Article Text

General medicine
Students 4 Best Evidence as a digital Problem-Based Learning method to improve Evidence-Based Practice competencies in undergraduate physiotherapy students: an observational study
  1. Chiara Arienti1,
  2. Stefano Giuseppe Lazzarini1,
  3. Joel Pollet1,
  4. Stefano Negrini2,3
  1. 1 IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy
  2. 2 Department of Biomedical, Surgical and Dental Sciences, University of Milan "La Statale", Milan, Italy
  3. 3 IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
  1. Correspondence to Dr Chiara Arienti, IRCCS Fondazione Don Carlo Gnocchi, Milan 20148, Italy; carienti{at}dongnocchi.it

Abstract

Background Evidence-based practice (EBP) is an essential element in the delivery of high-quality care and healthcare professionals make clinical decisions based on the best available research. Experts and international organisations have emphasised the need for healthcare professionals to possess adequate competencies for EBP. An EBP learning laboratory has been established at an Italian university to educate medical and other health professional students in the use of evidence in clinical practice and research. Students 4 Best Evidence (S4BE) is an online community of students from around the world, from school age to university, who are interested in learning more about EBP. As well as featuring a library of learning resources, the site also provides a platform for students to write their own blogs.

Objectives The aim of this study is to evaluate the effectiveness of an EBP laboratory, using S4BE as an educational tool, to teach EBP competencies to undergraduate physiotherapy students.

Design We ran an observational pretest and post-test study.

Participants and setting The sample included 121 students completing a bachelor’s degree in Physiotherapy at an Italian University.

Intervention The intervention consisted of using the S4BE platform as the digital Problem-Based Learning (DPBL) method to teach EBP competencies.

Results The students showed a significant improvement in all domains (p<0.001), except in the sympathy domain, where the percentage score decreased from 71% to 60%. The best improvements were reached in terminology (54% to 65%) and in practice (41% to 55%) domains.

Conclusion This study proposed an effective educational protocol, based on a DPBL approach, using S4BE as a digital technology tool. Further research is needed to test the effectiveness of this educational protocol compared with traditional learning methods for physiotherapy students.

Trial registration number NCT03707119.

  • evidence-based practice

Data availability statement

Data are available on reasonable request. Data are available on request to the corresponding author, CA.

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Summary box

What is already known about this subject?

  • Evidence-based practice (EBP) is a fundamental element in the delivery of high-quality care and healthcare professionals make clinical decisions based on the best available research. This highlights the need for healthcare professionals to possess adequate competencies for EBP. The last 20 years have seen EBP increasingly integrated as a core component into the curriculum of undergraduate, postgraduate and continuing education health programmes worldwide. Some studies showed that digital problem-based learning (DPBL) is more effective than traditional learning or traditional PBL but there are very few reports which have looked at the undergraduate learning environment. Therefore, Cochrane Rehabilitation proposed to set up an EBP Laboratory for undergraduate physiotherapy students to learn EBP competencies using the DPBL approach as an educational intervention, using as digital tool one of the Cochrane Knowledge Translation digital tools for health professional students called ‘Students 4 Best Evidence’ (S4BE).

Summary box

What are the new findings?

  • This study showed that an effective educational protocol based on a DPBL approach, using S4BE as a digital technology tool can improve the EBP competencies in physiotherapy students. The establishment of EBM laboratory could be a good way to implement the undergraduate curricula in physiotherapy school.

How might it impact clinical practice in the foreseeable future?

  • An effective educational protocol for the learning of EBP competencies allows to have the future health professionals better trained and aware about the use of EBP in daily clinical practice decision making.

Introduction

Evidence-based practice (EBP) is a fundamental element in the delivery of high-quality care and healthcare professionals make clinical decisions based on the best available research. This highlights the need for healthcare professionals to possess adequate competencies for EBP.1 The last 20 years have seen EBP increasingly integrated as a core component into the curriculum of undergraduate, postgraduate and continuing education health programmes worldwide.2 The health systems expect that all health professionals should be competent in EBP. Although many teaching strategies have been used and evaluated, a lack of EBP knowledge and skills is still one of the most commonly reported barriers to practising EBP.3 One of the potential explanations is the inconsistency in the quality and content of EBP teaching programmes. A standardised set of core competencies in EBP for clinicians and students may therefore improve EBP teaching and learning programmes as well as EBP knowledge and skills.4

The application of knowledge to improve health is called knowledge translation (KT), defined by Canadian Institutes of Health Research as ‘a dynamic and interactive process that includes the synthesis, dissemination, exchange and ethically sound application of knowledge to improve health, provide more effective health services and products, and strengthen the healthcare system’.5 The process to move from the knowledge to action is in accordance with Cochrane’s vision on the dissemination, use and effect of Cochrane evidence.6 Therefore, Cochrane has produced a KT strategy which sets out a framework for KT in Cochrane.7

In this context, Cochrane Rehabilitation aimed to ensure that all rehabilitation professionals know and apply EBP, using the best available evidence as gathered by high-quality Cochrane systematic reviews. Education is one of the fundamental instruments of KT to acquire EBP competencies, useful to keep the high quality of evidence.8 Previous research has shown that certain educational interventions are effective in improving cognitive and technical EBP skills in postgraduate and continuing medical education, mainly those which use digital problem-based learning (DPBL) as an educational approach.9 Some studies showed that DPBL is more effective than traditional learning or traditional PBL but there are very few reports which have looked at the undergraduate learning environment.10

Therefore, Cochrane Rehabilitation proposed to set up an EBP Laboratory for undergraduate Physiotherapy students to learn EBP competencies using the DPBL approach as an educational intervention, using as digital tool one of the Cochrane KT digital tools for health professional students. One of these is ‘Students 4 Best Evidence’ (S4BE), an online community of students from around the world, from school age to university, who are interested in learning more about EBP (https://www.students4bestevidence.net/). S4BE contributors pull together many resources on EBP into one virtual space to allow students to learn the key concepts and principles of EBP. Since nobody considered S4BE blog as a possible digital learning tool, the aim of this study was to evaluate if S4BE can be a valid digital tool to learn EBP competencies in undergraduate physiotherapy student, using a DPBL approach.

Methods

Study design

An observational study was conducted between January 2018 and June 2019 at the School of Physiotherapy, University of Brescia, Brescia. The protocol has been registered on clinicaltrials.gov (NCT03707119).

Procedure

An EBP laboratory was set up during the first year of the programme of the School of Physiotherapy and 121 students, completing a bachelor’s degree in physiotherapy, of both genders, were enrolled. The laboratory included a total of 24 educational training hours using S4BE blog, carried out over a 5-month period, with a total of six sessions, each 4 hour in length. The first five sessions were completed during the first 3 months, and the last session was completed after 2 months of clinical training within a hospital. The set of EBP core competencies developed by Albarqouni et al 11 was used as the EBP curricula model. It includes 68 competencies, grouped in five domains: introductory, ask, acquire, appraise and interpret, apply and evaluate. All students completed an Evidence-Based Practice Questionnaire (EBPQ2),12 a validated tool for the evaluation of EBP competencies at the beginning of the laboratory (T0) and at the end (T1).

Educational intervention

The DPBL method was delivered by a methodologist with 2 years of Cochrane expertise and a physiotherapist researcher with 1 year of expertise in methodology of research in rehabilitation, using, as a digital technology, the S4BE blog. It was applied following the key eight features of PBL: provision of adequate resources, planning of learning objectives, changing of student behaviour in expert, active learning, the use of examples, motivate learning, self-directed learning and self-assessment.13 The students were divided into three or four different working groups (WGs) composed of six or seven students and, during each session, they were given a specific ‘scientific problem’ to solve. The educational intervention was carried out inside a University classroom that provided internet connection for all students devices and enabled to divide them in different groups.

The intervention is described in line with the Template for Intervention Description and Replication14 (see online supplemental file 1).

Supplemental material

In the first session, the scientific problem was to identify EBP principles using the following sections of S4BE: ‘what is EBM’, ‘keys steps in EBM’, ‘introductions to EBP’, ‘critical thinking’, ‘searching for evidence’ and ‘shared decision making’. Each WG received one of these topics and it had the task to search, on that specific section of S4BE, the article that better described the topic. The students could then use the references indicated in the article to search for other related articles on the same topic. When the students found it, they had to summarise these articles, develop a presentation and then present what they had understood to their colleagues, through a plenary oral presentation. The learning objectives were to learn the EBP principle, the type of studies, and why EBP is important for their clinical practice.

In the second session, the scientific problem was to identify the definition of rehabilitation. Starting from S4BE, the students had to search for articles that described the definition of rehabilitation and then use the references of these articles or other resources proposed by them. The aim of this task was to find the definition of rehabilitation proposed by literature and to compare it with the definition they already knew. At the end of the session, they had to present this work to their colleagues through an oral presentation. The learning objective was to learn about the principles of their profession, such as role, competencies and clinical objectives.

In the third and fourth sessions, the scientific problems were to identify the effectiveness of rehabilitation interventions in patients with low back pain and neurological diseases, respectively. Starting from S4BE, the students had to search for articles that discussed the efficacy or effectiveness of rehabilitation interventions in low back pain and one neurological disease chosen by the WGs. At the end, the students presented one or more articles on the topic, showing which interventions were suggested by the literature and considered the best for the management of low back pain and the chosen neurological disease and if they were applicable to the clinical practice. The learning objectives were to learn the knowledge of health conditions discussed, the use of critical thinking skills and when and how to apply the evidence to clinical practice.

In the fifth and sixth sessions, the scientific problems were how to write an article on S4BE. Each WG had to define its research question, find articles that addressed the research question defined and then write a proposal of an article to upload onto the S4BE blog using plain language principles suitable for student readers. At the end of the session, each WG presented its own article proposal to the others as oral presentations. The learning objectives were to know the scientific article structure and how to synthetise the evidence, using a language suitable for students. The intervention adherence was assessed using the classroom register and at each lessons, the presences were collected.

Questionnaire

The EBPQ2 has been rigorously developed across a range of professions to cover the range of EBP domains likely to change as result of education training and was underpinned by a transparent and defensible psychometric process.12 It captures self-reported EBP domains such as relevance, terminology, confidence, practice and sympathy. Relevance (14 items) refers to items concerning the value, emphasis and importance an individual placed on EBP; Terminology (17 items) refers to items concerning an understanding of common research terms; Confidence (11 items) refers to items concerning a perception of an individual’s abilities with EBP skills; Practice (9 items) refers to items concerning an individual’s use of EBP and Sympathy (7 items) refers to items concerned with an individual’s sense of the compatibility of EBP with professional work. It was administered at the beginning of the laboratory (T0) and at the end, after 5 months (T1).

The questionnaire has demonstrated very good reliability and its validity allows the application for assessing and monitoring changes in the characteristics associated with EBP competencies at an individual and undergraduate curricula level and potentially beyond, when graduates move into the workforce. Every item scores 1 for each point on the 5-point Likert scale, that is, a minimum score of 1 and a maximum score of 5 per item. When a question is not answered, a score of 0 is considered for all items, except for those belonging to the sympathy domain, where a score of 6 is considered. The factor score is the sum of the scores for all items associated with that factor, with each item weighted equally. The completion time of the EBPQ2 ranges between 9 and 20 min.12

Statistical analysis

Statistical analysis was performed using STATA software V.14.0 (StataCorp LP, College Station, TX, USA). The descriptive analysis (mean and SD calculation) has been used to describe the participant characteristics. The final score of each domain has been calculated as the sum of the averages of each item.12 The within-group analysis has been performed using the Mann-Whitney U-test with two-tailed distribution between the mean scores of the domain items. Significance level was set at p<0.05.

Results

One hundred and twenty-one first year undergraduate physiotherapy students were enrolled. The mean age was 20.7±2.7 years (range 18–27), 73 were males and 47 females. One student did not report sex in the ‘Demographics’ section of the EBPQ2.

At the beginning (T0), the relevance domain mean value was 46.0±1.3, the terminology domain mean value was 45.5±1.4, the confidence domain mean value was 32.7±1.2, the sympathy domain mean value was 25.0±1.3 and the practice domain mean value was 18.6±1.4.

After 24 educational training hours and 2 months of clinical training (T1), a drop-out rate of 15% occurred due to the absence of the students during the last lesson, resulting in a sample of 103 students with mean age of 20.9±1.8 years (range 19–27), 61 were males and 41 females. One student did not report sex in the questionnaire.

At the end of the training period (T1), the relevance domain mean value was 50.6±0.9, the terminology domain mean value was 55.2±1.1, the confidence domain mean value was 35.2±0.9, the sympathy domain mean value was 21.1±0.9 and the practice domain mean value was 24.7±1.1. All data are reported in table 1.

Table 1

EBPQ2 domains pre/posteducational intervention

After training, the students showed a significant improvement in all domains (p<0.001), except in the sympathy domain, where the percentage score decreased from 71% to 60%. The best improvements were reached in terminology (54% to 65%) and in practice (41% to 55%) domains.

Discussion

The aim of this study was to evaluate if S4BE can be a valid digital tool to learn EBP competencies in undergraduate physiotherapy students, using a DPBL approach.

Our findings highlighted a statistically significant improvement of all domains of EBPQ2 through the use of S4BE, as a digital technology for delivering DPBL. Relevance, terminology and practice are the domains improved mainly and more related to clinical practice. The set of EBP core competencies developed by Albarqouniet al 11 also includes, between them, the application of evidence, through shared decision making, and evidence implementation at the individual clinical level, that are usually acquired during the clinical practice. Particularly, EBPQ2 relevance domain, defined as individual value given to EBP, is related to ‘introductory’ competence of EBP core competencies; EBPQ2 terminology domain, defined as the understanding of common research terms, is related to ‘ask’ competence of the core competence that includes the understanding of the rationale for using structured clinical questions and the identification of PICOs (Population-Intervention-Comparison-Outcome) elements. EBPQ2 practice domain, defined as an individual’s use of EBP in their own clinical practice, is related to ‘apply’ competence that includes the engagement of patients in the decision-making process, using shared decision making, that means explaining the evidence and integrating the patients’ preferences.11 This confirms that the clinical training, performed by our physiotherapy students, might have considerably influenced the learning of these specific EBP competencies.

Further, we used the DPBL method which has already been shown as more effective than traditional learning in improving the students’ postintervention knowledge10 and our findings support these results. S4BE allowed the students to reach an active learning stimulated by a scientific student community around a clinical question. The structure of the S4BE website facilitated the definition of the topics used during each laboratory session. The section ‘topics’ includes many topics related to the EBP competencies, such as ‘shared decision making’, ‘critical thinking’ and ‘searching for evidence’. There is also the topic ‘physiotherapy’, in which we found many clinical questions in rehabilitation. This approach led to a significant improvement of EBP competencies’ learning because it included great interaction, involvement, and engagement among the students, a key elements of the DPBL method.15 Previous studies confirm our findings, but they also highlight the need to test this approach for other outcomes such as satisfaction, attitudes, cost-effectiveness and adverse events.16 17

The limitations of this study were the high level of drop-out caused by organisational issues of the sessions and consequently of sample size.

All health professions know, at least in theory, the importance of the use of EBP during daily clinical practice, but its applicability is still difficult to achieve, particularly in the integration of EBP core competencies into the curriculum of undergraduate, postgraduate and continuing education health programmes worldwide. This study proposed an effective educational protocol, based on the DPBL approach, one of more significant learning methods used in medical educational literature, using S4BE as news digital technology tool. Further research is needed to test the effectiveness of this educational protocol compared with traditional learning in physiotherapy students.

Data availability statement

Data are available on reasonable request. Data are available on request to the corresponding author, CA.

Ethics statements

Patient consent for publication

Acknowledgments

We thank the School of Physiotherapy team from the University of Brescia, in particular: Marianna Dossena, Annamaria Roversi, Cristian Carubelli, Claudia Furlotti and Mariangela Bianchi for the collaboration and the educational support.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • Twitter @chiara_arienti

  • Contributors CA: study conception and design, analysis and interpretation of data, drafting of manuscript; SGL: acquisition of data, analysis and interpretation of data, drafting of manuscript; JP: acquisition of data, analysis and interpretation of data; SN: study conception and design, critical revision. All authors discussed the results and commented on the manuscript. All authors approved the submitted version of this article.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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