Evidence-based practice (EBP) involves clinical decision making that is based on the current best evidence in consultation with the patient and informed by the expertise of the practitioner.1–3 The “best” evidence is the most reliable and valid and can be obtained from sources ranging from critical summaries, evidence-based synopses, and systematic reviews of high-level, high-quality research, such as randomized controlled trials, to less reliable research such as individual case reports and expert opinions.4 The process of EBP involves the following five steps: asking answerable questions, searching for evidence, critically appraising evidence, making decisions, and evaluating outcomes.2,3,5 This process is sometimes referred to as the 5 A’s (“Ask,” “Acquire,” “Appraise,” “Apply,” and “Audit”).
Evidence-based practice is increasingly recognized in allied health disciplines including optometry.2,3,6–15 However, recognition of the need for EBP is only one step toward it becoming a reality for a profession; this cannot occur unless practitioners are properly trained and know how to practice in this way. Evidence-based practice requires a set of skills and knowledge including the ability to find and appraise evidence and to apply the best evidence at the point of clinical decision making.2,5 These attributes must be taught in undergraduate and continuing optometry education, acquired by students and practitioners, and hopefully maintained throughout practice life. Recent work on the design of undergraduate and continuing optometric education has resulted in EBP being a core part of many optometry curricula. For example, a survey of North American optometry and ophthalmology educators provided recommendations for enhanced EBP learning and teaching in these disciplines.16 In Australia and New Zealand, schools and departments of optometry collaborated on a project that aimed to ensure that all optometry students in that region graduate with the skills and knowledge needed for EBP.17 This in turn requires teachers and educators who are equipped for this task.
Evidence-based practice skills and knowledge may not, however, be enough to ensure EBP practice.18 Evidence-based practice may not be adopted by educators, students, and practitioners unless they understand the need for and significance of this approach and hold a positive attitude to EBP. Thus, evidence-based optometry depends in part on education and training including the EBP skills, knowledge, and attitude of the educators themselves, as well as their ability to teach EBP. In medicine and some allied health disciplines, the importance of high-quality EBP teaching has been widely recognized, and workshops and courses have been developed and implemented to ensure that teachers have the skills and attributes required to teach EBP. McMaster University has offered a 2-day course in evidence-based medicine (EBM) that has evolved over the past 20 years and includes interactive sessions, role playing, and mentoring.19 A different format has been used by the EBM Unity project team whose course is available online for teachers of EBM.20 The course was designed to allow practitioner-teachers to undertake sessions at their convenience, such as during breaks in clinical work, and to encourage teachers to use clinical situations to teach EBM.20 The Critical Appraisal Skills Program provides workshops that aim to develop skills in critical appraisal and in teaching EBP for any health care discipline.21 In allied health, a 2-day train-the-trainers workshop has been devised for podiatry educators, with face-to-face delivery of lectures and discussions as well as exercises relevant to EBP. The workshop was found to improve self-reporting of EBP skills, although some changes in practitioner-teacher behavior were not maintained in the longer term owing to a range of factors including a lack of necessary resources.22
Australian and New Zealand optometrists recently reported that their clinical decision making is based more heavily on sources of knowledge and information such as undergraduate and continuing education than on evidence they have sourced and appraised themselves, such as from scientific journals that may include recent, peer-reviewed research.10 Similarly, recent findings from a UK study indicate that optometrists rely largely on non–peer-reviewed professional journals for evidence to support advice for patients with age-related macular degeneration.23 Taken together, these findings suggest that optometrists may not always look for the best available evidence via the EBP process of search and appraisal. This may reflect a lack of EBP skills and knowledge and/or a failure to appreciate the need for an evidence-based approach to clinical decision making, as well as other factors such as lack of time or access to evidence. These barriers are commonly reported in other health fields including medicine.24–27
Discussion on the outlooks and approaches of academics and health care practitioners points to differences in their communities and cultures and suggests a divide between the two.28 However, these diverse perspectives and experiences are acknowledged as important components in the teaching of EBP for health care.9 The EBP skills, knowledge, and attitudes of the academics and practitioners responsible for teaching optometrists have not been explored to date. There are also no published reports of training in EBP for educators in optometry. Without such training, it is feasible that optometric teachers, who themselves have not necessarily received education in EBP, do not have the skills and knowledge needed for EBP, nor an understanding of the need for EBP in clinical decision making, and may not have experience or expertise in teaching EBP. The work described here is part of a larger collaborative project involving optometry schools and departments in Australasia.17 In the part of the project described here, our goal was to design and deliver a pilot workshop to enhance the teaching of EBP in an undergraduate optometry curriculum. As part of the workshop, we investigated the perspectives of optometric educators on EBP including their attitudes and any barriers to EBP perceived by them. The workshop intended to focus on both the practice and the teaching of EBP, with a primary focus on teaching because it was created for and attended by optometric educators.
A 1-day workshop was designed based in part on the published description of existing face-to-face workshops for teachers of EBP19 and by drawing on the experience of authors AL and NC in medical education. The workshop design took into account the fact that participants would be experienced in teaching within either a classroom or a clinical setting but that their EBP knowledge, skills, and attitude were unknown and may vary. We used a blend of didactic and nondidactic methods such as lectures, small-group discussions, facilitated and interactive sessions, and panel discussions. This was intended to enhance learning and to allow the participants to actively discuss the issues presented and to reach their own conclusions on any discussion topics,29 and broadly follows the format of the McMaster EBP workshops.19 Twenty-four of 27 participants including the facilitators signed an appearance release agreeing for audio, video, and statements recorded during the day to be used for educational, promotional, and editorial purposes. Although ethical approval was not required for the overall workshop as this was deemed curriculum improvement, it was obtained for one part of the workshop in which educators’ attitudes to EBP before and after completion of the workshop were sampled.
Evidence-based practice experts from outside of optometry (authors RT and LT; medicine and speech pathology, respectively) and within optometry were invited to cofacilitate the workshop alongside an education expert with experience of teaching medicine from an EBP perspective (author AL). Each facilitator brought extensive experience of teaching EBP in their field. All academic teachers in the host institution’s optometry program (UNSW Australia) who were not facilitators received an invitation to attend. Clinical teachers were selected for invitation from a larger pool of external visiting clinicians regularly delivering optometric education at the UNSW Optometry Clinic. Six of 12 invited (nonfacilitator) academics and 13 of 18 invited clinical teachers participated in the workshop. Selection was guided by the Optometry School’s clinic director (author KW), and, in line with maximum variation sampling strategies, was intended to ensure that the workshop attendees included a mix of optometric educators with different levels of perceived familiarity and interest in EBP and education. Of the 27 optometric educators who participated in the workshop, 14 were academics (including the 8 facilitators) and 13 were clinical supervisors.
Optometric educators were divided into small groups of four to five nonfacilitator participants for discussions at the workshop. Each small group included approximately equal numbers of academic and clinical teachers with the intention of including different perspectives in each group.19 Eight facilitators including five optometrists attended the workshop and were seated separately from other groups, so that all facilitators participated in all sessions and made contributions to discussions throughout the workshop but did not contribute directly to small-group discussion among optometric educators. In line with the McMaster recommendations, the workshop adopted the characteristics of small-group interactive sessions, high educator-to-learner ratio, heterogeneity of learners, and feedback.19 The content of the workshop is summarized in Table 1 and, as outlined above, included a mix of activities such as didactic presentations, interactive discussions, and self-directed exploration.
Evidence-based practice attitudes can be measured qualitatively30 or using one of a few existing tools.31–33 Attitudes toward EBP were assessed before and after the workshop using a modified version of the Evidence-Based Practice Attitude Scale (EBPAS-5031), which has previously been validated for use by mental health practitioners31 and physicians34 (see Appendix 1, available at http://links.lww.com/OPX/A204, which contains the EBPAS for optometry). The modifications involved changes to wording so that terminology was relevant for optometrists. These modifications included, for example, replacing the word clients with patients. Modifications were proposed and reviewed using an iterative process and feedback from a panel of 12 EBP experts (including 8 optometrists). The modified EBPAS is a 50-item questionnaire that samples optometrists’ attitudes toward EBP across 12 subscales or domains (see Appendix 1, available at http://links.lww.com/OPX/A204, which contains the EBPAS for optometry).
A score for each domain is obtained by averaging the responses to individual subscale items scored on a five-step 0 to 4 categorical scale where 0 = “not at all” and 4 = “to a very great extent” with a value of 4 representing a positive attitude and a value of 0 representing a negative attitude. The domains of divergence, limitations, monitoring, and burden were reversed to calculate the composite score EBPAS-50. All domains were combined to form the EBPAS-50 score.
The workshop included a number of small-group (four to five participants in each) discussions, one of which opened the workshop with discussion on perceptions and attitudes to EBP. Participants were asked, “What does evidence-based practice mean to you, and what is its significance to optometry?” (Table 1, session 1). In a second discussion, participants were asked, “What strategies do you use to teach optometry students to be evidence-based practitioners?” (Table 1, session 5). Responses were collected and the strategies were discussed with the whole group including facilitators. The aim of this session was to provoke thought and generate discussion on teaching strategies that could potentially be used to teach EBP in optometry, with input from facilitators with related experience.
The workshop included a lecture on the internationally accepted expert consensus view of EBP including its definition, the EBP process, and its significance to health care (Table 1, session 2).2 The rationale for including this lecture was to ensure that, once subjects’ thoughts on the meaning of EBP had been gathered, all were made aware of the widely accepted meaning and significance of EBP. The Sicily statements2,5 were outlined in this lecture, focusing not only on the Sicily group’s definition of the meaning and significance of EBP but also on its emphasis on the importance of effective teaching of EBP. Two additional lectures were delivered during the workshop describing experiences of teaching EBP in medicine (author RT) and teaching EBP in ophthalmology and optometry (author KP) (Table 1, sessions 3 and 4). These lectures were intended to illustrate teaching approaches and methods that have been used to develop skills and knowledge needed for EBP in these areas and to outline the nature and resolution of any difficulties encountered in teaching EBP.
During the workshop, a structured qualitative interactive session was conducted35 with the aim of identifying barriers to EBP in optometry (Table 1, session 6), as a basis for a discussion on overcoming such barriers. An approach combining the nominal group technique35 with a fishbowl technique36 was used to elicit, prioritize, and semiquantify barriers to EBP. A highly experienced health education expert facilitated this session (author AL).37 The nominal group technique is a qualitative method of data collection that enables a group to generate and prioritize a large number of issues with a structure that gives everyone an equal voice. It has been used in a number of health contexts to generate ideas and allow a group to reach consensus on barriers and facilitators to health practices.38,39 The 25 participants at this session were given an individual card and asked to record silently their responses to the question “What are the main difficulties and challenges you face in teaching and applying EBP?” The participants included the 19 nonfacilitators, 4 optometrist facilitators, and 2 nonoptometrist facilitators (authors LT and RT). Thus, the responses include a small contribution from a nonoptometry perspective. Eight nonfacilitator attendees were pseudorandomly selected (the first to return to the room after a break) to form the “fishbowl” with the remaining 17 participants forming an outer group seated behind them. Participants in the fishbowl took turns to read aloud a single response from their card with each response recorded on a flip chart. This continued in a round robin fashion until all responses from the fishbowl were exhausted. Omissions were identified by asking participants in the outer group to contribute any responses from their cards that had not already been nominated. A facilitated discussion followed in which responses were reviewed and clarified. Group consensus was reached on the meaning of each individual contribution and similar items were amalgamated, to ensure that all responses were accurately represented. Participants were then asked to individually choose, rank, and record five responses they personally considered most important with the most important granted a score of 5 and the least important granted a score of 1. The rankings were summed for each barrier and displayed on the flip chart for the group to see. The barriers were subsequently reviewed (after workshop) by two authors (IJ and CS) who identified themes individually and reviewed their findings collaboratively to reach consensus. For each barrier, the number of votes it received (maximum 25) and its total (maximum possible score of 125 if top rank of 5 was given by all 25 participants) and average score (total score divided by the number of votes) were recorded (see Appendix 2, available at http://links.lww.com/OPX/A205, which lists the identified barriers to EBP in optometry and their associated scores).
Once barriers had been identified, a moderated panel discussion featuring four EBP educators with backgrounds in optometry (authors KP and FS), medicine (author RT), and speech pathology (author LT) allowed participants to raise questions and to discuss points that may have arisen after the lectures and interactive sessions held previously. Discussions focused largely on possible solutions to the top five barriers identified in the previous session of the workshop. Feedback on the workshop was gathered by inviting the 19 nonfacilitator participants to complete a short semistructured evaluation questionnaire at the conclusion of the workshop.
Data analysis involved a combination of quantitative and qualitative methods as described above. Qualitative data analysis was carried out using a grounded theory approach by identifying themes. Statistical analysis was carried out using SPSS for Windows Version 22 (SPSS for Windows, Chicago, IL). Nonparametric statistics were used for analyzing the EBPAS score because of the categorical nature of the data. Associations were tested using Spearman ρ correlation. Statistical significance was set at 5%.
The demographic characteristics of 18 of the 19 nonfacilitator workshop participants who completed the EBPAS and of the 25 participants in the nominal group sessions are shown in Table 2. Participants’ attitudes toward EBP were generally positive with a mean (±SD) EBPAS-50 score of 2.7 (±0.3) (range, 2.3 to 3.1) out of a possible 4. Fig. 1 displays the boxplots of responses from the 18 participants across the 12 EBPAS domains. No difference was found between EBPAS-50 scores in the 6 nonfacilitator participants who categorized themselves as “academic” and the 12 who categorized themselves as “clinical supervisor/practitioner” (Mann-Whitney test, p = 0.3). A negative correlation was found between attitudes to EBP measured by the EBPAS-50 score and age (Spearman ρ = −0.57, p = 0.01) (Fig. 2A) and time since graduation (Spearman ρ = −0.57, p = 0.01) (Fig. 2B). Sex, education, and self-perceived EBP expertise level had no effect on attitudes to EBP (group t test or one-way analysis of variance; p > 0.05).
Nonfacilitator participants’ responses to the questions “What does evidence-based practice mean to you, and what is its significance in optometry?” and “What strategies do you use to teach optometry students how to be evidence-based practitioners?” are summarized in Table 3. All groups of optometric educators indicated that EBP means the application of the best available research to clinical decision making, whereas about half the groups indicated that it means the patient is informed as part of the decision-making process. Although these qualitative data cannot be analyzed quantitatively, this demonstrates that at least one educator in each of these groups understood that high-quality/high-level research is integral to EBP and that EBP involves the patient in clinical decision making. Educators made a range of other positive points about EBP. Some participants expressed reservations about EBP, namely, that it could mean a delay in treatment while awaiting evidence and may stifle creativity.
The nominal group process identified 35 distinct barriers to practicing or teaching EBP and these were segregated into the following four themes: time, knowledge/curriculum, attitude, and access (see Appendix 2, available at http://links.lww.com/OPX/A205, which lists the identified barriers to EBP in optometry and their associated scores). Fourteen of the 35 barriers pertained specifically to EBP teaching and not to EBP practice. The remaining 21 barriers could apply to both EBP practice and EBP teaching. The average score for each barrier varied from 0.0 to 4.4. Fig. 3 illustrates the most frequently cited barriers including the five that attracted the highest total scores. These represent the greatest perceived impediments to EBP teaching and/or practice for our sample of optometry educators. Although a number of barriers to teaching and practicing EBP in optometry were identified, the frequency at which the lack of time barrier was cited was much greater than for all other barriers. Lack of time was selected in the top five by most participants (17 out of 25) and attracted the highest total score of 75, well above the total score of any other nominated barrier (Fig. 3). In fact, lack of time was ranked as the top barrier (attracting a score of 5) by 13 participants. Although well behind, other important barriers consisted of negative attitude to EBP (9 votes; total score, 29), volume of evidence (8 votes; total score, 26), integration with clinical practice (6 votes; total score, 24), and lack of lifelong learning mind-set (6 votes; total score, 21) (Fig. 3). An additional two barriers were nominated by many participants but generally attracted low rankings, and these were understanding statistics and lack of evidence (Fig. 3). These last two items attracted 9 and 8 votes, respectively, but low total scores of only 15. We speculate that this low ranking may be because these items are considered very important to good EBP practice but perhaps perceived by our group of educators as easier to overcome than other barriers such as time. Interestingly, none of the 14 barriers specific to EBP teaching (see knowledge/curriculum in Appendix 2, available at http://links.lww.com/OPX/A205) were rated as highly by workshop participants as those related to practice.
Responses to the feedback questionnaire indicated that most (17/19; 89%) participants found the workshop discussions extremely or very useful. Some participants indicated that they would have liked more focus on the process of EBP, suggesting that, for our sample of optometry educators, enhanced EBP knowledge and skills would have been helpful, for example, “All helpful but still not sure how to actually apply…,” “I thought we would learn to search [for evidence] ourselves,” and “Didn’t really find out how to effectively do EBP.” Attendees appreciated the multidisciplinary input: “It was good to have representatives from [optometry], medicine [and] speech therapy here and to share their experiences,” “It was great to see how other professions do this, e.g. speech pathology and medicine,” and “Good to have multidisciplinary inputs.” Educators also felt that the panel discussion was helpful: “The discussion on overcoming barriers was very helpful” and “Good ideas of teaching methods [and] how to overcome barriers,” although one respondent stated that the “Panel discussion was interesting but lacked detail to be useful.” This feedback will inform the development of future iterations of the workshop.
Finally, although all 18 participants who had completed the EBPAS before the workshop were invited to complete it a second time, 1 week after the conclusion of the workshop, responses were received from only 11. Attitudes to EBP did not change significantly after the workshop (Wilcoxon signed rank test, p = 0.76) in these 11 participants. This may reflect the relatively positive attitude measured at the outset but may also be attributed to the small sample size. The interval between evaluations may also have been too short (1 week) to allow for a significant change in attitudes to occur. There was no significant difference in baseline EBPAS scores between the 11 participants who completed the questionnaire both before and after the workshop and the seven who only completed it before the workshop (Mann-Whitney test, p = 0.33).
Evidence-based practice cannot be implemented effectively without health practitioners having the competency required to practice it. This is facilitated in part by education to develop relevant knowledge, skills, and attitudes in this area. However, EBP education requires educators who themselves understand and have adopted EBP. The workshop described here is a pilot intended as a basis for designing future workshops or courses of this kind for optometry educators, including practitioners teaching within optometry curricula.
The workshop was designed to explore perspectives of EBP and develop understanding of the meaning of EBP using a mix of activities. A proportion of our educators arrived at the workshop with a high level of understanding of the concept of EBP and teaching methods for EBP. The EBP-related learning and teaching strategies identified by this group of optometric educators include those requiring students to present and discuss findings in grand round format and encouraging students to ask questions, as well as alignment with the five EBP steps. Interactive learning of this kind is thought to be an important part of effective learning and teaching for EBP,40 and alignment of EBP teaching with the five steps of the EBP process has been recommended for EBP teaching.2
This was not a skills development workshop; hence, EBP knowledge and skills were not measured and the extent to which we can comment on participants’ understanding of EBP is limited. However, we measured attitudes toward EBP before and in some participants also after the workshop.31 Overall, optometry educators’ attitudes toward EBP were positive. We chose to use the 50-item version of the EBPAS scale over the initial (truncated) EBPAS-15,41 which would have sampled the domains of divergence, openness, requirements, and appeal only. Had we used the EBPAS-15, our sample of optometrists would have yielded similarly positive values of 2.8 ± 0.4 (range, 1.8 to 3.8).
We have previously reported similar findings30 from a qualitative study of optometry practitioners. Studies conducted on other health professionals have also shown largely positive attitudes toward EBP and research use in practice.15,33,42 Negative comments about EBP (e.g., “treatment may be delayed and may stifle creativity”) were made by at least one optometric educator. In our survey of Australian and New Zealand optometrists, 14 (20%) respondents who made comments on EBP also voiced broadly negative comments, indicating that EBP is unimportant or unhelpful to optometry.10 Interestingly, the present findings suggest that younger optometrists and those recently trained may have more positive attitudes to EBP than older educators or those who have trained a long time ago. Similarly, a negative correlation between age and EBPAS score was demonstrated in physicians.34 A systematic review previously suggested that physicians “who have been in practice longer may be at risk for providing lower-quality care.”43 This may simply be a reflection of the relatively recent introduction of an EBP focus to the health care professions and their associated educational facilities.1–3,5
We were unable to demonstrate improved attitude to EBP after workshop attendance. The very positive attitude toward EBP measured in our participants before the workshop and the small sample size (11 participants completed the EBPAS after the workshop) may have limited the potential to measure a significant improvement. The interval of 1 week between the pre- and postworkshop assessments may also have been too short for a detectable change in attitude to occur. These findings should also be viewed in light of the fact that we did not validate the modified EBPAS before its use; it may therefore simply lack sufficient validity to measure and detect changes in EBP attitudes when used in optometrists. In fact, the questionnaire may be limited by a potential mismatch between individual items of the EBPAS-50 and the contemporary definition of EBP.1,2 In particular, the Appeal subscale includes item 9, “If you received training in a therapy or intervention that was new to you, how likely would you be to adopt it if it was intuitively appealing?,” which indicates a positive attitude to EBP on the EBPAS scale. Yet, such a response suggests blind acceptance of therapies based on nothing but intuitive appeal. This appears contrary to the accepted definition of EBP that requires practitioners to integrate the best research evidence with findings from their clinical examinations and the patient’s values and preferences.1,2 In addition, the Appeal subscale items are intended to assess the extent to which EBP appeals to the respondent but refer to “therapy” in general rather than specifying EBP. Thus, there is a need for validation of the EBPAS scale before any wider application of the questionnaire in optometry. Although the EBPAS indicated that our sample of optometry educators held a favorable attitude toward EBP, this finding should be viewed in light of the limitations outlined above.
Participants’ views on the most important factors that prevent them from teaching and/or practicing EBP were also gathered. The advantage of the nominal group technique over other qualitative methods such as focus groups and individual interviews is that it allows some quantitative data to be collected in the form of ranking. When using this technique, all participants are offered an opportunity to participate and no one participant is allowed to dominate discussions as could perhaps occur in focus group studies. Previous work on barriers to EBP has repeatedly shown that, in a range of health disciplines, “time” is a significant barrier to EBP.15,33,42 Our results in this small group suggest that the same applies in optometry: at least in this small group, time is the biggest factor preventing educators and practitioners from teaching and practicing EBP.
This raises the question of how such barriers can be overcome. In other health disciplines, a range of approaches have been used. For example, Allied Health Evidence is an online database through which practitioners can gain rapid access to up-to-date research evidence relevant to speech pathology, occupational therapy, psychology, and physiotherapy, with each piece of evidence rated independently in terms of validity.44 No such database exists for optometry, but other resources are available. Examples include the Cochrane Eyes and Vision Group systematic reviews,45 the Translating Research Into Practice database,46 and evidence-based clinical guidelines such as those maintained by the American Optometric Association,47 the British College of Optometrists,48 or the Australian Government’s National Health and Medical Research Council.49 Recent qualitative research suggests that optometrists could make more extensive use of existing guidelines.30,50,51 Further, existing resources are unlikely to address the wide range of clinical questions faced by optometrists. A resource like the Allied Health Evidence database may ultimately be needed for optometry.
The generalizability of our workshop findings to other optometry institutions in the region and worldwide is uncertain. However, the findings outlined above have formed the basis of further workshops of this kind being developed and delivered for optometry educators internationally, including both face-to-face and online delivery. The findings also led to the instigation of an Australian EBP Optometry Interest Group whose meetings include activities aimed at sharpening EBP skills and knowledge (such as critical appraisal, finding evidence, and the application of evidence in clinical decision making). With appropriate modification, the workshop described here may be applied in any optometric education setting, to raise awareness of the significance of EBP and factors related to educational practice in optometry, to generate discussion on EBP teaching methods for optometry, and also as a precursor to further development of the relevant skills, knowledge, and attitudes in optometric practitioners and educators.
School of Optometry and Vision Science
Sydney, NSW 2052
e-mail: [email protected]
Funding was provided by the Australian Government Office for Learning and Teaching Grant Project ID11-1988. This work was presented in part at the American Academy of Optometry Annual meeting held in Seattle, WA, on October 23 to 26, 2013. We thank Mr. Duncan Smith and Mr. Tim Salmon from the School of Mathematics and Statistics at the University of New South Wales for providing the facilities and IT support for the workshop. Professor Rob Jacobs, Associate Professor Peter Hendicott, and Dr. Michael Pianta provided expert feedback on the EBPAS scale.
Received July 22, 2014; accepted October 28, 2014.
Appendix 1, which contains the EBPAS for optometry, is available at http://links.lww.com/OPX/A204.
Appendix 2, which lists the identified barriers to EBP in optometry and their associated scores, is available at http://links.lww.com/OPX/A205.
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