Transferability of principles of evidence based medicine to improve educational quality: systematic review and case study of an online course in primary health care

Application value and feasibility analysis of humanistic health management for cancer screening in physical examination

OBJECTIVE

To investigate the application value and feasibility of humanistic health management in cancer screening in physical examination.

METHODS

A total of 100 carcinoma patients were randomly grouped into the control group and the experimental group, with 50 cases in each group. The patients in the control group received a general physical examination, while those in the experimental group received humanistic health care management model, health education, environmental management, private nursing and emergency management. The two groups were compared in missing item rate, health knowledge score, physical examination quality, basic literacy of nursing staff, adverse events and physical examination satisfaction.

RESULTS

There was 1 case of missing items in the ENT (ear nose throat branch) in the experimental group, with a missing item rate of 2.00%, and 7 cases of missing items in the control group, with a missing item rate of 14.00% (χ2=9.000, P=0.003). The score of mastering health knowledge in the experimental group was higher than that in the control group (t=15.663, P<0.001). Compared with the control group, the experimental group experienced shorter time of physical examination and obtained higher reliability and efficiency of physical examination (all P<0.05) and higher scores of professional ethics, interpersonal communication, coordination ability, humanistic quality and civility of nursing staff (all P<0.05). In addition, the incidence of adverse events in the control group was 32.00% (16/50), which was higher than that in the experimental group (18.00%, 9/50; χ2=3.920, P=0.048). There was no difference in satisfaction between the two groups (P>0.05).

CONCLUSION

Humanistic health management can improve the efficiency of medical examination, the mastery of health knowledge and reduce the rate of missed examinations and adverse accidents, thus improving the overall satisfaction of patients.

Re-envisioning paradigms of education: towards awareness, alignment, and pluralism

In this article we introduce a synthesis of education "paradigms," adapted from a multi-disciplinary body of literature and tailored to health professions education (HPE). Each paradigm involves a particular perspective on the purpose of education, the nature of knowledge, what knowledge is valued and included in the curriculum, what it means to learn and how learning is assessed, and the roles of teachers and learners in the learning process. We aim to foster awareness of how these different paradigms look in practice and to illustrate the importance of alignment between teaching, learning and assessment practices with paradigmatic values and assumptions. Finally, we advocate for a pluralistic approach that purposefully and meaningfully integrates paradigms of education, enhancing our ability to drive quality in HPE.

The Divergence and Convergence of Critical Reflection and Critical Reflexivity: Implications for Health Professions Education

As a field, health professions education (HPE) has begun to answer calls to draw on social sciences and humanities (SS&H) knowledge and approaches for curricular content, design, and pedagogy. Two commonly used SS&H concepts in HPE are critical reflection and critical reflexivity. But these are often conflated, misunderstood, and misapplied. Improved clarity of these concepts may positively affect both the education and practice of health professionals. Thus, the authors seek to clarify the origins of each, identify the similarities and differences between them, and delineate the types of teaching and assessment methods that fit with critical reflection and/or critical reflexivity. Common to both concepts is an ultimate goal of social improvement. Key differences include the material emphasis of critical reflection and the discursive emphasis of critical reflexivity. These similarities and differences result in some different and some similar teaching and assessment approaches, which are highlighted through examples. The authors stress that all scientific and social scientific concepts and methods imported into HPE must be subject to continued scrutiny both from within their originating disciplines and in HPE. This continued questioning is core to the ongoing development of the HPE field and also to health professionals' thinking and practice.

A Web-Based Course on Public Health Principles in Disaster and Medical Humanitarian Response: Survey Among Students and Faculty

BACKGROUND

Web-based public health courses are becoming increasingly popular. "Public Health Principles in Disaster and Medical Humanitarian Response" is a unique Web-based course in Hong Kong. This course aimed to fill a public health training gap by reaching out to postgraduates who are unable to access face-to-face learning.

OBJECTIVE

The aim of this paper was to use a structured framework to objectively evaluate the effectiveness of a Web-based course according to Greenhalgh et al's quality framework and the Donabedian model to make recommendations for program improvement.

METHODS

An interim evaluation of the first cohort of students in 2014 was conducted according to the Donabedian model and a quality framework by Greenhalgh et al using objective and self-reported data.

RESULTS

Students who registered for the first cohort (n=1152) from June 16, 2014 to December 15, 2014 (6 months) were surveyed. Two tutors and the course director were interviewed. The Web-based course was effective in using technology to deliver suitable course materials and assessment and to enhance student communication, support, and learning. Of the total number of students registered, 59.00% (680/1152) were nonlocal, originating from 6 continents, and 72.50% (835/1152) possessed a bachelor's or postgraduate degree. The completion rate was 20.00% (230/1152). The chi-square test comparing students who completed the course with dropouts showed no significant difference in gender (P=.40), age (P=.98), occupation (P=.43), or qualification (P=.17). The cost (HK $272 per student) was lower than that of conducting a face-to-face course (HK $4000 per student).

CONCLUSIONS

The Web-based course was effective in using technology to deliver a suitable course and reaching an intended audience. It had a higher completion rate than other Web-based courses. However, sustainable sources of funding may be needed to maintain the free Web-based course.

Re-positioning faculty development as knowledge mobilization for health professions education

Faculty development as knowledge mobilization offers a particularly fruitful and novel avenue for exploring the research-practice interface in health professions education. We use this 'eye opener' to build off this assertion to envision faculty development as an enterprise that provides a formal, recognized space for the sharing of research and practical knowledge among health professions educators. Faculty development's knowledge mobilizing strategies and outcomes, which draw upon varied sources of knowledge, make it a potentially effective knowledge mobilization vehicle.First, we explain our choice of the term knowledge mobilization over translation, in an attempt to resist the false dichotomy of 'knowledge user' and 'knowledge creator'. Second, we leverage the documented strengths of faculty development against the documented critiques of knowledge mobilization in the hopes of avoiding some of the pitfalls that have befallen previous attempts at closing knowing-doing gaps.Through faculty development, faculty are indeed educated, in the traditional sense, to acquire new knowledge and skill, but they are also socialized to go on to form the systems and structures of their workplaces, as leaders and workers. Therefore, faculty development can not only mobilize knowledge, but also create knowledge mobilizers. Achieving this vision of faculty development as knowledge mobilization requires an acceptance of multiple sources of knowledge, including practice-based knowledge, and of multiple purposes for education and faculty development, including professional socialization.

Blurring the boundaries: using institutional ethnography to inquire into health professions education and practice

CONTEXT

Qualitative, social science approaches to research have surged in popularity within health professions education (HPE) over the past decade. Institutional ethnography (IE) offers the field another sociological approach to inquiry. Although widely used in nursing and health care research, IE remains relatively uncommon in the HPE research community. This article provides a brief introduction to IE and suggests why HPE researchers may wish to consider it for future studies.

METHODS

Part 1 of this paper presents IE's conceptual grounding in: (i) the entry point to inquiry ('materiality'), (ii) a generous definition of 'work' and (iii) a focus on how 'texts' such as policies, forms and written protocols influence activity. Part 2 of this paper outlines the method's key features through exemplars from our own research. Part 3 discusses the ways in which research that blurs the lines between educational and clinical practice can be both generative for HPE and accomplished using IE.

RESULTS

The authors demonstrate the usefulness of IE for studying complex social issues in HPE. It is posited that a key added value of IE is that it goes beyond individual-level explanations of problems and phenomena, yet also closely studies individuals' activities, rather than remaining at an abstract or distant level of analysis. Thereby, IE can result in feasible and meaningful social change at the nexus of health professions education and other social systems such as clinical practice.

CONCLUSIONS

IE adds to the growing qualitative research toolkit for HPE researchers. It is worth considering because it may enable change through the study of HPE in relation to other social processes, structures and systems, including the clinical practice world. A particular benefit may be found in blending HPE research with research on clinical practice, toward changing practice and policy through IE, given the interrelated nature of these fields.

A Case Study of Knowledge Management in Multiagency Consumer-Informed `Communities of Practice': Implications for Evidence-Based Policy Development in Health and Social Services

We report a study that facilitated and evaluated two multiagency Communities of Practice (CoPs) working on improving specific aspects of health and social services for older people, and analysed how they processed and applied knowledge in formulating their views. Data collection included observing and tape-recording the CoPs, interviewing participants and reviewing documents they generated and used. All these sources were analysed to identify knowledge-related behaviours. Four themes emerged from these data: (1) the way that certain kinds of knowledge became privileged and accepted; (2) the ways in which the CoP members transformed and internalized new knowledge; (3) how the haphazard processing of the available knowledge was contingent upon the organizational features of the groups; and (4) the ways in which the changing agendas, roles and power-relations had differential effects on collective sense making. We conclude by recommending ways in which the process of evidence-based policy development in such groups may be enhanced.

The impact of Cochrane Reviews: a mixed-methods evaluation of outputs from Cochrane Review Groups supported by the National Institute for Health Research

BACKGROUND

The last few decades have seen a growing emphasis on evidence-informed decision-making in health care. Systematic reviews, such as those produced by Cochrane, have been a key component of this movement. The National Institute for Health Research (NIHR) Systematic Review Programme currently supports 20 Cochrane Review Groups (CRGs) in the UK and it is important that this funding represents value for money.

AIMS AND OBJECTIVES

The overall aim was to identify the impacts and likely impacts on health care, patient outcomes and value for money of Cochrane Reviews published by 20 NIHR-funded CRGs during the years 2007-11.

DESIGN

We sent questionnaires to CRGs and review authors, undertook interviews with guideline developers (GDs) and used bibliometrics and documentary review to get an overview of CRG impact and to evaluate the impact of a sample of 60 Cochrane Reviews. The evaluation was guided by a framework with four categories (knowledge production, research targeting, informing policy development and impact on practice/services).

RESULTS

A total of 3187 new and updated reviews were published on the Cochrane Database of Systematic Reviews between 2007 and 2011, 1502 (47%) of which were produced by the 20 CRGs funded by the NIHR. We found 40 examples where reviews appeared to have influenced primary research and reviews had contributed to the creation of new knowledge and stimulated debate. Twenty-seven of the 60 reviews had 100 or more citations in Google Scholar™ (Google, CA, USA). Overall, 483 systematic reviews had been cited in 247 sets of guidance. This included 62 sets of international guidance, 175 sets of national guidance (87 from the UK) and 10 examples of local guidance. Evidence from the interviews suggested that Cochrane Reviews often play an instrumental role in informing guidance, although reviews being a poor fit with guideline scope or methods, reviews being out of date and a lack of communication between CRGs and GDs were barriers to their use. Cochrane Reviews appeared to have led to a number of benefits to the health service including safer or more appropriate use of medication or other health technologies or the identification of new effective drugs or treatments. However, whether or not these changes were directly as a result of the Cochrane Review and not the result of subsequent clinical guidance was difficult to judge. Potential benefits of Cochrane Reviews included economic benefits through budget savings or the release of funds, improvements in clinical quality, the reduction in the use of unproven or unnecessary procedures and improvements in patient and carer experiences.

CONCLUSIONS

This study identified a number of impacts and likely impacts of Cochrane Reviews. The clearest impacts of Cochrane Reviews are on research targeting and health-care policy, with less evidence of a direct impact on clinical practice and the organisation and delivery of NHS services. Although it is important for researchers to consider how they might increase the influence of their work, such impacts are difficult to measure. More work is required to develop suitable methods for defining and quantifying the impact of research.

FUNDING

The NIHR Health Technology Assessment programme.

Evidence synthesis in international development: a critique of systematic reviews and a pragmatist alternative

Systematic reviews are an instrument of Evidence-Based Policy designed to produce comprehensive, unbiased, transparent and clear assessments of interventions' effectiveness. From their origins in medical fields, systematic reviews have recently been promoted as offering important advances in a range of applied social science fields, including international development. Drawing on a case study of a systematic review of the effectiveness of community mobilisation as an intervention to tackle HIV/AIDS, this article problematises the use of systematic reviews to summarise complex and context-specific bodies of evidence. Social development interventions, such as 'community mobilisation' often take different forms in different interventions; are made successful by their situation in particular contexts, rather than being successful or unsuccessful universally; and have a rhetorical value that leads to the over-application of positively valued terms (e.g. 'community mobilisation'), invalidating the keyword search process of a systematic review. The article suggests that the policy interest in definitive summary statements of 'the evidence' is at odds with academic assessments that evidence takes multiple, contradictory and complex forms, and with practitioner experience of the variability of practice in context. A pragmatist philosophy of evidence is explored as an alternative. Taking this approach implies expanding the definition of forms of research considered to be 'useful evidence' for evidence-based policy-making; decentralising decisions about 'what works' to allow for the use of local practical wisdom; and prioritising the establishment of good processes for the critical use of evidence, rather than producing context-insensitive summaries of 'the evidence'.

Reclaiming a theoretical orientation to reflection in medical education research: a critical narrative review

CONTEXT

Reflection and reflective practice have become popular topics of scholarly dialogue in medical education. This popularity has given rise to checklists, portfolios and other tools to inspire and document reflection. We argue that some of the common ways in which reflection has been applied are influenced by broader discourses of assessment and evidence, and divorced from original theories of reflection and reflective practice.

METHODS

This paper was developed using a critical narrative approach. First we present two theoretical lenses provided by theories of reflection. Next we present a summary of relevant literature, indexed in PubMed from 2004 to 2014, relating to the application of reflection or reflective practice to undergraduate and postgraduate medical education. We categorise these articles broadly by trends and problematise the trends relative to the two theoretical lenses of reflection.

RESULTS

Two relevant theoretical orientations of reflection for medical education are: (i) reflection as epistemology of practice, and (ii) reflection as critical social inquiry. Three prevalent trends in the application of reflection to medical education are: (i) utilitarian applications of reflection; (ii) a focus on the self as the object of reflection, and (iii) reflection and assessment. These trends align with dominant epistemological positions in medicine, but not with those that underpin reflection.

CONCLUSIONS

We argue for continued theorising of and theoretically informed applications of reflection, drawing upon epistemologies of practice and critical reflection as critical social inquiry. These directions offer medical education research broad and deep potential in theories of reflection, particularly in relation to knowledge creation within uncertain and complex situations, and challenging of dominant discourses and structures. Future work could explore how dominant epistemological positions and discourses in medicine influence theories from other disciplines when these theories are deployed in medical education.

Illuminating the process: enhancing the impact of continuing professional education on practice

BACKGROUND

There has been significant global investment in continuing professional education (CPE) to ensure healthcare professionals have the knowledge and skills to respond effectively to the needs of patients/service users. However, there is little evidence to demonstrate that this investment has had a tangible impact on practice. Furthermore, the current emphasis on evaluating outcomes has overlooked the importance of underlying processes which, when positive, are essential to good outcomes.

OBJECTIVE

The aim of this study was to identify the processes that key stakeholders perceive to be most important in facilitating a positive impact of CPE on practice.

DESIGN/METHOD

A qualitative design using two rounds of semi-structured interviews which were recorded and transcribed prior to analysis, informed by template analysis techniques.

SETTING

Two acute trusts, one primary care trust and two higher education institutions in one geographical region in England.

PARTICIPANTS

Representatives from four stakeholder groups-students, managers, educators and members of each healthcare organisation's governing board. A total of 35 interviews were conducted in the first round and 31 interviews in the second round (n=66).

RESULTS

Four overarching themes were identified that illuminate stakeholders' perspectives of the important factors affecting the process of CPE: organisational structure, partnership working, a supportive learning environment and changing practice.

CONCLUSIONS

This study suggests that a positive organisational culture, effective partnership working between key stakeholders with an understanding of each other's perspectives, aspirations and constraints, and a supportive learning environment in both the practice setting and education environment are central to establishing a culture and context where CPE can thrive and exert a positive influence on improving patient/service user experience and care. It is argued that an understanding of the processes that facilitate effective CPE is a crucial first step before it is possible to meaningfully evaluate outcomes.

Development of methodological guidance, publication standards and training materials for realist and meta-narrative reviews: the RAMESES (Realist And Meta-narrative Evidence Syntheses – Evolving Standards) project

Background

There is growing interest in theory-driven, qualitative and mixed-method approaches to systematic review, such as realist and meta-narrative review. These approaches offer the potential to expand the knowledge base in policy-relevant areas. However, the quality of such reviews can be difficult to assess.

Objectives

The aim of this project was to produce methodological guidance, publication standards and training resources for those seeking to undertake realist and/or meta-narrative reviews.

Methods/design

We (1) collated and summarised existing literature on the principles of good practice in realist and meta-narrative systematic reviews; (2) considered the extent to which these principles had been followed by published and in-progress reviews, thereby identifying how rigour may have been lost and how existing methods could be improved; (3) used an online Delphi method with an interdisciplinary panel of experts from academia and policy, to produce a draft set of methodological steps and publication standards; (4) produced training materials with learning objectives linked to these steps; (5) refined these standards and training materials prospectively on real reviews in progress, capturing methodological and other challenges as they arose; (6) synthesised expert input, evidence review and real-time problem analysis into more definitive guidance and standards; and (7) disseminated outputs to audiences in academia and policy.

Results

An important element of this study was the establishment of an e-mail mailing list to bring together researches in the field (www.jiscmail.ac.uk/RAMESES). Our literature review identified 35 and nine realist and meta-narrative reviews respectively. Analysis and discussion within the project team produced a summary of the published literature, and common questions and challenges into briefing materials for the Delphi panel, comprising 37 and 33 members (for realist and meta-narrative reviews respectively). Within three rounds this panel had reached a consensus on 19 (realist) and 20 (meta-narrative) key publication standards, with an overall response rate of 90% and 91% respectively. The Realist And Meta-narrative Evidence Syntheses – Evolving Standards (RAMESES) publication standards for realist syntheses and meta-narrative reviews were published in open-access journals and quickly became highly accessed. The RAMESES quality standards and training materials drew together the following sources of data: (1) personal expertise as researchers and trainers; (2) data from the Delphi panels; (3) feedback from participants at training sessions we ran; and (4) comments made on RAMESES mailing list. The quality standards and training materials are freely available online (www.ramesesproject.org).

Discussion

The production of these standards and guidance drew on multiple sources of knowledge and expertise, and a high degree of a consensus was achieved despite ongoing debate among researchers about the overall place of these methodologies in the secondary research toolkit. As with all secondary research methods, guidance on quality assurance and uniform reporting is an important step towards improving quality and consistency of studies. We anticipate that as more reviews are undertaken, further refinement will be needed to the publication and quality standards and training materials.

Limitations

The project’s outputs are not definitive and in the future updating and further development is likely to be needed.

Conclusion

An initial set of publication standards, quality standards and training materials have been produced for researchers, users and funders of realist or meta-narrative reviews. As realist and meta-narrative reviews are relatively new approaches to evidence synthesis, methodological development is needed for both review approaches.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Service-learning in the nursing curriculum: are we at the level of evidence-based practice?

Service-learning is implemented as a learning strategy in all levels of education. However,there is little evidence to support its efficacy and influence on student learners and those served, due in part to broad operational definitions and the dearth of empirical evidence. The current trend of including service-learning in the nursing curriculum falls short of evidence-based practice, a valuable pillar in nursing education. The purpose of this systematic review is to review the research that has been conducted on service-learning and to investigate outcomes on nursing students. Suggestions for future research include the development and use of standardized operational definitions. Concepts of interest for measurement and research instruments have been identified.

Protocol--realist and meta-narrative evidence synthesis: evolving standards (RAMESES)

Background

There is growing interest in theory-driven, qualitative and mixed-method approaches to systematic review as an alternative to (or to extend and supplement) conventional Cochrane-style reviews. These approaches offer the potential to expand the knowledge base in policy-relevant areas - for example by explaining the success, failure or mixed fortunes of complex interventions. However, the quality of such reviews can be difficult to assess. This study aims to produce methodological guidance, publication standards and training resources for those seeking to use the realist and/or meta-narrative approach to systematic review.

Methods/design

We will: [a] collate and summarise existing literature on the principles of good practice in realist and meta-narrative systematic review; [b] consider the extent to which these principles have been followed by published and in-progress reviews, thereby identifying how rigour may be lost and how existing methods could be improved; [c] using an online Delphi method with an interdisciplinary panel of experts from academia and policy, produce a draft set of methodological steps and publication standards; [d] produce training materials with learning outcomes linked to these steps; [e] pilot these standards and training materials prospectively on real reviews-in-progress, capturing methodological and other challenges as they arise; [f] synthesise expert input, evidence review and real-time problem analysis into more definitive guidance and standards; [g] disseminate outputs to audiences in academia and policy. The outputs of the study will be threefold:

1. Quality standards and methodological guidance for realist and meta-narrative reviews for use by researchers, research sponsors, students and supervisors

2. A 'RAMESES' (Realist and Meta-review Evidence Synthesis: Evolving Standards) statement (comparable to CONSORT or PRISMA) of publication standards for such reviews, published in an open-access academic journal.

3. A training module for researchers, including learning outcomes, outline course materials and assessment criteria.

Discussion

Realist and meta-narrative review are relatively new approaches to systematic review whose overall place in the secondary research toolkit is not yet fully established. As with all secondary research methods, guidance on quality assurance and uniform reporting is an important step towards improving quality and consistency of studies.

Innoversity in knowledge-for-action and adaptation to climate change: the first steps of an 'evidence-based climatic health' transfrontier training program

It has become increasingly clear to the international scientific community that climate change is real and has important consequences for human health. To meet these new challenges, the World Health Organization recommends reinforcing the adaptive capacity of health systems. One of the possible avenues in this respect is to promote awareness and knowledge translation in climatic health, at both the local and global scales. Within such perspective, two major themes have emerged in the field of public health research: 1) the development of advanced training adapted to 'global environment' change and to the specific needs of various groups of actors (doctors, nurses, public health practitioners, health care managers, public service managers, local communities, etc) and 2) the development of strategies for implementing research results and applying various types of evidence to the management of public health issues affected by climate change. Progress on these two fronts will depend on maximum innovation in transdisciplinary and transsectoral collaborations. The general purpose of this article is to present the program of a new research and learning chair designed for this double set of developmental objectives - a chair that emphasizes 'innoversity' (the dynamic relationship between innovation and diversity) and 'transfrontier ecolearning for adaptive actions'. The Écoapprentissages, santé mentale et climat collaborative research chair (University of Montreal and Quebec National Public Health Institute) based in Montreal is a center for 'transdisciplinary research' on the transfrontier knowledge-for-action that can aid adaptation of the public health sector, the public mental health sector, and the public service sector to climate change, as well as a center for complex collaborations on evidence-based climatic health 'training'. This program-focused article comprises two main sections. The first section presents the 'general' and 'specific contexts' in which the chair emerged. The 'general context' pertains to the health-related challenge of finding ways to integrate, transfer, and implement knowledge, a particularly pointed challenge in Canada. The 'specific context' refers to the emerging research field of adaptation of public health to climate change. In the second section, the characteristics of the research chair are more extensively detailed (the vision of 'innoversity' and ' transfrontier knowledge-for-action,' the approach of shared responsibility and complex collaboration, objectives, and major axes of research). We conclude with a call for complex collaboration toward knowledge-for-action in public health services/mental health services/public services' adaptation to climate change: this call is aimed at individual and institutional actors in the North and South/West and East concerned by these issues.

Dissemination and implementation of evidence-based practice in the social services: a UK survey

A cross sectional UK-wide survey assessed current levels of dissemination and implementation of evidence-based practice in social care and social work agencies. A structured questionnaire was e-mailed to 357 agencies of which 155 (43.4%) completed and returned it. Although the results show that evidence-based practice in this area is still in its early stages, most respondents reported a good knowledge of evidence-based practice as well as the view that professional decisions should be informed by-but not only-research evidence. The lack of time, resources, information, and training are identified as the main barriers to be overcome for an effective implementation of evidence-based practice in the social services.

Knowledge transfer for the management of dementia: a cluster randomised trial of blended learning in general practice

Background

The implementation of new medical knowledge into general practice is a complex process. Blended learning may offer an effective and efficient educational intervention to reduce the knowledge-to-practice gap. The aim of this study was to compare knowledge acquisition about dementia management between a blended learning approach using online modules in addition to quality circles (QCs) and QCs alone.

Methods

In this cluster-randomised trial with QCs as clusters and general practitioners (GPs) as participants, 389 GPs from 26 QCs in the western part of Germany were invited to participate. Data on the GPs' knowledge were obtained at three points in time by means of a questionnaire survey. Primary outcome was the knowledge gain before and after the interventions. A subgroup analysis of the users of the online modules was performed.

Results

166 GPs were available for analysis and filled out a knowledge test at least two times. A significant increase of knowledge was found in both groups that indicated positive learning effects of both approaches. However, there was no significant difference between the groups. A subgroup analysis of the GPs who self-reported that they had actually used the online modules showed that they had a significant increase in their knowledge scores.

Conclusion

A blended learning approach was not superior to a QCs approach for improving knowledge about dementia management. However, a subgroup of GPs who were motivated to actually use the online modules had a gain in knowledge.

Trial registration

Current Controlled Trials ISRCTN36550981.

Do we practice what we preach? A qualitative assessment of resident-preceptor interactions for adherence to evidence-based practice

BACKGROUND

Evidence-based medicine (EBM) is important in training doctors for high-quality care. Yet little is known about whether ambulatory precepting incorporates the concepts and principles of EBM.

METHODS

The authors observed and audiotaped 95 internal medicine residency precepting interactions and rated interactions using a qualitative analytic template consisting of three criteria: (1) presence of clinical questions; (2) presence of an evidence-based process; and (3) resident ability to articulate a clinical question.

RESULTS

Sixty-seven of 95 audio tapes (71%) were of acceptable quality to allow template analysis. Thirty (45%) contained explicit clinical questions; 11 (16%) included an evidence-based process. Resident ability to articulate a clinical question when prompted was rated as at least 'fair' in 59 of 67 interactions (88%).

CONCLUSIONS

EBM was not optimally implemented in these clinics. Future research could explore more systematically what factors facilitate or impair the use of EBM in the real-time ambulatory training context.

How do doctors use information in real-time? A qualitative study of internal medicine resident precepting

BACKGROUND

Despite the importance of evidence-based medicine in medical education, little observational research exists on how doctors-in-training seek and use evidence from information resources in ambulatory care.

OBJECTIVE

To describe information exchange behaviour by internal medicine residents and attendings in ambulatory resident clinic precepting rooms.

DESIGN

We observed resident behaviour and audiotaped resident-attending doctor interactions during precepting sessions.

PARTICIPANTS

Participating residents included 70 of an eligible 89 residents and 28 of 34 eligible attendings from one large academic internal medicine residency programme in the Midwestern USA. Residents were observed during 95 separate precepting interactions at four ambulatory sites.

APPROACH

Using a qualitative approach, we analysed transcripts and field notes of observed behaviours and interactions looking for themes of information exchange. Coders discussed themes which were refined using feedback from an interdisciplinary panel.

RESULTS

Four themes of information exchange behaviour emerged: (i) questioning behaviours that were used as part of the communication process in which the resident and attending doctor could reason together; (ii) searching behaviour of non-human knowledge sources occurred in a minority of precepting interations; (iii) unsolicited knowledge offering and (iv) answering behaviours were important means of exchanging information.

CONCLUSIONS

Most clinic interactions between resident and attending doctors relied heavily on spoken deliberation without resorting to the scientific literature or other published information resources. These observations suggest a range of factors that may moderate information exchange behaviour in the precepting context including relationships, space and efficiency. Future research should aim to more readily adapt information resources to the relationships and practice context of precepting.

Exploring the contribution of the Clinical Librarian to facilitating evidence-based nursing

AIM

To examine the potential role of the Clinical Librarian in facilitating evidence-based practice of nurses in acute hospital settings and develop a model for the role.

BACKGROUND

There is a growing policy and professional expectation that nurses will seek out and apply evidence in their clinical practice. Studies have demonstrated that nurses experience barriers in working with an evidence-based approach. The role of Clinical Librarian has been used in other countries and within medicine to overcome some of the barriers to evidence-based practice. There are limitations in the previous work in terms of rigour of evaluation, scope of the Clinical Librarian role and application to nursing in a UK setting.

DESIGN

A qualitative consultation of 72 nurses in acute care settings.

METHODS

Six consultation group interviews of between 4-19 participants. Written records were recorded by the scribe. Content analysis was undertaken to identify the range and frequency of comments.

RESULTS

Clinical questions currently go unanswered because of barriers of time, skills deficits and access to resources. Literature searching, skills training and evidence dissemination were the main areas of work the staff requested that a Clinical Librarian should undertake. It was anticipated that the Clinical Librarian could interact and work productively with nursing staff with a limited but regular presence on the ward. Interim communication could be via e-mail, phone and written suggestions and requests for work. It was seen to be vital that the Clinical Librarian worked in partnership with staff to build evidence-based practice capacity and ensure clinical relevance of the work.

CONCLUSIONS

This study has generated the first model for the Clinical Librarian role with an emphasis on nursing. It is derived from the views of clinical nurses. Recommendations are made for the implementation and evaluation of such a role.

RELEVANCE TO CLINICAL PRACTICE

The Clinical Librarian could be an invaluable support to promoting evidence-based nursing.

GINA guidelines on asthma and beyond

Clinical guidelines are systematically developed statements designed to help practitioners and patients make decisions regarding the appropriate health care for specific circumstances. Guidelines are based on the scientific evidence on therapeutic interventions. The first asthma guidelines were published in the mid 1980s when asthma became a recognized public health problem in many countries. The Global Initiative on Asthma (GINA) was launched in 1995 as a collaborative effort between the NHLBI and the World Health Organization (WHO). The first edition was opinion-based but updates were evidence-based. A new update of the GINA guidelines was recently available and it is based on the control of the disease. Asthma guidelines are prepared to stimulate the implementation of practical guidelines in order to reduce the global burden of asthma. Although asthma guidelines may not be perfect, they appear to be the best vehicle available to assist primary care physicians and patients to receive the best possible care of asthma.

Evaluating healthcare education: issues and methods

This paper analyses the methodological issues inherent in evaluating healthcare education and considers approaches for addressing these. Recent policies have exhorted practitioners to base their practice on evidence; however in healthcare education the evidence base is not extensive. Whilst educational evaluation has advanced in the last decades, standardised designs and toolkits are not available. Each evaluation has different aims and occurs in specific contexts, thus the design has to fit the circumstances, yet meet the challenge of scientific credibility. Indicators of educational processes and outcomes are not scientifically verified; no toolkit of standardised 'off-the-shelf' valid, reliable and sensitive measures exists. The evidence base of educational practice is largely derived from small-scale, single case studies; the majority of measures are self-devised, unvalidated tools of unproven reliability, thus meta-synthesis is not appropriate and results are not generalisable. Healthcare educational evaluators need valid and reliable assessments of both knowledge acquisition and its application to practice. The need to establish and explain attribution, i.e. the relationship between educational inputs and outcomes is complex and requires experimental/quasi-experimental design. In addition, educational evaluators face the pragmatic challenge of practice in healthcare contexts, where confounding variables are hard to control and resources are scarce.

Evaluating healthcare education: Issues and methods

This paper analyses the methodological issues inherent in evaluating healthcare education and considers approaches for addressing these. Recent policies have exhorted practitioners to base their practice on evidence; however in healthcare education the evidence base is not extensive. Whilst educational evaluation has advanced in the last decades, standardised designs and toolkits are not available. Each evaluation has different aims and occurs in specific contexts, thus the design has to fit the circumstances, yet meet the challenge of scientific credibility. Indicators of educational processes and outcomes are not scientifically verified; no toolkit of standardised 'off-the-shelf' valid, reliable and sensitive measures exists. The evidence base of educational practice is largely derived from small-scale, single case studies; the majority of measures are self-devised, unvalidated tools of unproven reliability, thus meta-synthesis is not appropriate and results are not generalisable. Healthcare educational evaluators need valid and reliable assessments of both knowledge acquisition and its application to practice. The need to establish and explain attribution, i.e. the relationship between educational inputs and outcomes is complex and requires experimental/quasi-experimental design. In addition, educational evaluators face the pragmatic challenge of practice in healthcare contexts, where confounding variables are hard to control and resources are scarce.

Feasibility of a Web-Based Continuing Medical Education Program in Dermatology: The DermoFAD Experience in Italy

BACKGROUND

Web-based systems are increasingly being considered for medical education. A draft legislation on distance-learning programs was licensed in Italy by the National Commission for Continuous Education in November 2003. A series of pilot studies were developed, among these the DermoFAD project, based on five simulated clinical cases of acne and a systematic appraisal of the evidence for their clinical management. From July 1 to August 27, 2004, a total of 500 medical doctors participated in a free of charge evaluation program of the project.

OBSERVATIONS

Users were distributed all over Italy. Two hundred and eighty-one (56.2%) were primary care physicians, 83 (16.6%) dermatologists, and 136 (27.2%) other medical specialists. A wide range of connecting times was observed. The pass rate of each individual case, at first attempt, ranged from 44 to 77%. When asked to assess the overall distance-learning experience, 98% of the doctors considered it to be enjoyable. A total of 2,152 continuing medical education (CME) credits were awarded. Over 50% of the users stated they would still use the system if they had to pay for it.

CONCLUSIONS

Our experience shows that distance learning is feasible and is well accepted by physicians. The DermoFAD program was an efficient means of delivering CME to the Italian medical community at large.

De la création à l'évaluation d'un site Internet pédagogique en anesthésie-réanimation

OBJECTIVES

The aim of this study was to conceive, create, validate and assess a pedagogic site to teach students.

STUDY DESIGN

Survey with questionnaires.

METHODS

First, we performed an educational need assessment in that field, conducting a review of legal regulations and international guidelines and a survey of 91 students. Afterwards, we drew up a reference document based on proven scientific data, with selected bibliography and we wrote a list of specific teaching objectives. We then created a pedagogic Web site including illustrated references, documents, a selected bibliography and useful Internet links. These pedagogic Web sites could be associated to well-conducted tutorial sites by qualified senior physicians in an academic process to improve procedural skill teaching. After internal and external validation, this educational Web site was evaluated by students. This evaluation used the questionnaire proposed by "Régie Régionale de la Santé et des Services Sociaux de Montréal" (regional authority control of health and social services of Montreal). Our pedagogic Web site obtained 76 out of 100 and can be considered satisfactory.

CONCLUSION

This study demonstrated that adapted multimedia tools can improve procedural skill teaching in anaesthesia and intensive care.

THE PROMISE AND PITFALLS OF SYSTEMATIC REVIEWS

The systematic review "movement" that has transformed medical journal reports of clinical trials and reviews of clinical trials has taken hold in public health, with the most recent milestone, the publication of the first edition of The Guide to Community Health Services in 2005. In this paper we define and distinguish current terms, point out important resources for systematic reviews, describe the impact of systematic review on the quality of primary studies and summaries of the evidence, and provide perspectives on the promise of systematic reviews for shaping the agenda for public health research. Several pitfalls are discussed, including a false sense of rigor implied by the terms "systematic review" and "meta-analysis" and substantial variation in the validity of claims that a particular intervention is "evidence based," and the difficulty of translating conclusions from systematic reviews into public health advocacy and practice.

Promoting the skills of knowledge translation in an online master of science course in primary health care

We present 4 key arguments: (1) knowledge translation requires tacit and explicit knowledge that must be introduced into the organization as well as simply acquired by individuals; (2) educating for knowledge translation must go beyond conveying facts and developing capability; (3) a constructivist and collaborative approach to education can address the needs of learners for knowledge translation; and (4) the online environment, if appropriately used, has many useful features for supporting constructivist and collaborative learning. We illustrate these arguments with reference to a part-time online master of science course whose learners are mostly senior health care professionals engaged in knowledge translation.

Towards evidence-based practice in medical training: making evaluations more meaningful

CONTEXT

The evaluation of training is problematic and the evidence base inconclusive. This situation may arise for 2 main reasons: training is not understood as a complex intervention and, related to this, the evaluation methods applied are often overly simplistic.

METHOD

This paper makes the case for construing training, especially in the field of specialist medical education, as a complex intervention. It also selectively reviews the available literature in order to match evaluative techniques with the demonstrated complexity.

CONCLUSIONS

Construing training as a complex intervention can provide a framework for selecting the most appropriate methodology to evaluate a given training intervention and to appraise the evidence base for training fairly, choosing from among both quantitative and qualitative approaches and applying measurement at multiple levels of training impact.

An application of the mini review to a complex methodological question: how best to research public health nursing and service quality?

This paper describes a mini review which enabled the identification of a suitable methodology to undertake a study about quality in the public health nursing in the Republic of Ireland. Reviews of literature increasingly adopt the methods of systematic review. In general, these methods have been developed to answer clearly focussed clinical questions. In this paper, we adopt the key elements of systematic review, comprehensive identification of relevant material and selection based on objectively defined validity, to a different type of question, that of an appropriate methodology to examine quality in the public health nursing service. In doing so, we demonstrate that questions of clinical effectiveness are but one application for systematic review.

Quels moyens de formation en chirurgie ? À propos d’une enquête aux hôpitaux universitaires de Strasbourg auprès des internes en chirurgie

OBJECTIVE

Numerous tools for surgical education are available. The objective of the study is to know how future surgeons do feel about these different possibilities to learn and what do they think about the place of e-learning, or virtual universities and on-line training and learning in their formation.

METHODS

A questionnaire has been sent to each surgical student of Strasbourg University. Learning and training methods were evaluated: observation, fellowship, Internet, reading videos, reading books or scientific journals, discovery of pathology by oneself or performing surgical procedures by oneself, sharing meetings, playing pedagogic games.

RESULTS

Fellowship is voted by plebiscite, as using Internet which grows the usual book contents thanks to interactivity, videos, quickenings and actuality of the inquiries. The difficulties to approach this tool is emphasized : the cost, availability, time consuming, lack of any tutor, ability with a computer. Dissection of corpses or live animals is wished by the majority of young surgeons. Using simulators or robots remains something for the future and must be evaluated.

CONCLUSION

Fellowship is voted by plebiscite for learning surgery. The interest for new technologies of communication is more out of curiosity than necessity.

A critical appraisal of 'evidence-based medicine' in allergy and asthma

Clinical guidelines are 'systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances'. They may offer concise instructions on which diagnostic or screening tests to order, stipulate how medical services should be provided, how long patients should stay in hospital, or many other details relevant to clinical practice. This paper argues that guidelines should be simple, adapted to the clinical setting they inform and to treatment availability in their respective geographic context and that they should not be viewed as a yardstick but as support for physicians. The benefits of evidence-based-medicine (EBM), which defines the value of medical interventions in terms of empiric evidence from clinical trials, are growing in many contexts and are well described. Not sufficiently acknowledged, however, are the limits of EBM. A gap still exists between clinical research and clinical practice which should be better recognized and assessed.

Evidence-based practice is a time of opportunity for nursing

The debate regarding evidence-based practice (EBP) continues to rage within nursing. This article reviews the existing situation regarding policy and the ability of nurses to engage with EBP. Recommendations are made regarding moving the debate away from a focus on barriers to EBP towards seizing it as an opportunity. The article suggests that a fundamental change in attitude is required by nurses in order for the nursing profession to progress. There is a need to recognize that the nature of health services are changing and that nurses need to grasp the opportunities this makes available, but in order to do this nurses need support.

Putting your course on the Web: lessons from a case study and systematic literature review

BACKGROUND

Education via the Internet offers enormous potential, but many online courses are pedagogically or technically weak and many good projects are never mainstreamed.

METHOD

In drawing up our recommendations to address the issues around putting a course on the web, we drew on 3 main sources of data: an extensive in-depth course evaluation; a systematic review of the literature, and questions raised by participants on our training-the-trainers courses.

RECOMMENDATIONS

For any web-based course to succeed, 10 overlapping and iterative areas of activity must be addressed. These are: the market for the course; course aims and intended learning outcomes; choice of software platform; staff training needs; writing high quality study materials; design features for active learning; technical and administrative challenges; evaluation and quality improvement; mainstreaming the course within the institution, and financial viability.