Instructional practices for evidence-based practice with pre-registration allied health students: A review of recent research and developments

Danielle HitchInstructional practices for evidence-based practice with pre-registration allied health students: A review of recent research and developments

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

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

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)

Consider the learners existing knowledge, beliefs and attitudes about evidence based practiceUnderstand the salient role of social negotiation and collaboration with peers in incorporating evidence in clinical decision makingAcknowledge 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 worldSupport collaborative learning which exposes students to alternative viewpoints and affords them the opportunity for apprenticeship learningScaffold learners from what is presently known to what is to be known, thereby facilitating the learners ability to perform just beyond the limits of current abilityFive recommendations

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

StepDescription of StepCurrent Study1Clinical / 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

StepDescription of StepCurrent Study3Identification: 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

StepDescription of StepCurrent Study4Deconstruction: 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 5Analysis: 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

StepDescription of StepCurrent Study6Reconstruction: 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. 7Transfer 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

Seventeen studies from universities around the worldBroad 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

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

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

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 programsdialoguing 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

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 attributesCollaborative learning

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

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

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

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

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

Danielle HitchLecturer in Occupational TherapyWaterfront Campus

dani.hitch@deakin.edu.authanks