (or did not work) and how things have improved, and reflect about the benefits of establishing the partnership between the facilitator and fellow and factors that might be important to consider for future facilitation efforts. An ongoing process of review and reflection allows JBI to identify strengths and weaknesses in the facilitation process and target those areas that require improvement or change. It also helps determine whether the program is meeting the needs of the clinical fellows and shape future initiatives.
Facilitation is an essential component of an evidence-based clinical fellowship program, maximizing the learning experiences through partnerships between clinicians and research staff. The ongoing facilitation role over the 6 months of the JBI clinical fellowship (and often extended beyond this time frame) is an opportunity to engage and develop new skills related to implementing evidence into clinical practice, within a supportive and individualized program. Although further research is required to fully evaluate facilitation and mentorship approaches (Gagliardi, Webster, & Straus, 2015), it has been established as an effective component and a highly valued and critical element of the JBI Clinical Fellowship program.
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Roles and Responsibilities
|Joanna Briggs Institute Facilitator||Clinical Fellow (and Team)||Joint Participation|
|Conduct literature search to determine best practice recommendations for the clinical problem||Identify the clinical problem or issue||Determine audit criteria|
|Develop the evidence summary||Advocate change in the practice setting||Develop an action plan|
|Provide resources (e.g. evidence based-tools, scientific literature)||Organize the project team||Write implementation report|
|Provide ongoing support and mentoring||Undertake clinical audit and barriers analysis, identify solutions, and implement interventions|
|Monitor progress||Report to stakeholders and obtain feedback
Drive sustainability of the practice change|