To be able to consistently apply evidence basis to their daily physical therapy practice, each physical therapist (PT) must learn to effectively access and apply appropriate, scientifically sound information whenever available. Access to evidence-based information includes at least two components: 1) identifying and locating the information and 2) retrieval of the article or manuscript. Access truly is key, as expressed by Farmer and Richardson1 who stated “Perhaps the single most important thing policy makers could do to encourage evidence-based practice among health professionals would be to provide good access to information professionals and information resources.”1(p98) Information professionals, particularly medical librarians, are the experts who can guide physical therapists to quality information and can educate them in effective search strategies. Evidence-based practice (EBP) is “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients”2 and involves three elements, “the integration of best research evidence with clinical expertise and patient values.”3(p1) Therefore, students and therapists must be taught to identify, access, and apply information. Attention to information from these three elements—best research evidence, clinical expertise, and patient values—will enable one to make sound clinical decisions, ie, evidence-based decision making (EBDM).
While best research evidence is found in recent, relevant, peer-reviewed research publications, as addressed in other articles in this issue, students should be taught to pay attention to the type, quality, and rigor of each study as they access the evidence. Students searching for best research evidence must be equipped to recognize the relative strength of the conclusions drawn from any particular study4,5 and the relative importance of all three elements of EBP. Clinical expertise includes use of clinical skills and past experience of the health care provider,3(p1) but can often be found in the form of published clinical practice guidelines6 or intervention guidelines, usually developed by agencies or professional groups for specific problems. Such guidelines, ideally based on recent research evidence,6 are often developed with no uniformity in methodology7 and are usually available in print or on government or organization Web sites, for example, www.guidelines.gov.8 Since patient values, or patient preferences, are something “each patient brings”3(p1) they are best obtained by direct report from the individual patient or caregiver/family, but evaluating the recent literature could inform the therapist's understanding of patient values. Attention to individual patient values and preferences is a factor that keeps EBP from becoming cookbook medicine.2 Involvement of the patient in the plan of care with attention to patient values and patient goals is a central aspect of “patient-centered care” in physical therapy.9-12 Educators in professional and postprofessional physical therapist education programs have the responsibility to teach students about the importance of EBP, the resources available, and the methods and strategies to access and obtain the most recent and relevant research information to answer the clinical question.
The purposes of this article are: 1) to discuss the importance of teaching access to EBP resources related to the discipline of physical therapy, including the relative roles of evidence, expert opinion, patient values; 2) to identify effective resources that provide evidence-based literature and the relative strengths of each resource; and 3) to outline strategies for teaching optimal methods for accessing EBP literature to students in physical therapy education.
The Importance of Teaching Access to Evidence-Based Resources
There are a number of important reasons to teach optimal access to evidence-based information as a basis for clinical decision making. Access to EBP Information:
- Will enhance a professional lifestyle that includes EBDM.
- Is required because of the rapid growth of the physical therapy literature.
- Will encourage open questioning of professional opinions that don't match the current professional knowledge base.
- Will promote the use of objective measures.
- Will foster professional self-esteem and respect.
- Is more accessible because of the growing emphasis on Internet and digital sources.
- Is a basic skill that supports clinical practice in accord with accreditation standards.
The ability to incorporate EBDM as an ongoing professional lifestyle will be enhanced if a person understands the importance and the principles of EBP and has access to the literature. Even if a person has a full grasp of the current understanding of physiologic, diagnostic, and therapeutic aspects of a particular clinical problem, the knowledge base in rehabilitation grows daily, requiring physical therapists to possess strategies to continue to update their professional knowledge. Unfortunately, one study has shown that for clinical decision making, physical therapists in one state incorporate “virtually no use of bibliographic databases.”13
With the proliferation of medical studies, innovative and efficient access to the literature is essential.5 To illustrate this phenomenal growth, a literature search was performed for this paper using MEDLINE and CINAHL. The terms “physical therapy techniques” and “physical therapy (specialty)” were exploded, including all more specific terms, ie, TENS, hydrotherapy, etc, which by no means is a complete search for physical therapy articles, but should be representative of change over time. Figures 1 and 2 illustrate the acceleration in physical therapy-related publications detected particularly since the early 1990s in MEDLINE (1966-2003) and in CINAHL (1982-2003). This growth in the literature is also reflected in the number of new physical therapy journals developed over this time, including Pediatric Physical Therapy in 1989, Physical Rehabilitation and Medicine Clinics of North America in 1990, Orthopedic Physical Therapy Clinics of North America in 1992, Physical Therapy Reviews in 1996, Physical Therapy Case Reports in 1998, Advances in Physiotherapy in 1999, and Physical Therapy in Sport in 2000. CINAHL currently indexes over 100 physical therapy and physical medicine-related journals. Because the growth in physical therapy and rehabilitation literature continues to accelerate, ready access to the most recent evidence becomes even more important for students and physical therapists, particularly through electronic methods. Because no one can keep up with all the new information, any clinician today and in the future must be prepared to utilize technology to help find and use updated, evidence-based information. Physical therapist educators must instill this standard in all students.
There is a growing emphasis on use of the Internet and other digital sources by health care professionals to access EBP information.3,15-20 Significant proportions of health care professionals in a variety of settings have access to the Internet,14,18,21,22 particularly for individuals affiliated with education programs.15 Jette et al14 reported that among a sample of physical therapists, 96% reported having access to professional journals in paper form, while only 89% reported having access to databases and the Internet at home and only 65% at work. Boyer23 has stated that “medical professionals have embraced the Internet, with nearly half (48.9%, n=1294) engaging in e-mail correspondence with their patients.” It has been proposed that Internet resources will improve the ease of access to health and medical information18,20-22,24,25 and has been demonstrated among physicians.26 In a survey of physicians conducted by Harris Interactive27 in 2002, the majority of physicians reported that they used the Internet to research health care information. Most also stated that the information gathered has an impact on their clinical decision making. In one study of computer use related to work among physical therapists in Tennessee (n=49), only 14% stated that they did not use a computer in their work, while 59% stated that they used the computer to search the Internet, and 49% stating that they specifically used it to search databases.28 Advancing technology has made information more accessible for physical therapists and other health care professionals. Internet access makes evidence-based materials available at the desktop computer. Laptop computers and PDAs make access portable. Because of wireless technology, access can be provided at the patient's side. Many institutions now provide laptops and/or PDAs with wireless technology so that the information can be accessed in “real time.”
Since teaching access to EBP information is important, it has been demonstrated that faculty should be equipped to impart this information to students. Workshops and faculty development institutes have been encouraged through which faculty are equipped to teach EBDM3,29 including methods to teach access to the literature as described in the next sections. Such institutes have been shown to increase knowledge and willingness to apply the teaching methods,30 significantly increase EBDM,29 and participants consistently report that they were prepared to integrate EBDM into their program curriculum.29 Forrest29 found that after training, 60% of individuals integrated the Patient/Problem, Intervention/Prognostic Factor/Exposure, Comparison, and Outcome (PICO) method into their coursework and 70% integrated database searching.
Specific skills that are essential for optimal access and use of research literature must be taught,31,32 particularly in physical therapist education programs. The essential task of teaching physical therapists and students to access literature that supports EBP is included in the Evaluative Criteria for Accreditation of Education Programs for the Preparation of Physical Therapists set forth by the Commission on Accreditation in Physical Therapy Education (CAPTE).33 These evaluative criteria require that graduates be prepared to access and evaluate scientific literature as part of maintaining optimal practice standards and appropriate intervention, including “secure and critically evaluate information related to new and established techniques and technology” (Criterion 188.8.131.52). The current version of the CAPTE draft revision of the Evaluative Criteria34 being considered could be implemented by January 2006 and speaks more specifically to EBP and particularly equipping students to access information. Criterion CC-5.20 states that graduates will be able to “consistently use information technology to access sources of information to support clinical decisions,”34(p37) while the criteria that follow address evaluation and integration of evidence and contribution toward written reviews and resulting design and implementation of patterns of best clinical practice. It is appropriate that the “access” criteria (CC-5.20) come first among this grouping, as access to information is a prerequisite for use of information as addressed by the criteria that follow.
Identifying Evidence-Based Sources and Retrieval of Articles
EBP information is published in a variety of formats—guidelines, peer-reviewed journal articles, and some Web pages. There are a number of databases that allow subject searching of these resources, especially guidelines and journal articles. The key resources through which articles or information to support evidence-based health care can be identified are summarized in Table 1, including a comparison of the features of each database. The list was developed by review of medical library Web pages and other resources. As the table shows, many such resources for evidenced-based health care are available without charge. Evidence-based practice resources can often be accessed via the institution library if a person is affiliated with an educational institution. General procedures for using database systems will be discussed in the next section.
Additionally, for ease of access, PubMed and other vendor systems will link to the journal publisher Web site if the article is available full-text, or sometimes on a for-fee basis if the individual does not pay a fee to subscribe to the resource. Other evidence-based practice resources such as Cochrane Databases and Clinical Evidence can often be accessed via the institution library if a person is affiliated with an educational institution. Clinicians outside the institutional setting may find access and retrieval more difficult and more expensive. Sometimes professional associations provide these resources and sometimes the clinician or the clinician's employer can contract with a local medical library to provide resources. If the medical library provides these services for a fixed annual cost, the physical therapists can budget accordingly. Because of the broad spectrum of journals from which the clinician may need articles, subscribing to specific journals would likely not be cost efficient. However, many publishers make individual articles available on a fee-for-service basis. Technology will improve access, but will probably not have an effect on fees charged. Open Access journals, discussed later in this paper, will also allow access without cost for the PT.
Ideally, fastest retrieval of desired articles occurs immediately when the manuscript can be downloaded and stored as an electronic document from the Web as a full-text document and reviewed immediately, including figures, tables, and references. Health care libraries can also be resources for obtaining copies of evidence-based articles that may not be available online as full-text. If the requested article is not available in a particular library, it can be borrowed from another library via interlibrary loan, often associated with additional cost. A growing trend in the publishing industry that allows retrieval of articles without cost is “Open Access” peer-reviewed publications, in which the author holds the copyright instead of the journal. The author often has to pay a fee for publication in an Open Access publication, but can then grant rights to the work as he or she sees fit. The complete version of these articles is then available electronically without charge, making it another retrieval option available for physical therapists. Directories of Open Access titles are available at http://www.doaj.org/ljbs?cpid=20, PubMed Central (http://www.pubmedcentral.nih.gov/), and BioMedCentral (http://www.biomedcentral.com/).
Several bibliographic management software programs are available to store citations and build personal databases of evidenced-based articles for future reference. References may be input manually into a reprint management program database or can be imported from a database such as MEDLINE or CINAHL. Once the references are in the database, items can be sorted according to various criteria such as author or year. The citations can also be searched by any of the fields included in the database such as author or journal name. Bibliographies of the references in the database can be created and formatted for publication or personal reference. Students can be encouraged to begin their own personal database while in school and continually add to it with each assignment. Use of this software could be an important start to one aspect of life-long learning. A personal database of citations of interest can be started as a student. This database can be the beginning of a resource that the clinician can continue to develop and reference throughout their career.
Some of the commonly used bibliographic management programs include:
Table 2 provides a comparison of features among these three programs adapted from Thomson ResearchSoft (http://thomsonisiresearch-soft.com/compare/).35 Other comparisons of reprint management programs can be found at http://www.lib.ucdavis.edu/healthsci/win-bibmanagers.html, http://www.biblio-tech.com/html/pbm_features.html, and http://www.lib.wayne.edu/resources/research_related_software/comparison.php.
Students or therapists can use these software programs to download the citations and store them creating a personal database. Figure 3 is a screen-shot to illustrate a collection of citations in EndNote.
A number of barriers that impede access to evidence-based resources have been identified in several health care professions and should be addressed when teaching access to EBP literature. Barriers that impede optimal access to the literature include inadequate computer technology and skill, inability to search efficiently, limited time, inadequate resources, and cost factors.36-40 It should be emphasized to professionals that while some cost may be involved in searching the literature and obtaining copies of the articles, the end result will be better health care for the individual receiving therapy services.36 Newman also cites the barrier of a “culture of practice which emphasizes ‘routine' patient care.”40 Berenholtz41 notes that providers often are unaware that a guideline exists or may lack the ability to implement the guideline. Tod et al20 have indicated that in the UK limited Internet access and a lack of knowledge and confidence are barriers to nurses accessing evidence via the Internet. In this study, open access to the Internet in an acute ward was valued and utilized by nurses. The authors emphasized the requirement for support and training. In addition, Maher et al42 has described barriers along with some potential solutions. “Real-time” access to EBP resources in clinical settings is available in many hospitals and clinics and the use in clinical decision making has been described in the literature.43-47 Real-time EBP decision making has been described during attending rounds with medical students and residents as a teaching method and was shown to influence the patient care plans developed by the learners.43 For real-time access, the clinician must be able to access the Internet at the point of care. Without wireless technology and a device that can be used at the bedside or patient treatment area, (such as a laptop computer or PDA), the clinician may not be able to access EBP resources at the point of care. Hopefully there will soon even be reports of evidence being cited in the patient medical record in support of certain therapeutic options that are implemented in specific cases.
Students and therapists in academic settings likely have greater ease of access and retrieval without additional fees than therapists in clinical practice, depending on the practice setting and available resources. This could imply a greater cost and inconvenience for therapists in clinical practice, and therefore a heightened barrier to implementing EBP when an individual changes status from student to licensed therapist. Time is another major barrier to accessing EBP information to support clinical decision making given the growing emphasis on productivity of health care professions in the health care environment. However, optimal intervention and professional growth and learning should not be impeded by such competing priorities.
Strategies for Teaching Access to Evidence-Based literature
Developing a “well-built clinical question,” as described by Sackett,3(pp13-28) is discussed in the article on “Teaching Evidence-Based Practice” by Mary Slavin earlier in this issue and must be the first step in successfully accessing EBP information. Learners must be taught to develop the right question so the literature search can identify the appropriate articles. Students should be taught to put the PICO components together to state the well-built clinical question3 before the literature search is attempted. An example of a good clinical question could be: “If a patient with patellofemoral pain syndrome receives biofeedback during therapeutic exercise and/or taping, will either intervention decrease the pain experienced by the patient or effect the recruitment of vastus medialis?” Educators should also teach students to use the specific clinical question to directly guide the selection of the specific search terms and strategy. As the search is performed, students should be taught to favor articles that represent more dependable sources of evidence-based information as represented in the “Evidence Pyramid,”48 particularly meta-analyses and systematic reviews if available, followed by randomized controlled trials and controlled trials.
Instruction regarding access to evidence-based information should include discussion of specific steps to optimize the results of the search: 1) Specify the clinical question and identify each key concept, 2) conduct individual searches for each key concept of the clinical question using subject heading or keyword searches, 3) focus the search by combining initial searches using Boolean connectors (eg, AND, OR), 4) narrow the search using specific limitations (language, EBP filters, specific years of publication, review articles, systematic reviews, age, gender, and others) until a reasonable number of articles remain that can be reviewed individually, and 5) review of each individual citation (article title and abstract and full-text article if available) in the final display, to determine which articles are applicable to the question and should be retrieved. Table 3 lists the steps in an effective literature search, including specific search strategies and examples. Table 4 outlines specific tactics that can be used to increase the number of citations in a search if a student is finding too few articles, as well as tactics to decrease the number of citations if there are too many articles to review. Screenshots illustrating the process of a specific search in Ovid and PubMed respectively are given in Figure 4 and 5.
Several filters have been developed that can be used with electronic databases to locate information to support EBP. These filters can be combined with a subject search to restrict the results to evidence-based articles (systematic reviews and meta-analysis, randomized controlled trials, cohort studies, and case control studies). Filters can be used to search the MEDLINE and CINAHL databases so that only articles based on evidence are retrieved. Several filters have been developed by medical libraries that can be used for both Ovid (MEDLINE and CINAHL) and for PubMed (MEDLINE). Resources for such filters are summarized in Table 5.
Resources for Teaching Access to EBP Information
Additional resources are available to assist in developing teaching strategies to equip the learner in accessing scientific literature to support EBP, including “How to find the best evidence” in Sackett,3 “Teaching Methods” in McKibbon,49 and “Searching for the Evidence” by Lou.50 Additional online sources that discuss teaching recommendations include:
- “Teaching EBM” available from the University of North Carolina EBM Education Center for Excellence at http://www.hsl.unc.edu/ahec/ebm-coe/pages/teaching.htm,
- The University of Toronto's Centre for Evidence-Based Medicine's “Teaching EBM: Teaching Materials” available at http://www.cebm.utoron-to.ca/teach/materials/, and
- “Evidence-Based Medicine: A New Approach to Teaching the Practice of Medicine” available from the Canadian Centre for Health Evidence at http://www.cche.net/usersguides/ebm.asp.
Clinicians can also have the option to build a specific search strategy in their area of clinical interest and have it automatically run on a regular basis with results or “alerts” automatically reported to the individual by e-mail. Most search services offer some method of retrieving updated information on a particular topic. For PubMed users, it is called “Cubby” and in Ovid an “Auto-Alert.” The collective name for this service is “selective dissemination of information,” or SDI. With SDI, the user will determine an effective search strategy and then save that strategy to be rerun on a periodic basis, eg, weekly or monthly. This allows the clinician to stay up to date on topics of choice in their primary areas of interest. A filter for EBP can also be included in the SDI search strategy.
Other services may also be used to support access to EBP information. Hooked on Evidence,51 described in Table 1, is a secondary-review database of extractions of journal articles that are relevant to physical therapy practice available free to APTA members. The summary extractions are searchable and have been contributed by APTA members. The extractions emphasize “current research evidence on the effectiveness of physical therapy interventions.” Students should be taught to use this service and to contribute to the database as a learning process. The APTA service e-Clips52 is an automatic news service alert available by subscription (annual fee for APTA members). The service provides timely physical therapy news and research updates delivered by e-mail twice a month, including news related to recent findings from studies that could support EBP.
Critically Appraised Topics (CATs) and Patient-Oriented Evidence that MattersTM (POEMs) are tools that have been used primarily in medicine, but could help digest and apply the ever-growing volume of new literature related to each area of practice in physical therapy. In the future, will physical therapists have more of these tools to help draw conclusions from the large number and variety of related studies? CATs, first developed in the early 1990s as a method to teach evidence-based medicine, are one-page summaries of the evidence. “When undertaking a CAT, a clinician typically 1) formulates a question based on a clinical problem, (and includes search terms), 2) searches the literature for clinical research that addresses the question, 3) evaluates the research for validity, importance, and applicability to the care of his/her patients, and 4) writes and files a page summarizing the findings.”53 The University of Alberta has developed a tutorial on developing a CAT,3(p87-89),53 and the Centre for Evidence Based Medicine has developed a CATmaker that can be downloaded to an individual's PC.54 POEMs, typically developed by physicians in internal medicine and family practice, address common clinical problems, report on outcomes, and meet three criteria: 1) addresses a question faced by clinicians; 2) measures outcomes such as symptoms, morbidity, quality of life, and mortality; and 3) has potential to change practice methods.55
Articles in the recent “Evidence in Practice” series, published in Physical Therapy, give specific patient examples “to illustrate how evidence is gathered and used to guide clinical decision making.”56(p916),57-61 These articles also provide examples of search strategies and retrieval methods and are excellent resources for students and physical therapists that want to be better equipped to search for evidence-based literature. Each article illustrates the search and synthesis processes that contribute to EBP regarding a specific clinical question. In each article, an abbreviated description of the examination, evaluation, and intervention of an individual is presented along with a specific clinical question related to the physical therapy care for the individual. As a learning tool for PT professionals, the author then describes a possible search process including specific databases and access systems utilized, the search strategies and keywords used in the search, modifications to the search, selection of articles to review, and the synthesis process that contributes toward EBP clinical decisions. A variety of specific search strategies can be observed by reading these articles.
Finally, a variety of specific examples from the field, emphasizing teaching methods and learning activities that have worked well in a variety of settings, are provided in Table 6. Some examples were obtained as a result of a nonscientific survey in April 2004 conducted on the APTA Section on Education listserv. Notably, among the responding programs, physical therapists usually taught EBP and access to literature with supplemental instruction by a health science librarian. All of the responding programs provided examples of activities to teach access to research evidence, fewer reported specific activities to retrieve expert opinion, and the majority of programs reported they did not have specific activities to teach students access to patient values. These informal results need to be substantiated through well-designed research, but could indicate areas of instruction that need to be clarified. The importance of curricula, educational experiences, and active teaching techniques have been supported in the literature.29 Small-group learning allows large enrollment courses to have small-group experiences without large numbers of faculty and has been associated with positive outcomes.62 Many teaching activities emphasized the importance of teaching appropriate search strategies and techniques to focus and limit the search.
New methodologies and techniques and a growing number of tests/measures and interventions are described and added to the physical therapy knowledge base daily. Therefore, it becomes paramount that the physical therapy clinician is able to retrieve and evaluate literature5 and not simply rely on anecdotal opinions as the basis for clinical decision making. These skills, taught well and experienced significantly in physical therapy education, will more likely become life-long practice and contribute to the reality of evidence-based practice in physical therapy.
While students should be taught the methods described to increase the ease with which EBP information can be located and retrieved, it should be emphasized that extra effort will, in many cases, improve the yield of a particular literature search. It is essential for a physical therapist to plan and complete an intentional multistep search process, then narrow the results, screen identified citations, and ultimately retrieve all pertinent articles. While many search systems will allow the user to restrict search results to articles that are available without charge or those available in full text, clinicians and students need to be made aware that they are likely not getting complete information. If only free or full-text articles are pursued and retrieved, many important pieces of evidence can be missed. Consultation and collaboration with medical librarians can be an effective means of teaching access to EBP information and can improve the effectiveness of individual literature searches.
The authors would like to acknowledge the contribution of each physical therapist and medical librarian who enthusiastically shared current teaching methods and activities for use in this article. Also special thanks to Jie Li, BA, MLS, Information Services Librarian and Medical Center Site Coordinator, University of South Alabama, for her assistance and review.
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