Imagine you are a visitor in a strange city and you need a taxi to take you to your hotel. Your taxi driver will ask you where you want to go, and sometimes (at least in Adelaide) they will suggest different routes. One may be the quickest but not necessarily the cheapest; the other will be the shortest distance and logically the cheapest. You are not surprised when they type your details into the electronic map finder in the car and you are reassured that they are using the latest, up-to-date technology to get you to your destination.
Now imagine the same scenario: you get into the taxi and when you ask the taxi driver to take you to your destination, he pulls out a very old dog-eared A to Z city map, which you can see by the cover is a 1999 edition. He spends several minutes searching for the right page and then asks you whether you have ever been to this hotel before. There is no sign of the latest technology in the taxi and by this time you are beginning to doubt the ability of the driver to get you to your destination and if he can, it is likely not going to be the quickest route. He is very charming and asks you whether you are comfortable in the back of the taxi; but somehow, you have a feeling that this journey might not be as straightforward as you want it to be.
We all probably have had experiences like this. And we all come away from them making a judgement about the ability of the taxi driver to execute his job safely and effectively, views about the company policy on providing drivers with the most up-to-date kit to do their job and then finally a view about the actual experience.
So if we are able to make judgements like this in our own lives on a daily basis, do we not think the people who use our health services are not making the same sort of judgements about our ability to navigate them through a complex journey? Consider a patient who is admitted to a surgical unit for a routine procedure. When they discuss their ‘journey’ are the ‘drivers’ using the equivalent of the electronic route finder or are some of them still using the 1999 A to Z edition of the city map? What will the experience of the patient be if several routes are suggested by several potential drivers, all using slightly different maps?
Considering healthcare delivery in this way does accentuate the need for health professionals to view it as a journey and as something we contribute to as part of another person's life experience. It is not us who are going on the journey. We are the agents that are responsible for safely and effectively transitioning the patient from one metaphorical and literal stop to another in their life. Why would we want to unnecessarily complicate, prolong or frustrate their journey by using the wrong map or not knowing the most up-to-date routes we need to take in order to get them to their destination? Why take them up an alley that has long been condemned as unsafe and inappropriate just because we have always taken that route?
It does not take a lot of working out to see that the taxi driver analogy relates to our healthcare industry's challenge to ensure all the ‘drivers’ in the ‘firm’ are equipped with the essential tools to do their jobs. The first, most fundamental criterion would therefore have to be easy access to the health route map. If we are able to provide taxi drivers with electronic gadgets and airline passengers with an infinite selection of ‘seat side’ electronic entertainment, should we not be a bit more proactive in ensuring that every healthcare professional has the same access to clinical information that helps them keep on the right route? Not every taxi driver is expected to know every street and lane of a city; similarly we do not expect every healthcare professional to have memorised every condition and complex case they are going to meet. So, we need appropriate, up-to-date, reliable, usable information at our fingertips, in real time and in a form that is user-friendly to the busy clinician.
These information delivery challenges surround our activities in getting evidence into practice. The Joanna Briggs Institute has long been an advocate of trying to bring inexpensive, reliable technology to frontline staff. However, it is clear when listening to the experiences of nurses and healthcare workers around the world that there is huge variation in issues of access to the internet and reliable use of electronics. This should not deter us from having an over arching vision of one day having the capacity to ensure that all patients wherever they are treated will have access to the best care that is based on the best available evidence. And not only evidence of clinical interventions but increasingly evidence around patient education, self-care and aspects of care that are undertaken by nurses and carers every day all over the world, what we call the fundamentals of care.1
As discussed in a recent editorial by Pearson2 and followed up by a letter by Stevens and Willard,3 the need to ensure easy access to best available evidence is the first step to transforming patient care. Both Pearson and Stevens identify the need for such information to be readily available in a form that can be used and networked between colleagues. But of course having the information does not necessarily mean that one will choose to use it. To continue the analogy, you can have your electronic map finder in the car but still choose to use the 1999 map. Now if the map still gets you to your destination surely that is okay? But what about the cost and the effectiveness of the care you have just delivered? These are questions that also need to be asked. As clearly articulated in Cornelissen et al.'s4 commentary in this issue:
regardless of the perspective taken, delivery of up to date, safe and effective care requires useful, relevant knowledge available when necessary and applicable to real life issues as perceived, critically by the knowledge end user.
Cornelissen et al. acknowledge the agency of the practitioner to exercise ultimate judgement as to how to access the relevant information and how to use it. This is as it should be but we also need to consider the broader systems and technological resource issues that may augment such decisions and spread the information round the system.5 It is one thing to argue for the primacy of individual clinical judgement but it is another thing to ensure that the system is designed to support the level of independent and autonomous decision-making.
However, it would be rather naive to think that we have reached a point in our understanding of implementation science or getting evidence into practice where we understand how to turn evidence into action. Stevens' new network is an acknowledgement that despite several years' labour around quality improvement and safety initiatives, we are still trying to work out how front line staff can consistently and continuously provide care that is based on the best available evidence. What we do know is that it is difficult, context sensitive, dependent upon a number of relational and personal dynamics and requires clear leadership at several levels of the organisation.6 What we are also discovering is that participation in a process does not necessarily mean that staff are then committed to implementation or improvement. Indeed, as inferred by Stevens, successful implementation of evidence does not necessarily imply improvement in patient care.
But the knowledge translation (KT) science community is making progress. Chan et al.7 in this issue have described an implementation project that has used the Titler Model8 to implement oral hygiene care for dependent adults. The Titler Model is one of several9–11 that can be used by front-line staff. Consider these models to be the same as different brands of cars – Ford, Holden, Ferrari and Toyota. They all have the same basic ingredients (wheels, engines, bonnets, etc.) but they differ in their design and style. So too, consider the basic ingredients of the implementation models. They all start off with identifying the trigger (gap, issue, problem, areas for improvement); they require a team and a lead; a method for finding and refining the evidence; a way of translating the evidence into a standard for local practice; an audit process; a plan to respond to any shortfalls between the actual practice from the observed practice; a re-audit or re-evaluation and a final period of consolidation. However, we know that if the elements are not ‘switched on’, that is, we do not start the engine, nothing works. So what is the KT equivalent of the ignition and the petrol in the engine?
Just like the competition between car manufacturers we could be seeing an increase in competition between different KT models, one out claiming the other in terms of performance or effectiveness. If we get into this space we are missing the point: the point is that by using the model as the literal and metaphorical vehicle you get from one spot to another. Most models do the same job; the skill is in the way the driver handles the machinery. Have you got enough fuel in the tank? Do you have sufficient room for the team? And do you know where you are going? Have you got your electronic map and is the log book up to date?