Authors

1. Ramis, Mary-Anne RN, BN, MPhil (Clinical Sciences)
2. Chang, Anne RN, BN, PhD, FRCNA
3. Nissen, Lisa PhD

Abstract

Review question/objective: The objective of this review is to find, critically appraise and synthesize the available quantitative evidence on the effectiveness of interventions that promote successful teaching of the evidence-based practice process in undergraduate health students, in preparation for them to become professional evidence-based practitioners.

More specifically, the question that this review seeks to answer is: What is the effectiveness of teaching strategies for evidence-based practice for undergraduate health students?

Background: Learning and teaching the evidence-based practice (EBP) process presents great challenges to undergraduate students and educators alike, as providing students with knowledge alone, may not automatically mean students will feel capable to practice EBP in their eventual respective clinical environments.1,2 However EBP is now part of professional practice registration standards for many health disciplines to which new graduates are expected to adhere.3-7 Consequently, there is a growing responsibility for educators to address the requirement to ensure students have the necessary required knowledge, skills, attitude, and confidence.

In 2005, the Sicily statement on evidence-based practice was published after a consensus process of 86 international delegates of the Evidence-Based Health Care Teachers and Developers conference.8 In an attempt to provide some consistency to the evidence-based practice movement, the statement addressed the demand for a clearer definition of what evidence-based practice really was, as well as provided recommendations for the future. The authors also supported the change in EBP language, suggesting that the term Evidence-based Medicine, be changed to and accepted as "evidence-based practice", to reflect a broader construct and recognize and encourage a shared approach to EBP across health care fields. In recognizing the growing evidence-to-practice gap, the statement acknowledged the importance of effective teaching of EBP to undergraduate students as a way of preparing practitioners for the future.8

An update to the Sicily Statement was published in 2011 to provide direction for educators when developing tools to measure EBP dimensions from a learner perspective.9 The paper also provided a platform for further discussion on dimensions of EBP learning and teaching and suggested that effective EPB learning and evaluation should be "matched to the needs and characteristics of the learner audience".9^(pg.2) Prior to the update being published, a systematic review by Shaneyfelt et al10 identified over 104 tools used to evaluate EBP teaching strategies for the field of medicine alone, with varying levels of validity and reliability.

It is generally agreed that the five basic steps of the EBP process include: asking a structured clinical question; collecting the best evidence available; critically appraising the evidence to ensure validity, relevance and applicability; applying or integrating the results into practice and evaluating outcomes.3,8,11,12 The teaching of these steps to undergraduates from a generic foundation has potential applicability across health fields13-15; however, studies available to date reflect a primarily segregated approach to the EBP process across health disciplines.16 While the content retrieved and the context for implementing the evidence will differ according to a students' clinical field, the process for searching and appraising the evidence will be similar when based on the five steps outlined above. There is some literature emerging which supports EBP education for undergraduate students to embrace an interprofessional context.17

Despite growing support for EBP, implementing the best evidence in practice is still suboptimal, with reports that some patients are still subject to inadequate and potentially unsafe care.18-21 Concomitant to this problem is the suggestion that some treatments are being implemented too early, without rigorous analysis of the research being implemented.18 The problem of translating knowledge into practice has become a focal point for many clinicians and researchers, and frameworks to address barriers for best practice present a multifaceted and complex phenomenon.21 One of the main tenets within knowledge translation frameworks is that of continuing education, with acknowledgement that this requires modification according to the target audience, e.g. health professional, health care service provider, policy maker and/or the patient.21 Tertiary educators are in a unique position to create a positive attitude toward EBP among students in the early years through teaching fundamental principles of EBP and building on them appropriately14, so that students can continue to develop these skills after graduation; however evidence to support strategies specifically for undergraduates is required.

A systematic review specifically on the effectiveness of strategies for teaching EBP to undergraduate students across health disciplines has not been reported to date, however systematic reviews on teaching all or part of the EBP process to postgraduate medical students and combinations of student and clinician populations have been conducted.22-28 A systematic review conducted by Coomarasamy & Khan compared stand-alone teaching methods to integrated clinical problem solving strategies in postgraduate medical students.22,23 Results identified that clinically integrated courses provided improvements in knowledge, skills, attitudes, and behaviors; however the population for this review was postgraduate medical students. A very recently published review of systematic reviews by Young, Rohwer, Volmink, and Clarke attempted to synthesize the available information on EBP education and reviewed 15 earlier published systematic reviews and one unpublished one, from 1993 to 2013.28 Each of the included reviews evaluated single and/or multi-faceted educational interventions aimed at improving various EBP outcomes including, but not limited to, knowledge, critical appraisal skills, attitudes, and EBM behaviors among a mixture of populations including undergraduate and postgraduate students as well as health professionals from medicine, nursing and allied health fields. Recommendations from the findings suggested that teaching strategies should take into account individual student factors such as learning style and capability as well as external organisational factors such as the setting of the learning activity and delivery format. The review suggested that a variety of EBP methods (e.g. journal clubs, small group discussions, incorporating clinical scenarios, lectures) had the greatest effect on improving critical appraisal skills and EBP behaviour and knowledge. Small sample sizes and heterogeneity of study aims, outcomes and samples were methodological limitations of the included studies and were highlighted by the authors as preventing meta-analysis. Although this review provides some guidance for teaching strategies of EBP to some populations, it does not provide specific guidance for the differing needs of students as opposed to health professionals.28

The focus of research on promoting EBP has been on changing health professionals' behavior to ensure their practice is based on evidence. The eventual reduction of such a focus to one of determining effective teaching strategies on the fundamentals of EBP behaviors for undergraduate students would enable development of positive EBP behavior. Proponents of the EBP process suggest the process is a lifelong learning journey,14,29 therefore starting in the undergraduate years would provide a solid basis from which learning can continue to develop. Teaching EBP to undergraduates is complex and challenging and consequently a strong evidence base is required to assist educators to better prepare students for professional evidence-based practice.

Definitions: Evidence-based practice: a process by which decisions on patient care are made utilizing best available evidence for the context in which care is being delivered and incorporating patient considerations and clinical expertise.30,31

Evidence-based medicine: the practice of EBP as applied to the field of medicine. Based on the widely cited definition by Sackett et al29,31 whereby EBM was defined as:

"[horizontal ellipsis]the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice."29^(p.71)

Evidence-based healthcare: Incorporation of the process outlined above, throughout all health fields including nursing, medicine, allied health, etc.30

Evidence-Based Practice behavior - refers to what the student actually does in clinical practice, which may be in a simulated scenario or as part of a clinical unit. It incorporates all the processes within EBP including incorporating patient preferences and the student's own level of competence to answer a specific clinical question. Behavior demonstrates how knowledge and skills are applied.8 Assessment of behaviour helps to uncover incongruence between what the student thinks they should or can do and what they actually do.9

Evidence-Based Practice skills - refers to the tasks within the process of EBP, e.g. searching for evidence, appraising the evidence. Evidence-based practice skills can be measured using an appropriate tool.9