A presentation about recent research and development in EBP teaching

1. Danielle Hitch
INSTRUCTIONAL PRACTICES
FOR EVIDENCE-BASED
PRACTICE WITH PRE-
REGISTRATION ALLIED
HEALTH STUDENTS:
A REVIEW OF RECENT
RESEARCH AND
DEVELOPMENTS

2.  Evidence based practice (EBP) is an imperative in heath
 Introduced to novice clinicians in their pre-registration
training
 Range of challenges to EBP in both university and healthcare
setting
 How do we translate classroom acquired understandings to
the very real (and very messy) world of clinical practice?
INTRODUCTION

3.  The aim of this study is to update a previous review on the
effectiveness of teaching and assessment interventions for
evidence based practice in health professions (Thomas et al.,
2011).
 This study also aims to analyse the extent to which the
recommendations made as a result of that review have
emerged in teaching practices.
AIM

4.  Based on literature published up until the end of 2010.
 Aimed to develop a pedagogically sound approach that
incorporated EBP into all aspects of allied health curriculum, as
a means of embedding it into the daily practice of clinicians.
 Reviewed the epistemological foundations of EBP and suggested
a social constructivist approach to the knowledge, beliefs and
attitudes inherent in EBP.
 Argued persuasively for the integration of clinical experience and
structured reflection as a core feature of effective EBP units.
 Reviewed evidence around the effectiveness of existing teaching
and assessment interventions for research methods and
evidence based practice in allied health. Noted the quality of the
evidence base to that point was relatively poor and could be fully
relied upon for translation into practice.
THOMAS ET AL., (2011)

5. 1. Consider the learner’s existing knowledge, beliefs and
attitudes about evidence based practice
2. Understand the salient role of social negotiation and
collaboration with peers in incorporating evidence in clinical
decision making
3. Acknowledge that the learning situations, content and learning
activities are meant to foster self-analysis, problem-solving,
higher-order thinking and deep understanding; as such, they
must be relevant, authentic and represent the natural
complexities of the world
4. Support collaborative learning which exposes students to
alternative viewpoints and affords them the opportunity for
apprenticeship learning
5. Scaffold learners from what is presently known to what is to be
known, thereby facilitating the learner’s ability to perform just
beyond the limits of current ability
FIVE RECOMMENDATIONS

6.  The ITEA (integrating theory, evidence and action) method
 Developed to allow the integration and synthesis of a range of
evidence, which originates from a range of inquiry traditions
 Seven steps, which are describe fully in Hitch, Pepin &
Stagnitti (2014)
METHOD OF THIS STUDY

7. Step Description of Step Current Study
1 Clinical / critical question: Choose a
clear, concise question which will be
addressed
Does the peer reviewed evidence
published about teaching research
methods and evidence based
practice between 2011 and 2015
reflect the pedagogical
recommendations of Thomas,
Saroyan and Dauphinee?
2 Framework: Choose a suitable
theory or model in which to embed
the evidence
Five recommendations for
instructional design about evidence
base practice for allied health
professionals
METHOD OF THIS STUDY

8. Step Description of Step Current Study
3 Identification: Define the
methodology and data required to
answer the clinical/critical question
Integrated review of literature.
Search Terms – evidence based
practice, evidence, research,
research methods, allied health, pre-
registration
Inclusion criteria – 1) Evidence
published in peer reviewed journal, 2)
Published between 2011 and 2015,
3) Published in English and 4)
Addressing pre-registration allied
health education
Exclusion criteria – 1) Evidence
related to medical or nursing
education and 2) Anything outside of
the identified inclusion criteria
METHOD OF THIS STUDY

9. Step Description of Step Current Study
4 Deconstruction: Sort and classify
data into the conceptual categories
of the chosen model
All data from identified evidence was
classified according to one of the five
recommendations
5 Analysis: Critically analyse collected
evidence, both at an individual
source level and collectively under
the theoretical concepts
Each article was individually critiqued
and provided a level of evidence from
either the NHMRC Evidence Hierarchy
(National Health And Medical
Research Council, 2000) or the
Rosalind Franklin Qualitative
Research Appraisal Instrument (RF-
QRA) (Henderson and Rheault, 2004).
All evidence for each of the five
recommendations was then analysed.
METHOD OF THIS STUDY

10. Step Description of Step Current Study
6 Reconstruction: Rebuild the data
into a coherent whole using the
chosen theoretical concepts
Evidence is correlated, consolidated
and compared before being
formulated into a prose statement
addressing the clinical/critical
question.
7 Transfer and Utilisation: identify the
ways in which the evidence can be
applied to practice and future
research
Evidence statements was the subject
of reflection and colleague
consultation, before a plan for
transfer and utilisation was made.
METHOD OF THIS STUDY

11.  Seventeen studies from universities around the world
 Broad range of allied health disciplines represented, with PT
(n=8, 47%) and OT (n=5, 29%) the most often included.
 Many studies (n=6, 35%) only provided a narrative of
initiatives or theoretical discussion.
 All quantitative studies (n=9, 53%) used methods of relatively
low rigour methods, including pre-post and descriptive. The
two qualitative studies adopted more rigorous methods.
 Studies tended to investigate only the experiences of students
(n=5, 29%) or teaching staff (n=3, 18%), although two studies
did attempt to triangulate by recruiting participants from both
groups.
FINDINGS

12.  Relatively few studies considered a learners pre-existing skills or
knowledge in evidence based practice
 A general sense that all allied health students begin from a very low basis
of prior knowledge.
 However, most of the evidence relevant to this recommendation discussed
around what knowledge, beliefs and attitudes was considered relevant (or
not) to evidence based practice.
 Competence in conducting research and competence in its use and
translation are not the same thing.
 General perception that allied health students perceive EBP as difficult,
time consuming and irrelevant to their clinical practice, and that these
attitudes are a barrier to their engagement in learning about EBP
 Clinical competencies are deeply rooted in the knowledge, beliefs and
attitudes developed prior to practice and tend to persist throughout
careers.
LEARNERS EXISTING KNOWLEDGE,
BELIEFS AND ATTITUDES

13.  Diverse views within the studies around whether social negotiation and
collaborative clinical decision making is present in current
instructional practices for EBP with allied health students.
 Several authors highlighted the lack of instructional practices which promote the
same skills with patients or clients, which is a major omission.
 The teaching of how to effectively communication evidence in ways that support the
understanding and engagement of clients and other non health professionals (such
as carers, funders and the wider community) is a recognised gap in current practices
 Methods currently being used to promote social negotiation and
collaborative decision making included
 group assignments
 the sharing of reading lists
 small group case discussions
 group activities around journal articles
 journal clubs
SOCIAL NEGOTIATION AND
COLLABORATIVE DECISION MAKING

14.  The recommendation with the strongest uptake, which is unsurprising given
the adult learning context of university education
 Outcomes for undergraduate allied health students are limited to changes in
potential clinical behaviours – the instructional practices are assessed only in
the university context and their translation to practice is not assured.
 Methods currently being used to provide relevant and authentic learning
included
 professional poster presentations and simulated research projects
 application of pre-appraised evidence
 production of EBP evaluations for community programs
 dialoguing about client diversity
 guest speakers and panel discussions
 Assignments embedded in or utilising case studies
 Extended assignment to transform students into EBP champions
RELEVANT AND AUTHENTIC LEARNING

15.  The idea of an ‘apprenticeship’ approach to EBP is related to the
process of lifelong learning in several of the studies.
 Relationships with librarians were regularly identified as a source of
valuable support and sustainable engagement in EBP
 Several problematic aspects of the collaborative learning and
apprenticeship are also identified in the partnerships that students are
likely to make with clinicians, who are often reluctant, ambivalent or
resistant to embed EBP regularly into practice
 Providing students with resources to sustain their EBP after graduation
from university was also recommended – information about reputable
free databases, lists of key research journals relevant to the discipline
and explicit linking of the EBP instructional practices to graduate
attributes
COLLABORATIVE LEARNING

16.  Near universal agreement in the evidence that allied health students
should be introduced to EBP as early as possible in their professional
education
 A number of articles described an EBP curriculm that was embedded in
all years of an allied health course, building skills each year and
including regular refresher classes and planned redundancy
 The process approach is preferred to the specialist approach, where
students are given the skills to conduct EBP rather than being taught
the specific evidence relevant to their profession
 A common trajectory through allied health courses is to begin with
basic EBP concepts, and work through clinical scenarios of increasing
complexity until the students complete a capstone project
 Current scaffolding practices also do not always address all five stages
of EBP identified in the Sicily Statement on Evidence Based Practice
 Asokan (2012) has recently proposed competencies related to each of
the five stages, which could provide a framework for scaffolding
students’ progression towards competence in each of these areas.
SCAFFOLDED LEARNING

17.  There remains a lack of rigour and methodological issues in the evidence
around instructional practices for EBP with allied health students, and it
remains mostly exploratory and descriptive in nature. The effectiveness of any
of the instructional practices identified is therefore yet to be rigorous tested,
which has implications for its implementation into educational practice.
 Several documents outlining the competencies required for EBP are available
(e.g. Asokan, 2012, Dawes et al., 2005), but the lack of uptake suggests they
may not meet the needs of all of the diverse disciplines that make up allied
health.
 The omission of ‘skills’ from Thomas et al.’s (2011) first recommendation is
also curious, given that must of the published evidence focuses on the
performance of tasks such as using databases and critiquing articles.
 Given the widening participation agenda in higher education globally (Gale,
2011) and the requirement of higher degrees for registration in some allied
health professions (Royeen and Lavin, 2007), students are entering allied
health profession courses with more diverse prior knowledge than previously. It
is therefore increasingly possible that students will already have some skills in
EBP, and not addressing these would lead to inappropriate scaffolding and
potential de-motivation.
REFLECTIONS

18.  Instructional design to promote social negotiation and collaborative
decision making does appear to have been implemented in some areas,
but this constructivist approach to EBP is not broadly prevalent.
 The limiting of negotiation and collaboration to colleagues in the
health professions is a potential barrier to students developing EBP
knowledge, skills, beliefs and attitudes. Allied health professionals
must be able to describe and justify their chosen assessments and
interventions to patients and clients (and others) to fulfil their ethical
obligations and professional values (Rozas and Grady, 2011).
 EBP findings and information must also be communicating differently
for different audiences (Torrey et al., 2001), while this skill is
addressed in existing competency statements, it is rarely taught to
students. However, without a grounding in communication skills for
these different audiences, the outcomes of the EBP process are
unlikely to be disseminated.
 While there are many methods being employed to ensure students
learning about EBP are authentic and relevant to clinical practice, the
observation from several authors about the limited reach of university
teaching is a sound one.
REFLECTIONS

19.  An allied health student could receive a comprehensive grounding in
EBP, but not be able to deploy their knowledge and skill post
graduation due to workplace culture. This undermines the fourth
recommendation, which proposed the creation of opportunities for
apprenticeship learning, if that learning is considered to be lifelong.
 If students continue to have access to library services post graduation,
the apprenticeship style of learning could be maintained, but this is not
always the case.
 The use of scaffolding appears to be widespread in instructional
practices for EBP with allied health students, and embedded
approaches are far more common than stand-alone. However, while the
teaching methods are scaffolding across the multiple years of each
course, they are not structured according to all five stages of EBP as
identified in the Sicily Statement (Dawes et al., 2005).
 There could be a ‘ceiling effect’ when only the first three steps of EBP
are covered, so the inclusion of the final two steps might allow more
senior students to continue their development.
REFLECTIONS

20.  The five recommendations made by Thomas et al. (2011) have been
implemented into practice in pre-registration allied health courses to a
varying degree. The social constructivist approach to EBP for allied
health students is being implemented, but prior knowledge of students
is not being assessed as a basis for scaffolding, communication of EBP
to varying audiences is rarely addressed and the impact of clinicians on
the learning of EBP knowledge, skills, beliefs and attitudes remains
problematic.
 Future research and development in this area should therefore
 Include more rigorous methods
 Include greater involvement of clinicians and patients or clients in the teaching of
EBP
 Investigate the poor uptake of existing resources (such as the established
competencies across all five steps of EBP)
 Include a periodic review of the literature addressing instructional design for EBP,
to track changes in practice around the world and provide momentum for
continuing improvement.
CONCLUSION

21.  Danielle Hitch
Lecturer in Occupational Therapy
Waterfront Campus
 dani.hitch@deakin.edu.au
THANKS