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Impact of an Evidence-Based Practice Intervention on Knowledge and Clinical Practice Behaviors Among Registered Dietitians
Abstract
Implementation of evidence-based practice in clinical practice is essential for safety, quality, cost, and reimbursement of dietetics services. This prospective randomized controlled trial aimed to measure changes in knowledge and practice behaviors of evidence-based practice after an educational intervention. The ability to interpret statistical results improved significantly in the intervention group. When motivation to change was controlled for over time, a higher total knowledge score was demonstrated in the intervention group. This finding suggests that motivation to change was an important factor for the adoption of evidence-based practice knowledge into clinical practice among registered dietitians.
... The survey instrument was originally developed and used by Vogt and colleagues to measure RDs' EBP knowledge and clinical practice behavior before and after an EBP educational session [21]. The first section of the survey on EBP knowledge consisted of free-text (2-point), multiple choice (1-point), and true/false (0.5-point) questions with a maximum knowledge score of 12. ...
... The first section of the survey on EBP knowledge consisted of free-text (2-point), multiple choice (1-point), and true/false (0.5-point) questions with a maximum knowledge score of 12. An independent-samples ttest was used to compare the interns' scores in the present study with the registered dietitians' scores in Vogt and colleagues' study [21]. Statistical significance was defined as a p-value <0.05. ...
... Dietetic interns scored a mean of 7.75 out of a possible score of 12 (65%) on the EBP knowledge portion of the survey. Compared to the RDs at baseline in Vogt and colleagues' study [21], dietetic interns were found to have similar EBP knowledge item scores (Table 1). Both groups had lowest scores on the statistics and patient or problem, intervention, comparison, outcomes (PICO) definition questions. ...
Objective:
This study explored dietetic interns' perceptions and knowledge of evidence-based practice (EBP), their use and observation of EBP principles during their clinical rotations, and their intentions to use EBP in their careers.
Methods:
A mixed methods design combining a survey and focus group was employed. Dietetic interns (n=16) from a large Midwestern university were recruited in person and via email to participate in the survey, focus group, or both. Perceptions and experiences of EBP were analyzed through the focus group (qualitative), and EBP knowledge and clinical practice behaviors were analyzed through the survey (quantitative). The focus group discussion was recorded, transcribed, and analyzed using thematic analysis.
Results:
Four major themes emerged from the focus group data: (1) observations of EBP in clinical practice, (2) use of EBP during clinical rotations, (3) barriers to EBP, and (4) perceived use of EBP as future registered dietitians. Interns considered EBP important for their profession and future careers. They struggled, however, with the discrepancies between current research and practice, and highlighted differences that they observed and barriers that they experienced across different clinical settings.
Conclusions:
This exploratory study is the first to examine dietetic interns' perceptions of and experiences with EBP in the clinical setting. Future research is needed to identify how dietetics educators, librarians, and preceptors can address the barriers that interns perceive in applying EBP in their internships.
... Only seven (58%) studies from our review reported on participants' training in EBP [21,25,26,28,29,32,34]. For instance, Byham-Gray et al (2005) [26] reported that 55% of RDs (n=258) received "critical appraisal training", and Chiu et al (2012) [29] reported that 27% of RDs (n=67) took an educational course in "evidence-based nutrition" [53]. ...
Background: Evidence-based practice (EBP) promotes shared decision-making between clinicians and patients and has been widely adopted by various health professions including nutrition & dietetics, medicine and nursing.
Objective: To determine EBP competencies among nutrition professionals and students reported in the literature.
Design: Systematic review.
Data sources: Medline, Embase, CINAHL, ERIC, CENTRAL, ProQuest Dissertations and Theses Global, BIOSIS Citation Index, and ClinicalTrials.gov up to March 2023.
Eligibility criteria for study selection: Eligible primary studies had to objectively or subjectively document the assessment of at least one of six predefined core EBP competencies, including formulating structured clinical questions, searching the literature for best evidence, and assessing studies for methodological quality, magnitude (size) of effects, certainty of evidence for effects, and determining the clinical applicability of study results based on patient values and preferences.
Data extraction and synthesis: Two reviewers independently screened articles and extracted data, including the reporting quality for eligible studies. Results were not amenable to meta-analysis and were thus summarized for each EBP competency.
Results: We identified 12 eligible cross-sectional survey studies, comprised of 1065 participants, primarily registered dietitians, across six countries, with the majority assessed in the United States (n=470). The reporting quality of the survey studies was poor overall, with 43% of items not reported and 22% of items partially reported. Only one study (8%) explicitly used an objective questionnaire to assess EBP competencies. The proportion of studies reporting on each competency were: 17% on the formulation of clinical questions, 83% on searching the literature, 75% on methodological quality or critical appraisal, 58% on interpreting statistical results, and 75% on applying study results. In general, the six competencies were incompletely defined or reported (e.g., it was unclear what applicability and critical appraisal referred to, and what study designs were appraised by the participants). Two core competencies, the magnitude (size) of effects and the certainty of evidence for effects, were not assessed.
Conclusions: Among 12 included articles the overall quality of study reports was poor, and when EBP competencies were reported they were predominantly self-perceived assessments as opposed to objective assessments. No studies reported on competencies in assessing magnitude of effect or certainty of evidence, skills that are essential for optimizing clinical nutrition decision-making.
Systematic review registration: PROSPERO CRD42022311916.
... Because their training is primarily acute care or disease prevention focused, they must seek out opportunities for evidence-based information. Professional competency evolves over-time fostered by mentorship from more experienced practitioners [27,28]. The authors hope that the outcomes of this study will be used as a guide for the Accreditation Council for Education in Nutrition and Dietetics (ACEND ® ) and dietetic educators for future revisions of entry-level and advanced practice preparation for integrative and functional nutrition therapy. ...
Background:
This study explored the health philosophy and practice orientation of RDNs in the United States.
Methods:
A randomly selected group of RDNs were recruited to take an online survey using a reduced version of Integrative Medicine practice (IM-30). Confirmatory factor analysis, analyses of variance, and non-parametric tests were used to investigate the relationships between dietetic professionals' personal health philosophy, lifestyle, and orientation to Integrative Medicine.
Results:
Overall construct validity of the IM-26 scale was demonstrated by Cronbach's α with reliabilities ranging from 0.766 to 0.89. Results from chi-square test of goodness-of-fit test (N = 477, χ2 = 228.72, p = 0.123) and RMSEA of 0.016 showed good model fit. IM orientation varied significantly by work setting and certification in one or more CAM therapies.
Conclusions:
The orientation towards Integrative Medicine for a majority of US dietitians is in the awareness and learning phases of adoption.
Background
Research is the scientific basis for the profession of dietetics, as it must be located and applied in evidence‐based practice (EBP). EBP is often presented as a foundational skill for research. CEAR – Core, Evidence Application, Research – is a newly proposed model that separates Research and Evidence Application skills into distinct domains, jointly supported by a set of Core skills, thus acknowledging that education and advancement in one domain neither requires nor precipitates education and advancement in the other. The goal was to investigate the content and construct validity of the new CEAR Model.
Methods
A cross‐sectional online survey of randomly selected dietitians in the United States was used to collect CEAR domain scores, validated measures of research or EBP skills and self‐reported characteristics. Exploratory factor analysis, Cronbach's α and Pearson correlation between various tools and CEAR domains were used to assess validity and reliability. Analysis of variance (ANOVA) and multiple linear regression between CEAR domains and participant characteristics were used to assess convergent and divergent validity.
Results
One hundred and fifty‐four responses with a valid CEAR score were received and led to a three‐factor solution, supporting the theorised differentiation of research from evidence application skills (content validity). Internal reliability for the CEAR Model overall and for each domain was high. The hypothesised correlations between existing research or EBP measurement tools and the relevant CEAR domains were found (construct validity). Known groups analysis demonstrated the expected differences in CEAR domain scores based on participant characteristics.
Conclusions
The CEAR Model demonstrates preliminary validity and internal reliability. It adds to the current literature by acknowledging the separateness of evidence application skills from research skills.
Background:
Evidence-based practice (EBP) is described as the integration of three main dimensions in health professions decision making: the best currently available research evidence, professional expertise, and patient's values and circumstances. Barriers to EBP at individual level have been assessed using questionnaires. Knowing which EBP dimensions are actually explored in these questionnaires is essential to promote EBP and its adoption.
Objectives:
To identify and describe questionnaires that have been used among dietitians to evaluate knowledge, skills, attitudes and/or behaviors related to EBP, and to perform a content analysis of these, drawn on the EBP dimensions explored.
Methods:
Questionnaires were identified through a systematic review in MEDLINE, EMBASE and CINHAL (last search: 11.2022). Eligibility criteria were: studies using, evaluating or developing questionnaire(s) meant to evaluate knowledge, skills, attitudes and/or behaviors related to EBP among dietitians. The content analysis was conducted to identify the EBP dimensions explored (research evidence, professional expertise, and/or patient's values and circumstances). Questionnaires' items were categorized as follows: one sole EBP dimension, a combination of these or no identifiable dimension.
Results:
30 reports (25 studies) were included. The analysis of the 847 items extracted from the 25 questionnaires used showed that the main EBP dimension explored was the integration of research evidence into decision making, found in 75% of items, sole or in combination with another dimension. Professional expertise was explored in 18% of the items, while patient's values and circumstances were found in 3% of them and the combination of these three dimensions in less than 1%.
Conclusion:
The important imbalance of explored EBP dimensions in the questionnaires used may lead to a partial and misleading evaluation that prevents efficient strategies to foster EBP. There is an important need to develop more integrative and accurate evaluations of EBP targeting dietitians, to promote and develop high-quality dietetics practice.
Introduction:
Continuing allied health professional (AHP) clinical education is essential to ensure high-quality patient care; however, the effectiveness of current education programs is unclear. This review aimed to determine whether AHP education programs improve the knowledge of AHPs, change their clinical practice behavior, and/or improve patient-related clinical outcome and to identify important components of these programs.
Methods:
Four electronic databases were searched. Controlled clinical trials investigating the effectiveness of clinical education programs were included. Education programs were diverse, varying in design, delivery mode, and intensity. Only therapy-specific AHPs were included. Effectiveness was determined by differences in group outcomes in the domains of AHP knowledge, AHP clinical practice behavior, and patient-related clinical outcomes.
Results:
Forty-four studies were identified, of which 26 included physiotherapists only. Most control groups were waitlist, passive dissemination of information, or usual care, limiting comparisons between programs. Changes in AHP knowledge was investigated in 20 trials, with 13 showing an improvement. Thirty studies investigated changes in AHP clinical practice behavior, with half demonstrating a difference between groups. Seventeen studies investigated a patient-related clinical outcome, with five finding a difference between groups. Where improvements in outcomes were demonstrated, programs tended to incorporate self-selection and cater to the learner's contextual needs.
Discussion:
AHP knowledge is effectively improved through targeted education programs. To change AHP behavior and patient outcomes, it seems important to incorporate self-selection for the program and consider the learner's individual needs and contexts through mentoring, outreach visits, reflection, and incorporating patient participation in the learning.
Background:
Exact quantification of research conducted by dietitians and tracking the effectiveness of interventions or training programs to increase either evidence-based practice (EBP) or research behaviours have been hampered by the variety of tools used to measure these constructs.
Methods:
In this narrative review, we identified and classified the various tools previously used to measure constructs related to research and/or EBP in the dietetics profession, and to summarise estimates of the constructs measured.
Results:
We identified and classified 15 scored tools that had been used at least once in the dietetics profession and extracted tool parameter estimates from 22 resulting papers. We also identified six unscored tools and three qualitative studies. The most frequent constructs measured were attitudes and behaviours. Very few tools measured objective knowledge (skills). No objective measures of research outputs were identified. Several tools were closely related to one another.
Conclusions:
Even when tools were used across multiple papers, reporting method varied making comparisons difficult. This review should encourage future researchers to utilise existing tools when possible, and encourage the development or adaptation and testing of tools that fill identified gaps. The constructs measured by the tools identified may also provide a starting point for the development of educational interventions aiming to increase research or EBP skills among dietitians. Only by using consistent tools will the dietetics profession be able to track the progress in increasing research conduct and EBP implementation over time.
Aims:
There is a lack of research assessing perceived and actual evidence-based dietetics practice knowledge among registered dietitian nutritionists. This cross-sectional research examined the association between determinant factors (i.e., education attainment) and objective knowledge (i.e., quiz items) of evidence-based dietetics practices. Other determinant factors associated with perceived knowledge and skill, attitudes, behaviours and outcomes related to evidence-based dietetics practice were also assessed. Perceived knowledge items were compared to objective knowledge items to evaluate the accuracy of self-assessed evidence-based dietetics practice knowledge among dietitians in the United States.
Methods:
A modified and adapted evidence-based practice survey was emailed to registered dietitian nutritionists in the United States via the Commission on Dietetic Registration database between November and December 2020. Analysis of variance assessed the relationship between highest degree held and actual knowledge of evidence-based dietetics practices. Multiple linear regression and ordinal logistic regression determined participant-level characteristics associated with survey subscales and survey items, respectively. Pearson's correlation coefficient evaluated the relationship between subjective and objective items.
Results:
Four hundred and eighty-two dietitians completed the survey. Each increase in degree type was associated with an increase in objective knowledge score (all comparisons p < 0.001). Other determinants included recency of degree completion and peer-reviewed publications. Moderate positive associations (r = 0.35, p < 0.001) were found between subjective and objective measures.
Conclusion:
Graduate-level education, recency of degree completion and peer-reviewed publications were supportive of evidence-based dietetics practice-related outcomes. Future research should evaluate the efficacy of training, particularly among those further from their highest completed degree.
Purpose: Integrative Medicine (IM) is a growing area of practice for registered dietitian nutritionists (RDNs) and other allied health professionals. The alternative health perspective, the systems orientation or holism, focuses on the creation of health rather than the prevention or curative view of disease.
Methods: A randomly selected group of RDNs were recruited to take an online survey on a reduced version of Integrative Medicine practice (IM-30). Confirmatory factor analysis, multivariate analyses of variance, and non-parametric tests were used to investigate the relationships between dietetic professionals’ personal health philosophy, lifestyle, and orientation to Integrative Medicine.
Results: Overall construct validity of the IM-26 scale was demonstrated by Cronbach’s a with reliabilities ranging from .766-.891 with zero-order correlations between latent factors ranging from .270 to .507 indicating good discriminant validity. A chi-square test of goodness-of-fit was performed to determine whether the four latent factors in the IM-26 scale (awareness, learning, readiness to practice, and patient-centered care) were consistent with the data (N = 477, c2 = 228.72, p=.123; RMSEA =.016). Comparison of dietitians’ IM orientation varied significantly by work setting and certification to practice one or more CAM therapies versus traditional allopathic specialties.
Conclusions: Integrative medicine, a paradigm that is wellness and healing oriented, is in the early phases of diffusion into mainstream medical nutrition therapy by both its educators and practitioners. The orientation towards IM for a majority of dietitians is in the awareness and learning phases of adoption. Dietetic practice patterns should be followed longitudinally as they impact the pre-professional curriculum and continuing education needs of RDNs.
Reflective judgement is a critical capability for dietitians since they are often confronted with contradictory evidence and conflicting viewpoints. The lack of reflective judgment literature for nutrition education revealed an imperative need to find ways to enhance nutrition-majored students' reflective judgement. Thus, this study aimed to employ online reflection strategy to enhance nutrition-majored students' reflective judgment performance. One hundred and twenty nutrition-majored college juniors participated in the four-week experimental online reflective judgment learning activity. The independent variable was the type of online reflection strategy (the collective reflection using branched threading, the collective reflection using linear threading, and self-reflection) while the dependent variables included reflective judgement performance and participants' perceived learning. The results indicated that all of the three online reflection strategies promoted learners’ reflective judgment performance equally with an increment of 0.75 stage. Participants showed positive perceptions toward reflective judgement learning. Further research is needed to better understand the long-term impact of the online collective reflection strategies in the real-world practice of dietetics.
The purpose of this study was to measure the effect of a social cognitive career theory (SCCT)-based educational intervention combined with an evidence-based practice (EBP) continuing professional education (CPE) program (standard-plus group) as compared to the EBPCPE program alone (standard group) and a no-treatment control on research outcome constructs (research self-efficacy, research outcome expectations, research interest and research involvement) in dietitians.
This randomized controlled trial measured the effect of an online 14-week educational intervention, with measurements made pre- and post-intervention and at 3-month follow-up. A randomly selected list of registered dietitians (RDs), who reported clinical nutrition as their primary practice area, was obtained from the Commission on Dietetic Registration. Subjects (n=580) were randomly assigned to three study groups, and 47.2% (n=272) completed data collection.
The treatment effect between the groups was significantly different for research self-efficacy (p<0.001) and research involvement (p=0.005), with positive effects observed in the standard-plus and standard groups. There were no significant effects for research outcome expectations and research interest.
This is the first known application of SCCT to RD research involvement as a career-related behavioral outcome, and it demonstrated that a significant increase in research self-efficacy occurs following participation in an educational intervention on EBP.
One way many universities have approached the process of better understanding and meeting the needs of their students is through student evaluations. The evaluation data provide not only diagnostic feedback but also useful information in terms of the quality of learning and teaching experiences. In an effective quality cycle, the data gathered are analysed and used to make improvements. This is often referred to as ‘closing the loop’. However, for any evaluation data to be of value an important prerequisite for ‘closing the loop’ is that response rates should be sufficiently high to be representative of the student cohort. This paper describes how a faculty within Monash University utilising only web based surveys developed a successful communication strategy to elicit staff and student participation in the unit (subject) evaluation process which achieved a response rate as high as 83.2%.
Teaching the steps of evidence-based practice (EBP) has become standard curriculum for health professions at both student and professional levels. Determining the best methods for evaluating EBP learning is hampered by a dearth of valid and practical assessment tools and by the absence of guidelines for classifying the purpose of those that exist. Conceived and developed by delegates of the Fifth International Conference of Evidence-Based Health Care Teachers and Developers, the aim of this statement is to provide guidance for purposeful classification and development of tools to assess EBP learning.
This paper identifies key principles for designing EBP learning assessment tools, recommends a common taxonomy for new and existing tools, and presents the Classification Rubric for EBP Assessment Tools in Education (CREATE) framework for classifying such tools. Recommendations are provided for developers of EBP learning assessments and priorities are suggested for the types of assessments that are needed. Examples place existing EBP assessments into the CREATE framework to demonstrate how a common taxonomy might facilitate purposeful development and use of EBP learning assessment tools.
The widespread adoption of EBP into professional education requires valid and reliable measures of learning. Limited tools exist with established psychometrics. This international consensus statement strives to provide direction for developers of new EBP learning assessment tools and a framework for classifying the purposes of such tools.
Health educators need rigorously developed instruments to evaluate cognitive skills relating to evidence based practice (EBP). Previous EBP evaluation instruments have focused on the acquisition and appraisal of the evidence and are largely based in the medical profession. The aim of this study was to develop and validate an EBP evaluation instrument to assess EBP cognitive skills for entry-level health professional disciplines.
The Fresno test of competence in evidence based medicine was considered in the development of the 'Knowledge of Research Evidence Competencies' instrument (K-REC). The K-REC was reviewed for content validity. Two cohorts of entry-level students were recruited for the pilot study, those who had been exposed to EBP training (physiotherapy students, n = 24), and who had not been exposed to EBP training (human movement students, n = 76). The K-REC was administered to one cohort of students (n = 24) on two testing occasions to evaluate test-retest reliability. Two raters independently scored the first test occasion (n = 24) to evaluate the inter-rater reliability of the marking guidelines. Construct validity was assessed by comparison of the two groups, 'exposed' and 'non-exposed', and the percentage of students achieving a 'pass' score in each of these groups. Item difficulty was established.
Among the 100 participants (24 EBP 'exposed', and 76 EBP 'non-exposed' students), there was a statistically significant (p < 0.0001) difference in the total K-REC scores. The test-retest and inter-rater reliability of the individual items and total scores ranged from moderate to excellent (measured by Cohen's Kappa and ICC, range: 0.62 to perfect agreement).
The K-REC instrument is a valid and reliable evaluation instrument of cognitive skills of EBP in entry-level student health professionals. The instrument is quick to disseminate and easy to score, making it a suitable instrument for health educators to employ to evaluate students' knowledge of EBP or in the evaluation of entry-level EBP training.
To assess the effectiveness (change in knowledge and skills measured by the Fresno test) of a short course in Evidence Based Practice (EBP) carried out in a group of family medicine residents
Before-after study. Participants' were 152 Family Medicine residents in their second year of the training programme. Settings were Primary Care Teaching Units in Catalonia. Intervention was comprised of a four half-day training course designed to develop the knowledge and skills required to practice evidence-based care. The main outcome measure was change in EBP knowledge and skills, measured using the Spanish version of the Fresno test (score range, 0-212)
The mean difference between pre-test and post-test was 47.7, a statistically significant result with 95% CI of 42.8-52.5 (p < 0.0001). An important improvement was observed in the questions related to calculations such as sensitivity, specificity, the absolute risk reduction or the number needed to treat. A more modest increase was found in the residents' knowledge and skills in finding the best clinical evidence, and appraising the validity and applicability of an article. Finally, a weak and non-statistically significant improvement was found in formulating a clinical question.
The study provides evidence for responsiveness to changes in knowledge and skills in EBP after an educational intervention.
Evidence implementation continues to challenge health professionals most especially those from developing countries. Filipino physiotherapists represent a group of health professionals in a developing country who by tradition and historical practice, take direction from a doctor, on treatment options. Lack of autonomy in decision-making challenges their capacity to deliver evidence-based care. However, this scenario should not limit them from updating and up-skilling themselves on evidence- based practice (EBP). EBP training tailored to their needs and practice was developed to address this gap. This study will be conducted to assess the effectiveness of a tailored EBP-training program for Filipino physiotherapists, in improving knowledge, skills, attitudes and behaviour to EBP. Participation in this program aims to improve capacity to EBP and engage with referring doctors to determine the most effective treatments for their patients.
A double blind randomised controlled trial, assessing the effectiveness of the EBP training intervention, compared with a waitlist control, will be conducted. An adequately powered sample of 54 physiotherapists from the Philippines will be recruited and randomly allocated to EBP intervention or waitlist control.Intervention: The EBP program for Filipino physiotherapists is a one-day program on EBP principles and techniques, delivered using effective adult education strategies. It consists of lectures and practical workshops. A novel component in this program is the specially-developed recommendation form, which participants can use after completing their training, to assist them to negotiate with referring doctors regarding evidence-based treatment choices for their patients.Pre and post measures of EBP knowledge, skills and attitudes will be assessed in both groups using the Adapted Fresno Test and the Questions to EBP attitudes. Behaviour to EBP will be measured using activity diaries for a period of three months.
Should the EBP-training program be found to be effective in improving EBP-uptake in Filipino physiotherapists, it will form the basis of a much needed national intervention which is contextually appropriate to Filipino physiotherapists. It will therefore form the genesis for a model for building EBP capacity of other health professionals in the Philippines as well as physiotherapists in developing countries.
Current Controlled Trials: ISRCTN74485061.
One possible reason for the continued neglect of statistical power analysis in research in the behavioral sciences is the inaccessibility of or difficulty with the standard material. A convenient, although not comprehensive, presentation of required sample sizes is provided. Effect-size indexes and conventional values for these are given for operationally defined small, medium, and large effects. The sample sizes necessary for .80 power to detect effects at these levels are tabled for 8 standard statistical tests: (1) the difference between independent means, (2) the significance of a product-moment correlation, (3) the difference between independent rs, (4) the sign test, (5) the difference between independent proportions, (6) chi-square tests for goodness of fit and contingency tables, (7) 1-way analysis of variance (ANOVA), and (8) the significance of a multiple or multiple partial correlation.
To examine evidence for properties of the transtheoretical model stages of change-decisional balance relationship as applied to dietary behavior.
Data extracted from 27 studies of 8 different behaviors were examined.
The measurement structure of decisional balance, relative magnitude of the pros and cons within stages, and shifts in the pros and cons across stages were consistent with theory. Across behaviors, the average increase in pros (.82) was greater than the average decrease in cons (.55) from precontemplation to action stages.
The transtheoretical model is useful for understanding the decision-making process involved in dietary behavior change.
Background:
In the previous version of this review, the effectiveness of interventions tailored to barriers to change was found to be uncertain.
Objectives:
To assess the effectiveness of interventions tailored to address identified barriers to change on professional practice or patient outcomes.
Search strategy:
For this update, in addition to the EPOC Register and pending files, we searched the following databases without language restrictions, from inception until August 2007: MEDLINE, EMBASE, CINAHL, BNI and HMIC. We searched the National Research Register to November 2007. We undertook further searches to October 2009 to identify potentially eligible published or ongoing trials.
Selection criteria:
Randomised controlled trials (RCTs) of interventions tailored to address prospectively identified barriers to change that reported objectively measured professional practice or healthcare outcomes in which at least one group received an intervention designed to address prospectively identified barriers to change.
Data collection and analysis:
Two reviewers independently assessed quality and extracted data. We undertook quantitative and qualitative analyses. The quantitative analyses had two elements.1. We carried out a meta-regression to compare interventions tailored to address identified barriers to change with either no interventions or an intervention(s) not tailored to the barriers.2. We carried out heterogeneity analyses to investigate sources of differences in the effectiveness of interventions. These included the effects of: risk of bias, concealment of allocation, rigour of barrier analysis, use of theory, complexity of interventions, and the reported presence of administrative constraints.
Main results:
We included 26 studies comparing an intervention tailored to address identified barriers to change to no intervention or an intervention(s) not tailored to the barriers. The effect sizes of these studies varied both across and within studies.Twelve studies provided enough data to be included in the quantitative analysis. A meta-regression model was fitted adjusting for baseline odds by fitting it as a covariate, to obtain the pooled odds ratio of 1.54 (95% CI, 1.16 to 2.01) from Bayesian analysis and 1.52 (95% CI, 1.27 to 1.82, P < 0.001) from classical analysis. The heterogeneity analyses found that no study attributes investigated were significantly associated with effectiveness of the interventions.
Authors' conclusions:
Interventions tailored to prospectively identified barriers are more likely to improve professional practice than no intervention or dissemination of guidelines. However, the methods used to identify barriers and tailor interventions to address them need further development. Research is required to determine the effectiveness of tailored interventions in comparison with other interventions.
The Transtheoretical Model (TTM) has gained widespread popularity and acceptance, yet little is known about its effectiveness as a basis for health behavior intervention. A systematic review was conducted in order to evaluate the effectiveness of TTM interventions in facilitating health-related behavior change. Thirty-five electronic databases, catalogues, and internet resources were searched for relevant studies. In addition, the bibliographies of retrieved references were scanned for further relevant publications and authors were contacted for further information where necessary. Thirty-seven randomized controlled trials, targeting seven health-related behaviors, satisfied the inclusion criteria. Overall, the methodological quality of trials was variable, and there was limited evidence for the effectiveness of stage-based interventions as a basis for behavior change or for facilitating stage progression, irrespective of whether those interventions were compared with other types of intervention or with no intervention or usual care controls. The theoretical and practical implications of these findings are discussed.
The transtheoretical model posits that health behavior change involves progress through six stages of change: precontemplation, contemplation, preparation, action, maintenance, and termination. Ten processes of change have been identified for producing progress along with decisional balance, self-efficacy, and temptations. Basic research has generated a rule of thumb for at-risk populations: 40% in precontemplation, 40% in contemplation, and 20% in preparation. Across 12 health behaviors, consistent patterns have been found between the pros and cons of changing and the stages of change. Applied research has demonstrated dramatic improvements in recruitment, retention, and progress using stage-matched interventions and proactive recruitment procedures. The most promising outcomes to date have been found with computer-based individualized and interactive interventions. The most promising enhancement to the computer-based programs are personalized counselors. One of the most striking results to date for stage-matched programs is the similarity between participants reactively recruited who reached us for help and those proactively recruited who we reached out to help. If results with stage-matched interventions continue to be replicated, health promotion programs will be able to produce unprecedented impacts on entire at-risk populations.
To describe the development and validation of a test of knowledge and skills in evidence based medicine.
Cross sectional study.
Family practice residency programme in California; a list server for those who teach evidence based medicine; and an evidence based medicine seminar series.
Family practice residents and faculty members (n=43); volunteers self identified as experts in evidence based medicine (n=53); family practice teachers (19) beginning a seminar series on evidence based medicine.
The Fresno test is a performance based measure for use in medical education that assesses a wide range of evidence based medicine skills. Open ended questions are scored with standardised grading rubrics. Calculation skills are assessed by fill in the blank questions.
Inter-rater reliability, internal reliability, item analyses, and construct validity. Results: Inter-rater correlations ranged from 0.76 to 0.98 for individual items. Cronbach's alpha was 0.88. Item difficulties ranged from moderate to difficult, all with positive and strong ability to discriminate between candidates. Experts scored consistently higher than novices. On the 212 point test, the novice mean was 95.6 and the expert mean was 147.5 (P<0.001). On individual items, a higher proportion of experts than novices earned passing scores on 15 of the 17 items.
The Fresno test is a reliable and valid test for detecting the effect of instruction in evidence based medicine. Its use in other settings requires further exploration.
Some strategies to change the practice or behaviour of health care professionals are successful in improving health care while others are not. One explanation may be that there are different barriers to change in different settings and at different times. Change may be more likely if the strategies are specifically chosen to address the identified barriers. Barriers could be related to the individual (e.g. uncertainty about the risks of a procedure); related to social issues (e.g. peer pressure to perform a certain way); or related to the organisation (e.g. no access to equipment). And to successfully change behaviour, barriers should be identified and a strategy developed to overcome those barriers. In other words, it is thought that strategies tailored to overcome barriers should be more effective to change behaviour than non-tailored strategies or no strategy at all. Fifteen studies evaluated tailored strategies for behaviour change in health care professionals. The results were mixed. It is therefore, unclear whether tailored strategies are more effective than non-tailored strategies or no strategy. Due to a small number of studies, it is also not possible to determine whether strategies tailored to overcome organisational barriers are more effective than those that were not. It is also not clear whether all barriers or important barriers were identified and addressed by the strategies. More research about how to identify and overcome barriers is needed.
Many health professionals lack the skills to find and appraise published research. This lack of skills and associated knowledge needs to be addressed, and practice habits need to change, for evidence-based practice to occur. The aim of this before and after study was to evaluate the effect of a multifaceted intervention on the knowledge, skills, attitudes and behaviour of allied health professionals.
114 self-selected occupational therapists were recruited. The intervention included a 2-day workshop combined with outreach support for eight months. Support involved email and telephone contact and a workplace visit. Measures were collected at baseline, post-workshop, and eight months later. The primary outcome was knowledge, measured using the Adapted Fresno Test of Evidence-Based Practice (total score 0 to 156). Secondary outcomes were attitude to evidence-based practice (% reporting improved skills and confidence; % reporting barriers), and behaviour measured using an activity diary (% engaging/not engaging in search and appraisal activities), and assignment completion.
Post-workshop, there were significant gains in knowledge which were maintained at follow-up. The mean difference in the Adapted Fresno Test total score was 20.6 points (95% CI, 15.6 to 25.5). The change from post-workshop to follow-up was small and non-significant (mean difference 1.2 points, 95% CI, -6.0 to 8.5). Fewer participants reported lack of searching and appraisal skills as barriers to evidence-based practice over time (searching = 61%, 53%, 24%; appraisal 60%, 65%, 41%). These differences were statistically significant (p = 0.0001 and 0.010 respectively). Behaviour changed little. Pre-workshop, 6% engaged in critical appraisal increasing to 18% post-workshop and 18% at follow-up. Nearly two thirds (60%) were not reading any research literature at follow-up. Twenty-three participants (20.2%) completed their assignment.
Evidence-based practice skills and knowledge improved markedly with a targetted education intervention and outreach support. However, changes in behaviour were small, based on the frequency of searching and appraisal activities. Allied health educators should focus more on post-workshop skill development, particularly appraisal, and help learners to establish new routines and priorities around evidence-based practice. Learners also need to know that behaviour change of this nature may take months, even years.
Stress has been associated with a variety of chronic and acute conditions and with higher use of health care services. This research reports on 18-month outcomes of a randomized clinical trial of a stress-management program based on the transtheoretical model (TTM; J. O. Prochaska & C. C. DiClemente, 1986). A national sample of 1,085 individuals participated (age range = 18-91 years, M = 55.33; 68.9% female, 31.1% male; 84.8% Caucasian; 15.2% non-Caucasian). Both the treatment and control groups received assessments at 0, 6, 12, and 18 months. In addition to the assessments, the treatment group received 3 individualized reports (0, 3, 6 months) and a manual. The 18-month assessment was completed by 778 individuals (72%). A random effects model indicated that participants completing the study in the treatment group had significantly more individuals reporting effective stress management at follow-up time points than did completers in the control group. Results also indicate that the intervention had significant effects on stress, depression, and specific stress-management behaviors. Results provide evidence for the effectiveness of this TTM population-based stress-management intervention.
Training in Evidence-Based Practice (EBP) has been widely implemented throughout medical school and residency curricula. The aim of this study is to systematically review studies that assessed the effectiveness of EBP teaching to improve knowledge, skills, attitudes and behavior of postgraduate healthcare workers, and to describe instruments available to evaluate EBP teaching.
The design is a systematic review of randomized, non-randomized, and before-after studies. The data sources were MEDLINE, Cochrane Library, EMBASE, CINAHL and ERIC between 1966 and 2006. Main outcomes were knowledge, skills, attitudes and behavior towards EBP. Standardized effect sizes (E-S) were calculated. The E-S was categorized as small (E-S < 0.2), small to moderate (E-S between 0.2 and 0.5), moderate to large (E-S between 0.51 and 0.79), large (E-S > 0.79). Reliability and validity of instruments for evaluating education were assessed. Studies excluded were those that were not original, performed in medical students, focused on prescribing practices, specific health problems, theoretical reviews of different components of EBP, continuing medical education, and testing the effectiveness of implementing guidelines.
Twenty-four studies met our inclusion criteria. There were 15 outcomes within the 10 studies for which E-S could be calculated. The E-S ranged from 0.27 (95%CI: -0.05 to 0.59) to 1.32 (95%CI: 1.11 to 1.53). Studies assessing skills, behavior and/or attitudes had a "small to moderate" E-S. Only 1 of the 2 studies assessing knowledge had E-S of 0.57 (95 CI: 0.32 to 0.82) and 2 of the 4 studies that assessed total test score outcomes had "large" E-S. There were 22 instruments used, but only 10 had 2 or more types of validity or reliability evidence.
Small improvements in knowledge, skills, attitudes or behavior are noted when measured alone. A large improvement in skills and knowledge in EBP is noted when measured together in a total test score. Very few studies used validated measures tests.
It is common to find published studies in which the authors claim to have found significant results. However, many times these results are only statistically significant with no meaningful impact in clinical settings.
The authors aim to clarify and differentiate the concepts of statistical and clinical significance, as well as to provide guidance on how to interpret research results to determine whether an observed difference is meaningful.
Study results are considered to be statistically significant if statistical tests that examine the null hypothesis of no difference yield P values that are smaller than the significance level prespecified by the authors. In this way, researchers can use hypothesis testing to assess the possibility that observed results could have arisen by chance. However, hypothesis testing cannot establish the clinical implications of these results. Rather, clinical significance can be established once the magnitude of results is larger than the minimal clinically important difference. Clinical significance then would encompass not only statistical significance, but also the importance of the outcomes to patients, clinicians and policymakers.
The values for statistical significance alone cannot convey the complete picture of the effectiveness of an intervention or of a difference between two groups. Both clinical and statistical significance are important measures for interpretation of clinical research results and should complement each other. Practical Implications. Any benefit in terms of improved health outcomes must be both clinically and statistically significant. If there is no benefit at the threshold of both clinical and statistical improvement, then the intervention should not be used for that purpose.
Evidence-based practice (EBP) has evolved from concerns for patient safety. Few studies exist regarding EBP among registered dietitians (RDs). The objective of this pilot study was to describe perceptions, attitudes, and knowledge and clinical use of EBP among practicing RDs. Results suggest that despite access to databases, RD respondents used evidence-based resources less than once a month. Primary barriers to the implementation of EBP were lack of available mentors, insufficient training, and limited time. Increased frequency of using resources was positively associated with an improved ability to incorporate EBP in clinical practice. In conclusion, targeted educational interventions may be needed to increase clinical use of EBP among practicing RDs.
Obesity is a global public health threat. The transtheoretical model stages of change (TTM SOC) model has long been considered a useful interventional approach in lifestyle modification programmes, but its effectiveness in producing sustainable weight loss in overweight and obese individuals has been found to vary considerably.
To assess the effectiveness of dietary and physical activity interventions based on the transtheoretical model, to produce sustainable weight loss in overweight and obese adults.
Studies were obtained from searches of multiple electronic bibliographic databases. Date of last search for The Cochrane Library was issue 10, 2010, for MEDLINE Dezember 2010, for EMBASE January 2011 and for PSYCHINFO Januar 2011.
Trials were included if they fulfilled the following criteria: randomised controlled clinical trials using TTM SOC as a model, theoretical framework or guideline in designing lifestyle modification strategies, mainly dietary and physical exercise versus a comparison intervention of usual care; one of the outcome measures of the study was weight loss; and participants were overweight or obese adults.
Two researchers independently applied the inclusion criteria to the identified studies and assessed risk of bias. Disagreement was resolved by discussion or by intervention of a third party. Descriptive analysis was conducted for the review.
A total of five studies met the inclusion criteria and a total of 3910 participants were evaluated. The total number of participants randomised to intervention groups was 1834 and 2076 were randomised to control groups. Overall risk of bias was high. The trials varied in length of intervention from six weeks to 24 months, with a median length of nine months. The intervention was found to have limited impact on weight loss (about 2 kg or less) and other outcome measures. There was no conclusive evidence for sustainable weight loss. However, TTM SOC and a combination of physical activity, diet and other interventions tended to produce significant outcomes (particularly change in physical activity and dietary intake). TTM SOC was used inconsistently as a theoretical framework for intervention in the trials. Death and weight gain are the two adverse events reported by the included trials. None of the trials reported health-related quality of life, morbidity, and costs as outcomes.
TTM SOC and a combination of physical activity, diet and other interventions resulted in minimal weight loss, and there was no conclusive evidence for sustainable weight loss. The impact of TTM SOC as theoretical framework in weight loss management may depend on how it is used as a framework for intervention and in combination with other strategies like diet and physical activities.
Several clinical practice guidelines focusing on nutrition therapy in mechanically ventilated, critically ill patients are available to assist busy critical care practitioners in making decisions regarding feeding their patients. However, large gaps have been observed between guideline recommendations and actual practice. To be effective in optimizing nutrition practice, guideline development must be followed by systematic guideline implementation strategies. Systematic reviews of studies evaluating guideline implementation interventions outside the critical care setting found that these strategies, such as reminders, educational outreach, and audit and feedback, produce modest to moderate improvements in processes of care, with considerable variation observed both within and across studies. Unfortunately, the optimal strategies to implement guidelines in the intensive care unit are poorly understood, with scarce data available to guide our decisions on which strategies to use. The authors identified 3 cluster randomized trials evaluating the implementation of nutrition guidelines in the critical care setting. These studies demonstrated small improvements in nutrition practice, but no significant effect on patient outcomes. There are some data to suggest that tailoring guideline implementation strategies to overcome identified barriers to change might be a more effective approach than the multifaceted "one size fits all" strategy used in previous studies. Adopting this tailored approach to guideline implementation in future studies may help bridge the current guideline-practice gap and lead to significant improvements in nutrition practices and patient outcomes.
Individual and workplace barriers affect uptake of evidence-based practice (EBP). This study evaluated the effects of a 1-day workshop with workplace supports on allied health professionals' EBP knowledge and behaviour.
A prospective longitudinal pre-post design was used. A total of 88 allied health professionals participated. Knowledge was measured using the Adapted Fresno Test (AFT), behaviour was measured using frequency counts of presentations using EBP methodologies and critically appraised topics (CATs) were produced. Mean differences were analysed using paired t-tests.
EBP knowledge significantly improved immediately after education on the AFT (from 36.67 to 46.84/156) a mean change of 10.17 points (95% confidence interval (CI): 7.19-13.50) (P <0.001). Behaviour also changed over 18 months. EBP content in presentations increased from 3 to 100% (t = 24.39, P <0.001, 95%CI: 0.86-1.03). CATs produced significantly increased by 0.26 per head (t =5.55, P <0.001, 95% CI: 0.17-0.35).
Education with workplace supports (supervision, incentives, resource allocation and working groups) may lead to improvements in EBP knowledge and implementation.
Health care professionals are expected to use a systematic approach based on evidence, professional reasoning and client preferences in order to improve client outcomes. In other words, they are expected to work within an evidence-based practice (EBP) context. This expectation has had an impact on occupational therapy academic programs' mandates to prepare entry-level clinicians who demonstrate competence in the knowledge, skills and behaviors for the practice of evidence-based occupational therapy. If the EBP approach is to be entrenched in the day to day practice of future clinicians, a pedagogically sound approach would be to incorporate EBP in every aspect of the curriculum. This, however, would require a comprehensive understanding of EBP: its basis, the principles that underpin it and its effectiveness in promoting core professional competencies. The existing literature does not elucidate these details nor does it shed light on how requisite competencies for EBP are acquired in professional education in general and in occupational therapy education in particular. Drawing from educational psychology and EBP in the health professions, this paper provides a critical review of the evidence that supports EBP and the effectiveness of EBP teaching and assessment interventions in professional heath sciences programs and offers suggestions for the design of EBP instruction, grounding recommendations in educational theory for the health professions.
The purpose of this study was to evaluate whether effectiveness of a special intervention to improve diet vs a control intervention differs by readiness to reduce dietary saturated fat based on the Transtheoretical Model Stages of Change among family members of hospitalized cardiovascular disease patients.
Stages of change (ie, precontemplation, contemplation, preparation, action, maintenance) were assessed by standardized questionnaire. Diet was measured by Block 98 Food Frequency Questionnaire at baseline and 1 year in participants in the Family Intervention Trial for Heart Health (n=501; 36% racial/ethnic minorities; 66% female). Therapeutic Lifestyle Change diet education was provided to each special intervention subject tailored to baseline stage of change.
Multivariable linear regression was used to examine whether the effect of the intervention was modified by stage of change.
Baseline saturated fat and cholesterol intakes were lower among those in maintenance stage vs others (9.9% vs 11.2% kcal; P<0.0001 and 112.2 vs 129.7 mg/1,000 kcal; P=0.0003, respectively). Overall, change in the percentage of calories from saturated fat from baseline to 1 year was -0.7 in the special intervention vs -0.4 in the control intervention (P=0.18). Among participants in contemplation, greater reductions in saturated fat (-2.1% vs +0.3% kcal; P=0.04) and cholesterol (-34.0 vs +32.6 mg/1,000 kcal; P=0.01) were seen in the special intervention vs control intervention. The special intervention was more likely than control intervention to achieve new adherence to a diet of <10% saturated fat/<300 mg cholesterol at 1 year among those not in maintenance stage (30% vs 15%; P=0.03). Control intervention participants were more likely than special intervention to revert to lower levels on the stage of change continuum from baseline to 1 year (17% vs 7%; P=0.002).
Effectiveness of an intervention to lower saturated fat varies by baseline stage of change among family members of hospitalized cardiovascular patients. This can be important to consider when designing research or clinical diet interventions.
This article is about differences between, and the adequacy of, response rates to on line and paper-based course and teaching evaluation surveys. Its aim is to provide practical guidance on these matters. The first part of the article gives an overview of on-line surveying in general, a review of data relating to survey response rates and, practical advice to help boost response rates. The second part of the article discusses when a response rate may be considered big enough for the survey data to provide adequate evidence for accountability and improvement purposes. The article ends with suggestions for improving the effectiveness of evaluation strategy. These suggestions are: to seek to obtain the highest response rates possible to all surveys; to take account of probable effects of survey design and methods on the feedback obtained when interpreting that feedback; and, to enhance this action by making use of data derived from multiple methods of gathering feedback. Yes Yes
This paper is a report of a study to evaluate the effectiveness of the evidence-based practice (EBP)-focused interactive teaching (E-FIT) strategy.
Although EBP is a mandatory competency for all healthcare professionals, little is known about the effectiveness of E-FIT in nursing.
Aquasi-experimental, controlled, pre- and post-test study involving senior, 4th-year nursing students (N = 208) at two nursing schools in the USA was carried out from August 2007 to May 2008. The experimental group (n = 88) received the E-FIT strategy intervention and the control group (n = 120) received standard teaching. A Knowledge, Attitudes and Behaviors Questionnaire for Evidence-Based Practice was used to assess the effectiveness of the E-FIT strategy.
Independent t-tests showed that the experimental group had statistically significant higher post-test Evidence-Based Practice Knowledge (mean difference = 0.25; P = 0.001) and Evidence-Based Practice Use (mean difference = 0.26; P = 0.015) subscale scores compared to the control group, but showed no statistically significant differences in Attitudes toward Evidence-Based Practice and Future Use of Evidence-Based Practice (mean difference = 0.12; P = 0.398 and mean difference = 0.13; P = 0.255 respectively). Hierarchical multiple regression analyses of the post-test data indicated that the intervention explained 7.6% and 5.1% of variance in Evidence-Based Practice Knowledge and Evidence-Based Practice Use respectively.
The EBP-focused interactive teaching strategy was effective in improving the knowledge and use of EBP among nursing students but not attitudes toward or future use of EBP.
Physicians are continuously engaging in continuing medical education (CME) activities. Whether CME activities actually improve their knowledge and whether multiple media, instructional techniques, and exposures are better than single experiences are questions that are still under discussion.
The Johns Hopkins Evidence-based Practice Center for Healthcare Research and Quality conducted a systematic review of the effectiveness of CME (Agency for Healthcare Research and Quality Evidence Report) from which the guideline panel used 28 (+/- 2) studies to answer these questions about improvements in knowledge. The studies were selected based on the presence of an adequate control group from an initial pool of 136 studies on CME.
Despite the heterogeneity of the studies reviewed and the low quality of the evidence, the results from the majority of the studies (79%) showed that CME activities were associated with improvements in physician knowledge.
The evidence gathered about the use of media and instructional techniques and the frequency of exposure suggests that multimedia, multiple instructional techniques, and multiple exposures be used whenever possible in CME. Future studies of CME should include assessment of applied knowledge, and should incorporate programmatic and collaborative studies of CME.
Transitioning to an evidence-based practice (EBP) environment is a new and often overwhelming challenge for many organisations. The most effective strategies to implement EBP have yet to be determined. In this study an accelerated development EBP program, which was administered to nurses from five hospitals was evaluated. At each hospital, nurses were selected as an "EBP champion" whose role would be to help facilitate the transition within that organisation.
The purpose of this study was to evaluate the effectiveness of an accelerated educational program on the attitudes toward and implementation of EBP among nurses employed in acute-care facilities.
Forty-nine nurses from five acute-care facilities participated in an 8-week program to develop into EBP champions. Participants attended a 2-hour class each week conducted by four faculty members of a local university. Pre- and post-test mean scores of the EBP barriers (EBPB) and EBP implementation (EBPI) scales were compared using paired t tests to determine the effect of the accelerated development program.
Respondents reported higher scores on both the beliefs and implementation scales at the end of the program. Paired t tests indicated a significant difference in means for both the EBPB (p < .01) and EBPI (p < .01).
Nurses who attend an accelerated educational program have the potential to significantly improve beliefs and attitudes about EBP. Administrative support and collaboration between academia and service are essential for successful intervention.
Unlabelled:
Health decision making is both the lynchpin and the least developed aspect of evidence-based practice. The evidence-based practice process requires integrating the evidence with consideration of practical resources and patient preferences and doing so via a process that is genuinely collaborative. Yet, the literature is largely silent about how to accomplish integrative, shared decision making.
Implications:
for evidence-based practice are discussed for 2 theories of clinician decision making (expected utility and fuzzy trace) and 2 theories of patient health decision making (transtheoretical model and reasoned action). Three suggestions are offered. First, it would be advantageous to have theory-based algorithms that weight and integrate the 3 data strands (evidence, resources, preferences) in different decisional contexts. Second, patients, not providers, make the decisions of greatest impact on public health, and those decisions are behavioral. Consequently, theory explicating how provider-patient collaboration can influence patient lifestyle decisions made miles from the provider's office is greatly needed. Third, although the preponderance of data on complex decisions supports a computational approach, such an approach to evidence-based practice is too impractical to be widely applied at present. More troublesomely, until patients come to trust decisions made computationally more than they trust their providers' intuitions, patient adherence will remain problematic. A good theory of integrative, collaborative health decision making remains needed.
A new paradigm for medical practice is emerging. Evidence-based medicine de-emphasizes intuition, unsystematic clinical experience, and pathophysiologic rationale as sufficient grounds for clinical decision making and stresses the examination of evidence from clinical research. Evidence- based medicine requires new skills of the physician, including efficient literature searching and the application of formal rules of evidence evaluating the clinical literature.
See PDF for full text of the original JAMA article.
The Grades of Recommendation Assessment, Development and Evaluation Working Group (GRADE) has developed a framework for the formulation of treatment recommendations that is based on the contemporary principles of EBM.¹¹ The GRADE process highlights the importance of clear specification of the question with identification of all patient-important outcomes and the necessity for systematic summaries of all the best evidence to guide recommendations. The GRADE process includes an important evolution in EBM: the definition of quality of evidence and the components that determine quality (including study design and study limitations, consistency, precision, and the extent to which the evidence directly applies to the patients, interventions, and outcomes of interest). The GRADE framework requires the specification of values and preferences in making recommendations and demands attention to circumstances (and resources for competing priorities) in deciding how confident one is that following a recommendation will do more good than harm. This system produces either strong recommendations (ideal targets for quality improvement efforts) or weak ones (ideal targets for careful incorporation of patient preferences [eg, using decision aids in practice]).
Most evidence-based practice (EBP) educational assessment tools evaluated to date have focused on specific knowledge components or technical skills. Other important potential barriers to the adoption of EBP, such as attitudinal, perceptual and behavioural factors, have yet to be studied, especially in the undergraduate setting. Therefore, we developed and validated a knowledge, attitude and behaviour questionnaire designed to evaluate EBP teaching and learning in an undergraduate medical curriculum.
We derived the questionnaire from a comprehensive literature review, informed by international and local experts and a Year 5 student focus group. We determined its factor structure and refined and validated the questionnaire according to the responses of a cohort of Year 5 and a combined group of Years 2 and 3 students using principal components factor analysis with varimax rotation. Factor reliability was computed using Cronbach's alpha coefficient. We assessed construct validity by correlating the factors with other measures of EBP activity and examined responsiveness through paired t-test of the pre/post factor mean scores.
A 43-item questionnaire was developed. Four factors were identified from both student groups. The overall questionnaire as well as each factor had high construct validity (Cronbach's alpha > 0.7 for each scale). No significant correlations were found between the 4 factors, confirming their orthogonality. Positive correlations, however, resulted between factor mean scores and other EBP activities. The responsiveness of the questionnaire was satisfactory.
A reliable knowledge, attitude and behaviour measure of EBP teaching and learning appropriate for undergraduate medical education has been developed and validated.
The objective of this study was to measure dietitians' perceptions, attitudes, and knowledge of evidence-based practice (PAK score), and to determine whether antecedent factors (eg, sociodemographic characteristics, education and training, professional experiences, and employment setting) predicted PAK score.
This cross-sectional, descriptive study used the Dietitian Research Involvement Survey following the Tailored Design Method.
This study surveyed 500 randomly selected registered dietitians from seven dietetic practice groups of the American Dietetic Association.
Bivariate relationships were examined between antecedent factors and PAK score. Multiple linear regression analyses were conducted to test whether these factors predicted PAK score.
Higher PAK scores were associated with registered dietitians who completed more years of education (r=0.28, P<.0005), had taken a research course (r=0.28, P<.0005), frequently read research articles (r=0.41, P<.0005), earned an advanced-level board certification (r=0.18, P=.004), worked full-time (r=0.26, P<.0005), or belonged to professional organizations (r=0.18, P=.003). The strongest predictors for PAK score were "last time read research" (beta=.33, P<.0005), work status (beta=.20, P<.0005), level of education (beta=.19, P=.001), and association memberships (beta=.14, P=.01).
Results indicated that dietitians' ability to incorporate an evidence-based approach is largely determined by their education and training, work experience, and professional association involvement. This study identified a need to integrate concepts and principles of evidence-based practice into dietetics curriculums so that practitioners are able to routinely apply research findings to clinical practice.
A consistent finding in articles on quality improvement in health care is that change is difficult to achieve. According to the research literature, the majority of interventions are targeted at health care professionals. But success in achieving change may be influenced by factors other than those relating to individual professionals, and theories may help explain whether change is possible. This article argues for a more systematic use of theories in planning and evaluating quality-improvement interventions in clinical practice. It demonstrates how different theories can be used to generate testable hypotheses regarding factors that influence the implementation of change, and it shows how different theoretical assumptions lead to different quality-improvement strategies.
A complicating factor affecting the treatment of individuals with coexisting substance use problems and serious mental illness is their motivation for change and how these interacting, chronic conditions affect the entire process of intentional behavior change. This selective review explores conceptual and assessment issues related to readiness to modify substance use and readiness to initiate behaviors helpful for managing mental illness in the search for a better understanding of patient motivation for change. The recent but limited research on motivation and stages of change among dually diagnosed patients indicates that these individuals appear to access and use an intentional behavior change process. However, it is not completely clear how this process works and what precise adaptations are needed to assess and to access motivation to change to encourage sustained behavior change in this population. Nevertheless, motivation and readiness to change are important dimensions that need to be addressed in treatment and research with dually diagnosed populations.
Bridging the guideline-practice gap in critical care nutrition: a review of guideline implementation studies
- Cahill
Perceptions, attitudes, knowledge and clinical use of evidence-based practice: a prospective descriptive pilot study
- Vogt
The adequacy of response rates to online and paper surveys: what can be done?
- Nulty