Introduction

The biennial Joanna Briggs Oration serves as an occasion to celebrate the evidence-based healthcare movement, and its accomplishments and to focus on a vision for the future. This discourse brings together health professionals from a diverse range of backgrounds to celebrate achievements and anticipate the further evolution of evidence-based healthcare. The following is a transcript of Professor Watts' Oration delivered on Thursday 19 November 2009 at the close of the second day of the Joanna Briggs Institute International Convention. Previous Joanna Briggs Orations were delivered by Dr Jos Kleijnen (2007) and Dr Donna Ciliska (2005).

Professor Robin Watts, who is the Foundation Professor of Nursing at Curtin University and Director of the Western Australian Centre for Evidence Based Nursing and Midwifery, spent her early career as a nurse educator in Honduras. She then became part of the great change in nursing education in Australia, serving for nine years as the Royal College of Nursing Australia nominee on the Australian Health Ethics Committee of the National Health and Medical Research Council (NHMRC).

Oration

I, no doubt like many here tonight, have sat through a number of orations. Some may well have nodded off during same. From these orations I drew some inspiration, felt good and/or took away some ideas. However I must admit I never thought about from where the orators drew their initial inspiration for the theme or ideas on which they spoke. I just assumed they were the sort of erudite people who were always mulling over high level thoughts as part of their daily life at Oxford, Harvard or University of Adelaide or where ever. Then when asked to deliver an oration, thought 'Ah, here is a great opportunity to speak on "x" and "y". I can easily pull something together'. On reflection I'm not sure today's demanding world still allows for too many of those sorts of scholars.

Being invited to take on this role today focused my mind squarely on this question of source of inspiration. I had read somewhere that Ian Fleming of the James Bond 007 fame had drawn much of his inspiration for his characters on his walks through the countryside around where he lived at the time in Kent, England: 'I go out on Romney Marsh and hope to find one there'. Well the closest thing we have to Romney Marsh in my home town of Perth is about to have a major highway built through it so the only message I would gain by going for a walk there would be the depressing destruction of a beautiful wild habitat so trucks can save 5 minutes in delivering their loads to the nearby port.

So my search for inspiration turned to other sources. To cut a long story short I ended up with a file of cuttings and printouts of items from an eclectic array of sources that had caught my eye as having potential to contribute to or develop into some relevant and coherent theme. To that I've added questions, comments and ideas generated by the keynote papers delivered so far in the conference. The latter certainly focused my attention on what the presenters had to say - there was no question that the content was meaningful to me. I will deal with the appropriateness and feasibility of some aspects of that content in due course.

So what follows is the outcome of that process. Rather than a coherent theme however, what eventuated were thoughts on a number of issues placed within the framework of the work of the Joanna Briggs Institute and its companion Joanna Briggs Collaboration and their possible futures. In developing these thoughts I have been mindful of a comment made by Professor Kim Beazley when being interviewed about the challenges he faces after the announcement of his recent appointment as Australia's ambassador to the USA: 'As an academic, you can say just about anything you like' (p. 1).1 I would hasten to add for the benefit of the US residents in the audience today that 'Bomber' Beazley as we fondly call him will, I'm sure, be much more circumspect in his new role.

The first question that immediately comes to mind is: Do these bodies have a longer-term future? This is probably a particularly pertinent question given all the talk about revolution at this conference. You will recall that clinicians did not feature as a driver of revolution in Muir Gray's2 list of three drivers. Norman Swan3 also categorically stated that the revolution would be led by consumers. To survive a revolution the minimum requirement is that you are perceived by the leaders and their followers as not a threat and/or not dispensable. To play an active role in a revolution you must demonstrate commitment to its core principles and be perceived as being able to make a contribution. Of course if you are the leaders of a revolution, your future is assured - at least until the infighting and struggle for power at the top starts.

However, before I share some thoughts with you on the first question, I wish to comment briefly on the terms 'revolution' and 'evolution'. I suggest that a conceptual or linguistic analyst would have had a field day yesterday with the differing ways in which these and related terms were applied, although the accompanying enthusiasm is to be lauded. I've been musing for example on how the means of persuasion differ between a revolution and an evolutionary process. However as interesting as a conceptual analysis would be, I won't pursue this path but I will clarify how I am defining the terms. By revolution I mean a radical and fundamental change, in contrast to evolution, which is a developmental process, although the speed at which the development occurs may be quite rapid; that is I question the position put yesterday that evolution inevitably equates with 'slow'.

Although there is not a consensus as to whether a revolution or evolution, however, defined, is the path to take, we are all agreed that some sort of shake-up is necessary. The outstanding issues listed by Sir Muir Gray4 are ones that resonated I'm sure with everyone in this audience no matter from what part of the world you come: problems such as errors and mistakes, substandard clinical practice and poor patient experience, inequalities and failure to prevent the preventable.

Even suggesting that an evolution is occurring in many countries could well be an optimistic statement. Those of us who are old enough to remember the Alma-Ata Declaration on Primary Health Care for All in 1978, which launched the health for all movement, and who naively believed or at least hoped that this signalled a revolution in healthcare particularly for developing countries, are understandably a little cynical about another revolution. That is not to say that healthcare didn't benefit in some ways in the longer term from that movement but the goal was not achieved, that is, the revolution didn't happen.

Why didn't this fundamental reshaping of healthcare happen? To quote Dr Margaret Chan, Director General of the World Health Organisation: 'The approach was almost immediately misunderstood. It was a radical attack on the medical establishment. It was utopian. It was confused with an exclusive focus on first level care. For some proponents of development, it appeared cheap: poor care for poor people, a second rate solution for developing countries'. And there was, as always, the context in which this vision was to be implemented. What these visionaries could not foresee was: 'the oil crisis, a global recession and the introduction, by development banks, of the structural adjustment programs that shifted national budgets away from the social services, including health' (p. 1).5

Emerging from this analysis there are some lessons to be learnt: the vital role of clear and comprehensive communication of the concept and its application; the need to identify where the opposition will come from, both obvious and not so obvious sources, and planning to neutralise or win over this opposition if possible; plus the need to identify actual and potential threats in the environment by out-of-the-box thinking.

As illustrated by the Health for All movement, one feature of a revolution that is apparent in responses to proposed health reforms in a number of countries is strong opposition from those who benefit from the current status quo. These sources of opposition are usually, if not always in very influential or powerful political positions. Witness the defeat of what in reality were relatively small decreases in reimbursement for procedures for a group of medical specialists by the Senate of the Australian Parliament recently. Another example is the vehement opposition in the USA to some form of national health insurance to protect the uninsured, led we understand by insurance and pharmaceutical companies. The rest of the world looked on totally bemused by the misinformation being promulgated by these groups about health care in countries with a national insurance program of some sort.

Healthcare reform is a very multifaceted beast and takes on varying emphases and forms in different countries. But evidence-based practice or evidence-informed practice seems to be a stated common element internationally now in word if not in deed, albeit the degree of understanding and rate of implementation varies depending on leadership, knowledge and resources within countries. But will this principle of care survive or is it just another passing fad that will disappear like many others have in the past? Will it continue to 'be around' but be eclipsed by something else in terms of priorities or interest? Or will it be maintained as one of the essential, upfront elements of healthcare?

I might well be a very good example of a brainwashed disciple but I now have great difficulty imagining not using the best available evidence to inform the care one delivers. Not that that is the only basis for care, but it is an essential one in company with ethics, professional codes of conduct, safety, etc.

But to be a revolution the fundamental change has to happen and in turn become the prevailing norm. At that point Stewart's claim that revolutions never go backwards might hold. The illustration in one of the articles in the latest PACEsetterS of the painting from the French Revolution of 'Liberty leading the people' against a background of destruction reminds us that one essential element of a revolution is the extinction of what currently exists in order to replace it with the objectives and outcomes of that uprising or radical change. This radical change is not necessarily brought about by violent physical means but even in the area of science Kuhn6 argued that the replacement of one conceptual world view with another involves 'intellectually violent' revolutions.

Have the 'old' ways been extinguished? We wish, but we have to answer 'no' to that question. If I can again borrow from Muir Gray's4 Knowledge into Action list of problems, one of these is the failure to maximise value as a result of waste and overenthusiastic adoption of interventions of low value and failure to get new evidence into practice. We can add to that: 'failure to get existing evidence into practice'. What evidence do we have to support this statement? Professor Runciman7 provided that evidence in the previous session. Estimates of patients who fail to receive the best evidence care in some developed countries range from 30% to 50% while 20-25% of care provided is either not necessary or potentially harmful. And of course to receive care informed by evidence you have to actually be able to access healthcare.

In respect to Nursing I agree with Alison Kitson's assessment: 'Nursing is still struggling to achieve connectivity between research, education and practice' (p. 12).8 I think in the last decade as a discipline we have made great strides but there is still a long way to go before nursing care universally reflects best available evidence. In my more pessimistic moments I think that winning more ground in the next decade will be harder than in the first 10 years. Why? The innovators and early adopters in Nursing are now on board; the ones still to incorporate evidence into their care arsenal will be the harder nuts to crack for variety of reasons. Some of these reasons may be easier to address than others but some will not have a quick or easy solution. Among the latter I would include negative attitudes to anything new; the budget-driven decisions to replace registered nurses with much care cheaper assistants (despite the availability now of sound evidence of the negative impacts on a number of patient outcomes); and what I call those who regard nursing as an occupation - 'don't bother me with all this new jargon, I just want to get my tasks done and go home'; 'when I was training we were taught to do "X" and I can see no reason to change anything' - in contrast to a profession. Several speakers yesterday indicated that other health disciplines face similar challenges.

I found a quote from Sister Elizabeth Kenny9 the other day that for me has relevance here. For those in the audience who don't recognise the name, Sister Elizabeth Kenny was an Australian who developed a radical and at the time a very controversial method of rehabilitating children with polio in the 1930s using heat, hydrotherapy and intensive exercising of affected muscles. Her methods were derided by the majority of the medical profession in this country. In 1940 she was forced to move to the USA so she could continue to provide the care that demonstrated far more positive outcomes than did the then conventional method of treatment of prolonged immobilisation in plaster casts. By all reports she was a very direct woman as this quote illustrates: 'Some minds remain open long enough for the truth to not only enter but to pass on through by way of a ready exit without pausing anywhere along the route'.9

This may be a somewhat jaundiced view but from my observation while there are some pockets of excellence and considerable progress being made in others in the use of evidence to inform practice, there is still a long way to go before the war is won.

So to return to my initial question, do the JBI and its related Collaboration or more generally organisations whose raison d'etre is evidence translation, transfer and/or utilisation, which for short we'll call EOs - evidence organisations, have a future and what might that look like?

I think it is reasonable to assume that evidence-based care will not be something that passed in the night so in turn we can assume we have a future. However we will need to constantly evolve as healthcare evolves, or alternatively, to remain in the forefront of the revolution. This brings to mind a line in a play currently on the stage in Sydney: 'Empires rise, Empires fall. And we play out our little lives in their shadows.'10 At the rate the JBI/JBC is currently growing the term 'empire' might be considered by some to be rather apt; we are rapidly colonising the world!! I think I am on safe ground when I say the sun never sets in the Joanna Briggs Collaboration!! Together with the Cochrane Collaboration to which its own adherents often half jokingly refer to as having a religious tenor (as might well the JBI), what hope does healthcare have to resist conquest!!

But to return to a more serious consideration of the characteristics that we currently demonstrate that would or could provide a solid base for the future.

Size can be both a positive and a negative. Being large can mean that a wide variety of skills, creativity, and the like are available to be tapped into, and the aggregated power and energy has the potential to be awesome. Being large and having tentacles that penetrate into many corners of the world has to be a plus from the perspective of the communication and penetration of the message. But that potential has to be unleashed, activated, operationalised, and just as importantly the momentum generated maintained.

This brings to mind a news report I was watching a month or two ago on the Square Kilometre Array or what we call the SKA for short. This reference is probably totally meaningless to most of this audience unless you are into radio astronomy or live in the isolated Murchison region of Western Australia. The SKA is the biggest radio telescope ever to be built with a collecting area two orders of magnitude larger than current technology. It will be built in an isolated radio quiet zone in either Australia or South Africa. Its reach and prodigious computing power will allow new galaxies to be identified on the outer regions of the cosmos, to seek an answer to the age old question - is there intelligent life out there, and the means to test Einstein's general relativity theory in depth (no pun intended). The prediction is that this project will, in the longer term, have a major societal impact.11,12

What, you may well ask, is the relevance of this to evidence-informed practice? The proponents of this massive project were thinking big, not just small incremental steps but one giant leap. They built on the legacy of innovations in radio astronomy and computing and no doubt a number of other disciplines. And there has been significant collaboration between large numbers of scientific organisations and universities across the globe. Given the work that is already occurring at the SKA site at Boolardy station in the Murchison and the rate at which it is progressing, the assumption can be made that this collaboration has so far been very productive. Perhaps the definition of collaboration provided yesterday - suppression of mutual loathing - doesn't operate in astronomy!!

Thinking big has been a feature of a number of the leaders of the organisations working towards universal adoption of evidence-informed practice, although it took some time to get the foundations or legacy in place. Although by no means complete, particularly in relation to developing countries' needs - and, as Norman Swan3 demonstrated yesterday, orthopaedics, the evidence base available is now quite large and growing. Have we, however, been 'thinking big' when it comes to the implementation component? I suggest not. Does this component need cooperation and coordination, development of a joint action plan at an international level among the relevant organisations? Do we need the modern day equivalent of a Rosetta stone to assist with the translation into the world of practice? Are there other possible solutions?

Collaboration between EOs already occurs but is it sufficient and is it productive? I suggest we have only put our big toe in the water. Not that we have burnt our toe by doing so but the depth of collaborative activity is still superficial and tentative in most cases, if we take Cochrane and JBI as an example. Is collaboration in and of itself sufficient?

It is common to see the concepts 'collaboration' and 'partnerships' used as synonyms. Although both involve 'working with', I regard the latter that is partnerships, as a more solid, more formal, longer-term relationship between, in this case, consenting organisations. Successful partnerships generate mutual benefits to the parties involved. They require two-way trust and goodwill; sharing of knowledge, skills and learning. They involve time and resources and commitment to develop and evolve.

According to the editors13 of several of the world's top management journals in a recent article, the future is all about partnerships - they are the key to surviving and thriving. Organisations can no longer work effectively in isolation. They see partnerships as the means to increase innovation.

Would productive partnerships or collaboration between the EOs be sufficient to achieve the goal of universal enactment of evidence-informed practice? Or do we need to consider going one step further - merging into one organisation? This would certainly give the movement, for want of a better word, significant size and market penetration to use that popular term. The potential synergies could result in increased creativity and output. But as always there are the negative impacts to consider. The smaller organisations might feel they have been taken over and become junior members rather than being equal partners. The strengths of some of the organisations might be lost and/or the commitment of members might be negatively affected in the larger structure. These are not inevitable impacts but the risks would need to be carefully analysed and assessed.

Setting those perhaps controversial thoughts aside, let's return to more immediate issues. What might we need to make a significant difference in the rate of adoption of evidence to inform practice? Two things come to mind immediately. The SKA Project has literally bucket loads of resources being provided to it, both in terms of highly knowledgeable and skilled people, and funds. The evidence organisations have the people. However, with some notable exceptions, what we don't have is a significant amount of readily available funding. The majority of the work in translating and transferring evidence seems to be done by committed people working in their own time. What can be done to convince funding bodies to direct significant resourcing to this work? Are we being sufficiently political, are we marketing the need well enough - are we marketing at all? Are we pressing the right buttons?

Particularly right now, funds are limited. Are there areas of duplication or less urgent areas of research needs from which resources can be redirected? I was taken aback a few months ago when I was interviewed for a grant to undertake a systematic review. The panel asked why we weren't developing clinical guidelines for nurses working in rural areas instead of doing systematic reviews. In response I pointed out that there were numerous clinical guidelines developed by reputable organisations either freely available on the web or for the cost of a small membership fee, that could, with permission, be suitably modified for their rural context. Alternatively the major hospitals in the state would in all likelihood be more than happy to provide access to their practice guidelines. Several examples of a move to develop national guidelines in particular areas of care and then adapt for local contexts have been discussed at this conference. However there are numerous examples that I am sure we could all provide of where agencies start everything from scratch.

If we are going to transform care providers, approaches to care, the culture in which that care is provided, and the systems and processes that support that provision, we will need leaders with those qualities and skills. In this country at this time I suggest we would be hard pressed to find transformational leaders in the higher echelons of the healthcare system. Those we had have fled from a system dominated by what we refer to as the 'bean counters' or more formally the financial controllers, of which we have an abundance. Hopefully there are some within healthcare agencies at lower levels of management who have the freedom to enthuse and inspire their staff, to re-enchant them with safe, quality patient care. These leaders, if we are fortunate enough to find and keep them in the system long enough to effect the required fundamental change, will need support. While having particular strengths, transformational leaders also have areas in which they are often not so strong. They tend to see the big picture but are not into detail. Others with an eye for detail can play a role here.

Returning to home base, be it revolution or evolution, what must remain a constant through all this is the achievement and maintenance of quality in all we do and all we produce. I think this is the major challenge for the JBI and JBC. How we manage that as the JBC grows at an expediential rate is a question that should be constantly exercising our minds. We also need to constantly tend to 'the glue' that keeps us all involved in this organisation; that keeps us together across the many kilometres and cultures. We don't want the Empire to fall!!

I am mindful of one of Peter Cosgrove's (p. 9)14 two phobias. Peter is a very down-to-earth, former Chief of Australia's Armed Services who served with distinction in a number of overseas missions, including East Timor. In his words this phobia is of 'speakers who rabbit on too long - well, life is too short'!! Thank you - and as one of my favourite Australian comedians says every Thursday night at 8 pm on the ABC: 'Good to be with you'.15

References