Evidence-based exercise teaching for healthcare professions: an expert view

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  1. Elaine Lehane1,
  2. Patricia Leahy-Warren1,
  3. Cliona O'Riordanone,
  4. Eileen Savage1,
  5. Jonathan Drennan1,
  6. Colm O'Tuathaigh2,
  7. Michael O'Connorthree,
  8. Mark Corrigan4,
  9. Francis Shush5,
  10. Martina Hayes5,
  11. Helen Lynchvi,
  12. Laura Sahm7,
  13. Elizabeth Heffernanviii,
  14. Elizabeth O'Keeffe9,
  15. Catherine Blake10,
  16. Frances Horgan11,
  17. Josephine Hegarty1
  1. i Catherine McAuley School of Nursing and Midwifery, University College Cork, Cork, Ireland
  2. two School of Medicine, University College Cork, Cork, Ireland
  3. iii Postgraduate Medical Grooming, Cork University Hospital/Royal College of Physicians, Cork, Ireland
  4. four Postgraduate Surgical Preparation, Breast Cancer Centre, Cork Academy Infirmary/Regal College of Surgeons, Cork, Ireland
  5. five School of Dentistry, University College Cork, Cork, Ireland
  6. 6 Schoolhouse of Clinical Therapies, Academy College Cork, Cork, Republic of ireland
  7. vii School of Chemist's shop, University College Cork, Cork, Ireland
  8. viii Nursing and Midwifery Planning and Evolution Unit of measurement, Kerry Middle for Nurse and Midwifery Education, Cork, Ireland
  9. 9 Symptomatic Breast Imaging Unit, Cork University Hospital, Cork, Republic of ireland
  10. 10 School of Public Health, Physiotherapy and Sports Science, University Higher Dublin, Dublin, Ireland
  11. 11 School of Physiotherapy, Majestic Higher of Surgeons in Ireland, Dublin, Republic of ireland
  1. Correspondence to Dr Elaine Lehane, Catherine McAuley School of Nursing and Midwifery, University College Cork, Cork T12 K8AF, Ireland; e.lehane{at}ucc.ie

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  • qualitative inquiry

Introduction

To highlight and advance clinical effectiveness and evidence-based practice (EBP) agendas, the Constitute of Medicine set a goal that past 2020, xc% of clinical decisions will be supported by authentic, timely and up-to-date clinical data and will reflect the best bachelor evidence to achieve the best patient outcomes.1 To ensure that future healthcare users can exist bodacious of receiving such care, healthcare professions must effectively incorporate the necessary knowledge, skills and attitudes required for EBP into educational activity programmes.

The promotion of EBP requires a healthcare infrastructure committed to supporting organisations to evangelize EBP and an teaching system efficient in supporting healthcare professionals in acquiring EBP competencies.2 To this end, healthcare education programmes must effectively implement curricula that target these competencies.three To facilitate this, the Sicily consensus statement on EBP provides a description of core knowledge and skills required to practise in an prove-based manner and a curriculum that outlines the minimum requirements for educating health professionals in EBP.two Initiatives such equally the European Union Show-Based Medicine project4 and EBP education programmes for educators facilitated by Oxford (Heart for Evidence-Based Medicine) and McMaster Universities provide support in advancing the EBP calendar within healthcare education. Over the past two decades, more than 300 articles accept been published on didactics show-based medicine alone and in backlog of thirty experiments take been conducted to measure its furnishings.5 Recent reviews3 vi evaluating the adoption of show-based recommendations for teaching EBP however point to poor uptake of existing resources available to guide EBP education.

The application of EBP continues to exist observed irregularly at the bespeak of patient contact.two 5 7 The effective development and implementation of professional educational activity to facilitate EBP remains a major and immediate claiming.2 3 half-dozen 8 Momentum for continued improvement in EBP education in the course of investigations which can provide direction and structure to developments in this field is recommended.6

As role of a larger national project looking at current practice and provision of EBP education across healthcare professions at undergraduate, postgraduate and standing professional development programme levels, we sought cardinal perspectives from international EBP pedagogy experts on the provision of EBP education for healthcare professionals. The two other components of this study, namely a rapid review synthesis of EBP literature and a descriptive, cross-sectional, national, online survey relating to the current provision and practise of EBP education to healthcare professionals at third-level institutions and professional person preparation/regulatory bodies in Ireland, will exist described in later publications.

Methods

EBP expert interviews were conducted to ascertain current and nuanced information on EBP education from an international perspective. Experts from the Uk, Canada, New Zealand and Commonwealth of australia were invited by email to participate based on their contribution to peer-reviewed literature on the discipline area and recognised innovation in EBP instruction. Over a 2-month period, individual 'Skype' interviews were conducted and recorded. The interview guide (online supplementary appendix A) focused on current practice and provision of EBP education with specific attention given to EBP curricula, core EBP competencies, assessment methods, educational activity initiatives and key challenges to EBP education within respective countries. Qualitative content assay techniques equally advised by Bogner et al ix for exam of good interviews were used. Specifically, a six-step procedure was applied, namely transcription, reading through/paraphrasing, coding, thematic comparison, sociological conceptualisation and theoretical generalisation. To ensure trustworthiness, a number of practices were undertaken, including explicit description of the methods undertaken, participant contour, all-encompassing use of interview transcripts by way of representative quotations, peer review (PL-Due west) of the information analysis procedure and invited interviewees to feedback in relation to the overall findings.

Supplementary file 1

Results

Five EBP experts participated in the interviews (table 1). All experts waived their right to anonymity.

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Table 1

EBP education expert contour

Three main categories emerged, namely (1) 'EBP curriculum considerations', (2) 'Teaching EBP' and (3) 'Stakeholder engagement in EBP teaching'. These categories informed the overarching theme of 'Improving healthcare through enhanced teaching and awarding of EBP' (figure 1).

EBP curriculum considerations

Definitive advice in relation to curriculum considerations was provided with a articulate accent on the need for EBP principles to exist integrated throughout all elements of healthcare professions curricula. Educators, regardless of didactics setting, need to exist able to 'draw out evidence-based components' from any and all aspects of curriculum content, including its incorporation into assessments and examinations. Integration of EBP into clinical curricula in particular was considered essential to successful learning and practice outcomes. If students perceive a dichotomy between EBP and actual clinical intendance, then "never the twain shall come across" (GG) requiring integration in such a fashion that information technology is "seen as part of the basics of optimal clinical care" (GG). Situating EBP as a cadre element within the professional curriculum and linking it to professional accreditation processes places further accent on the necessity of didactics EBP:

…it is also core in residency programmes. So every residency programme has a curriculum on evidence-based exercise where once again, the residency programmes are accredited…They have to show that they're pedagogy evidence-based do. (GG)

In terms of the focus of curriculum content, all experts emphasised the oft-cited steps of asking questions, acquiring, appraising and applying bear witness to patient care decisions. With regard to identifying and retrieving data, the post-obit in particular was noted:

…the key competencies would be to identify evidence-based sources of information, and one of the primal things is there should exist no expectation that clinicians are going to get to primary research and evaluate principal research. That is simply not a realistic expectation. In teaching it…they accept to be able to place the pre-processed sources and they take to exist able to sympathize the bear witness and they accept to be able to utilise it… (GG)

In improver to attaining proficiency in the central EBP steps, developing competence in communicating evidence to others, including the patient, and facilitating shared decision-making were also highlighted:

…So our ability to communicate risks, benefits, understand doubtfulness is so poor…that'southward a key area we could improve… (CH)

…and a big emphasis [is needed] on the applicability of that information on patient care, how practice y'all use and share the decision making, which is becoming a bigger and bigger bargain. (GG)

Information technology was suggested that these EBP 'nuts' can be taught "from the outset in very similar means" (GG), regardless of whether the educatee is at an undergraduate or postgraduate level. The concept of 'developmental milestones' was raised by one expert. This related to different levels of expectations in learning and assessing EBP skills and noesis throughout a programme of study with an incremental approach to teaching and learning advocated over a course of report:

…in terms of developmental milestones. So for the novice…it's really trying to get them enlightened of what the structure of bear witness-based practice is and knowing what the process of asking a question and the PICO process and learning about that…in their final twelvemonth…they're asked to practise critically appraised topics and relate it to clinical cases…It's a developmental process… (LT)

Teaching EBP

Adoption of constructive strategies and practical methods to realise successful educatee learning and agreement was emphasised. Of item note was the grounding of educational activity strategy and associated methods from a clinically relevant perspective with student exposure to EBP facilitated in a dynamic and interesting manner. The utilise of patient examples and clinical scenarios was repeatedly expressed as one of the most effective instructional practices:

…ultimately trying to become people to teach in a way where they become, "Look, this is actually relevant, dynamic and interesting"…and so we teach them in loads of different ways…you're teaching and feeding the ideas as opposed to ""Here's a definitive course in this way". (CH)

…It'south pretty obscure stuff, just then I get them to practice three examples…when they have done that they have pretty well got their heads around it…I build them lots of practical examples…clinical examples otherwise they think it's all didactic garbage… (BA)

EBP function models were emphasised as beingness integral to demonstrating the awarding of EBP in clinical decision-making and facilitating the contextualisation of EBP within a specific setting/organisation.

…where we've seen success is where organisations have said, "There's going to be two or three people who are going to be the champions and lead where we're going"…the issue about evidence, it'south complex, it needs to be contextualised and it'due south different for each setting… (CH)

It was further suggested that these healthcare professionals have the 'Ten-factor' required of EBP. The conquering of such expertise which enables a practitioner to integrate private EBP components culminating in evidence-based decisions was proposed every bit a definitive target for all healthcare professionals.

And nosotros telephone call it the X factor…the idea is that the clinician who has the X factor is the expert clinician. It's really integrating the bear witness, the patient values, the patient's pathophysiology, etc. It could be behavioural issues, systems problems…Those are the four quadrants and the clinical expertise is virtually integrating those together…You're not actually adding clinical expertise. It seems to me that the clinical expertise is the ability to integrate those 4 quadrants. (RJ)

The provision of training for educators to assistance the farther evolution of skills and utilize of resources necessary for effective EBP teaching was recommended:

…then we cull the option to train people every bit really good teachers and requite them really high level skills so that they can then seed it across their organisation… (CH)

Attaining a disquisitional mass of people who are 'trained' was also accounted important in making a sustained modify:

…and it requires getting the teachers trained and getting enough of them. You don't need everybody to be doing it to make an impression, but yous need enough of them really doing it. (GG)

Stakeholder engagement in EBP didactics

Engagement of national policy makers, healthcare professionals and patients with EBP was considered to accept significant potential to advance its teaching and application in clinical care. The lack of a coherent government and national policy to EBP teaching was cited as a barrier to the implementation of the EBP agenda resulting in a somewhat 'ad-hoc' approach, dependent on individual educational or research institutions:

…there'due south no cohesive or coherent policy that exists…It's non been a consequent approach. What we've tended to see is that people have started going around particular initiatives…only there's never been any coordinated approach even from a college perspective, to say we are about improving the uptake and use of bear witness in practice and/or generating testify in do. And then largely, it's been left to research institutions… (CH)

To further ingrain EBP within healthcare professional practice, it was suggested that EBP processes, whether related to developing, disseminating or implementing evidence, be embedded in a more than structured way into everyday clinical care to promote agile and consequent engagement with EBP on a continuous basis:

…nosotros recollect it should exist embedded into care…nosotros've got to have people beingness active in developing, disseminating and implementing evidence…developing tin come in a number of formats. It can be an audit. Information technology tin can exist almost a practice improvement. It can be about doing some attribute similar a systematic review, only it'southward very clearly shut to healthcare. (CH)

Enabling patients to appoint with testify with a view to informing healthcare professional/patient interactions and intendance decisions was also advocated:

…I recall we really need to put some energy into…this whole idea of patient-driven intendance, patient-led intendance and putting some of these tools in the hands of the consumers then that they're enabled to be able to ask the right questions and to go into an interaction with some background cognition about what treatments they should be expecting. (LT)

If patients are considered as recipients of EBP rather than key stakeholders, the premise of shared controlling for care cannot be achieved.

The implementation of a successful EBP education is necessary so that learners not only sympathise the importance of EBP and exist competent in the primal steps, but information technology ultimately serves to influence behaviour in terms of decision-making, through awarding of EBP in their professional person practice. In essence, it serves the function of developing practitioners who value EBP and have the knowledge and skills to implement such do. The ultimate goal of this agenda is to enhance the delivery of healthcare for improved patient outcomes. The overarching theme of 'Improving healthcare through enhanced instruction and awarding of EBP' represents the focus and purpose of the effort required to optimally structure healthcare professional person (HCP) curricula, promote effective EBP education and learning strategies, and engage with key stakeholders for the overall advancement of EBP didactics as noted:

…we retrieve that anybody in training should exist in the game of improving healthcare…It'south not just saying I desire to exercise some evidence-based exercise…it'southward ultimately about…improving healthcare. (CH)

Discussion and recommendations

Education programmes and associated curricula act as a key medium for shaping healthcare professional person knowledge, skills and attitudes, and therefore play an essential role in determining the quality of care provided.10 Unequivocal recommendations were fabricated in relation to the pervasive integration of EBP throughout the academic and clinical curricula. Such integration is facilitated by the explicit inclusion of EBP as a core competency within professional standards and requirements in addition to accreditation processes.11

Further accent on communication skills was also noted as beingness key to enhancing EBP competency, particularly in relation to realising shared decision-making between patients and healthcare practitioners in making evidence-based decisions. A systematic review past Galbraith et al,12 which examined a 'existent-world' arroyo to show-based medicine in general practice, corroborates this recommendation by calling for farther attending to be given to communication skills of healthcare practitioners inside the context of existence an evidence-based practitioner. This resonates with recommendations by Gorgon et al 13 for the need to expose students to the intricacies of 'real world' contexts in which EBP is applied.

Experts in EBP, together with trends throughout empirical research and recognised educational theory repeatedly, brand a number of recommendations for enhancing EBP teaching and learning strategies. These include (ane) clinical integration of EBP teaching and learning, (2) a conscious try on behalf of educators to embed EBP throughout all elements of healthcare professional person programmes, (3) the use of multifaceted, dynamic didactics and cess strategies which are context-specific and relevant to the individual learner/professional person cohort, and (4) 'scaffolding' of learning.

At a practical level this requires a more than concerted effort to motility away from a predominant reliance on stand up-solitary didactic teaching towards clinically integrative and interactive teaching.10 14–17 An instance provided by one of the EBP experts represents such integrated teaching and experiential learning through the performance of GATE/CATs (Graphic Appraisal Tool for Epidemiological studies/Critically Appraised Topics) while on clinical rotation, with assessment conducted by a clinician in practice. Such an action fulfils the criteria of existence reflective of practice, facilitating the identification of gaps betwixt current and desired levels of competence, identifying solutions for clinical problems and allowing re-evaluation and opportunity for reflection of decisions made with a practitioner. This level of interactivity facilitates 'deeper' learning, which is essential for knowledge transfer.viii Such practices are also essential to bridge the gap betwixt academic and clinical worlds, enabling students to feel 'real' translation of EBP in the clinical context.half-dozen 'Scaffolding' of learning, whereby EBP concepts and their awarding increase in complexity and are reinforced throughout a program, was also highlighted equally an essential instructional approach which is in keeping with contempo literature specific both to EBP instruction and from a broader curriculum development perspective.three 6 18 19

In addition to addressing challenges such every bit curriculum system and programme content/structure, identifying salient barriers to implementing optimal EBP instruction is recommended as an expedient approach to effecting positive change.20 Highlighted strategies to overcome such barriers included (1) 'Training the trainers', (2) development of and investment in a national coherent approach to EBP education, and (3) structural incorporation of EBP learning into workplace settings.

National surveys of EBP education delivery21 22 establish that a lack of academic and clinical staff knowledgeable in instruction EBP was a barrier to effective and efficient student learning. This was echoed past findings from EBP skilful interviews, which correspond with assertions by Hitch and Nicola-Richmond6 that while recommended educational practices and resource are available, their uptake is somewhat express. Constructive teacher/leader education is required to improve EBP instruction quality.10 16 23 24 Such formal training should extend to bookish and clinical educators. Supporting staff to have confidence and competence in teaching EBP and providing opportunities for learning throughout education programmes is necessary to facilitate tangible change in this area.

A national and coherent programme with associated investment in healthcare education specific to the integration of EBP was highlighted every bit having an important affect on educational outcomes. The lack of a coordinated and cohesive arroyo and perceived value of EBP in the midst of competing interests, specially within the context of the healthcare agenda, was suggested to atomic number 82 to an 'ad-hoc' arroyo to the implementation of and investment in EBP education and related core EBP resources. Findings from a systematic scoping review of recommendations for the implementation of EBP16 draw attention to a number of interventions at a national level that have potential to farther promote and facilitate EBP education. Such interventions include government-level policy direction in relation to EBP education requirements beyond health profession programmes and the instalment and financing of a national constitute for the development of evidence-based guidelines.

Incorporating EBP activities into routine clinical practice has potential to promote the consistent participation and implementation of EBP. Such incorporation tin exist facilitated at various dissimilar levels and settings. At a health service level, the provision of computer and internet facilities at the bespeak of care with associated content management/determination back up systems assuasive admission to guidelines, protocols, critically appraised topics and condensed recommendations was endorsed. At a local workplace level, access to EBP mentors, implementation of consistent and regular journal clubs, grand rounds, audit and regular research meetings are of import to embed EBP inside the healthcare and education environments. This in plough can nurture a culture which practically supports the observation and actualisation of EBP in day-to-twenty-four hour period practice16 and could in theory allow the coherent development of cohorts of EBP leaders.

There are study limitations which must be acknowledged. 4 of the five interviewees were medical professionals. Further inclusion of allied healthcare professionals may have increased the representativeness of the findings. Still, the primary selection criteria for participants were extensive and recognised expertise in relation to EBP education, the fundamental premises of which traverse specific professional boundaries.

Conclusion

Despite positive attitudes towards EBP and a predominant recognition of its necessity for the delivery of quality and condom healthcare, its consistent translation at the bespeak of care remains elusive. To this cease, continued investigations which seek to provide further management and structure to developments in EBP education are recommended.6 Although the quality of evidence has remained variable regarding the efficacy of private EBP pedagogy interventions, consequent trends in relation to valuable andragogically sound educational approaches, fundamental curricular content and preferential instructional practices are evident within the literature in the past decade. The adoption of such trends is far from prevalent, which brings into question the extent of awareness that exists in relation to such recommendations and accompanying resource. There is a need to translate EBP into an agile clinical resolution, which volition take a positive impact on the commitment of patient intendance. In particular, an exam of current discourse between academic and clinical educators across healthcare professions is required to progress a 'real world' pragmatic approach to the integration of EBP education which has meaningful relevance to students and engenders agile engagement from educators, clinicians and policy makers akin. Further attending is needed on strategies that not only focus on problems such as curricula structure, content and plan delivery but which back up educators, education institutions, wellness services and clinicians to have the capacity and competence to see the claiming of providing such EBP pedagogy.

Summary Box

What is already known?

  • Show-based do (EBP) is established as a fundamental element and primal indicator of high-quality patient intendance.

  • Both achieving competency and delivering instruction in EBP are complex processes requiring a multimodal approach.

  • Currently in that location exists only a modest utilisation of existing resources available to further develop EBP education.

What are the new findings?

  • In addition to developing competence in the primal EBP steps of 'Inquire', 'Acquire', 'Assess', 'Employ' and 'Assess', developing competence in effectively communicating prove to others, in particular patients/service users, is an area newly emphasised as requiring boosted attention by healthcare educators.

  • The successful expansion of the assessment and evaluation of EBP requires a pragmatic distension of the discourse between academic and clinical educators.

How might it impact on clinical practice in the foreseeable future?

  • Quality of intendance is improved through the integration of the best available evidence into conclusion-making as routine practice and not in the extemporised manner often currently practised.

Acknowledgments

Special thanks to Professor Leanne Togher, Professor Carl Heneghan, Professor Bruce Arroll, Professor Rodney Jackson and Professor Gordon Guyatt, who provided primal insights on EBP education from an international perspective. Thank you lot to Dr Niamh O'Rourke, Dr Eve O'Toole, Dr Sarah Condell and Professor Dermot Malone for their helpful direction throughout the projection.

References

  1. 1.↵

    Institute of Medicine (IOM) (US) Roundtable on Testify-Based Medicine . Leadership Commitments to Improve Value in Healthcare: Finding Common Ground: Workshop Summary. Washington (DC: National Academies Press (Us), 2009.

  2. 2.↵
  3. three.↵
  4. 4.↵
  5. v.↵
  6. 6.↵
  7. 7.↵
  8. 8.↵
  9. 9.↵
  10. 10.↵
  11. 11.↵
  12. 12.↵
  13. 13.↵
  14. 14.↵
  15. fifteen.↵
  16. sixteen.↵
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  18. eighteen.↵
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  20. 20.↵
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  22. 22.↵
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  24. 24.↵
  25. 25.
  26. 26.
  27. 27.
  28. 28.

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