|Ahead of print publication
Knowledge, attitudes, and practices of evidence-based practice among health-care professionals: Results of a cross-sectional questionnaire-based study
Deepali Rajpal1, Manu Mathew Lal1, Varsha Vyas2, Vikram Vardhan2, RP Gehdoo2, Surekha Patil2
1 Department of Emergency Medicine, Dr. D. Y. Patil Medical College, Navi Mumbai, Maharashtra, India
2 Department of Anesthesia, Dr. D. Y. Patil Medical College, Navi Mumbai, Maharashtra, India
|Date of Submission||06-Jun-2020|
|Date of Decision||05-Sep-2020|
|Date of Acceptance||07-Dec-2020|
Department of Anesthesia, Dr. D. Y. Patil Medical College, Nerul, Navi Mumbai - 400 706, Maharashtra
Source of Support: None, Conflict of Interest: None
Objective: To study knowledge, attitudes, and practices (KAP) of evidence-based practice (EBP) among health-care professionals (HCPs). Materials and Methods: In this cross-sectional study, a pre-tested questionnaire regarding KAP related to EBP was administered to HCPs. The responses were compared based on level of education, work profile and years of experience. Results: Out of 93 HCPs (47.31% male), 64 (68.82%) were Doctor of Medicine or Master of Surgery and 63 (69.23%) were in clinical practice. Thirteen (14%) had experience of <5 years. Eighty seven (93.55%) HCPs were aware about the term “EBP.” Fifty-three (56.99%) were aware about core elements of EBP with significant difference in responses based on level of education (P < 0.0001). Sixty-two (66.67%) had understanding regarding usage of research findings in clinical practice with significant difference based on the level of education (P = 0.003586). Forty-five (48.39%) reported having discussions at workplace about EBP with significant difference based on level of education (P = 0.03991). Seventy-one (76.34%) HCPs responded that they ask patients about their preferences and consider them in decision-making. Eighty-two (88.17%) HCPs showed interest in improving knowledge of EBP with significant difference based on the highest level of education (P = 0.04043). Conclusion: In the studied population, awareness about the term “EBP” was good. There is further scope for improvement in literature search, understanding core elements of EBP, critical analysis of research findings, statistics, and knowledge to implement EBP. Most of the study population showed interest in improving knowledge about EBP.
Keywords: Evidence-based medicine, evidence-based practice, health-care professional, research
|How to cite this URL:|
Rajpal D, Lal MM, Vyas V, Vardhan V, Gehdoo R P, Patil S. Knowledge, attitudes, and practices of evidence-based practice among health-care professionals: Results of a cross-sectional questionnaire-based study. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Jun 13]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=316411
| Introduction|| |
In clinical practice, therapies used for treatment of any disease should be efficacious, well tolerated and cost effective. Therapies which satisfy these criteria should be incorporated into clinical care for improved health care and patient satisfaction. In order to understand and implement the decision based on results of clinical trials, health-care professionals (HCPs) should have knowledge and skills to understand and critically analyze the findings originating from research. Building and nurturing the culture of evidence-based practice (EBP) is important for delivering clinically effective and well-tolerated therapies in the management of any disorder.
Over the past few decades, EBP has been the focus of discussion for improvement in clinical decisions for improvement of patient outcomes. Higher quality care and reduced cost are the other advantages of implementation of EBP.
Resources in the form of computer, internet and skills of literature search, understanding essential elements of evidence-based medicine (EBM), interpretation, and critical analysis of available evidence are essential for EBP. Nonavailability of resources or skills may be responsible for myth that EBP is difficult and/or time-consuming. Culture of inquiry should be embedded in the health-care settings willing to implement and practice EBM.
Despite the known advantages of EBP, its low implementation among nurses and midwives has been reported in many places in the world. Similarly, studies involving osteopaths show support to EBP, but less frequent engagement in EBP related activities., A small cross-sectional study among clinical physiotherapy practitioners around Mumbai showed awareness, positive attitudes, and beliefs about EBP. Studies evaluating knowledge, attitudes, and practices (KAP) of HCPs from India regarding EBP are limited.
The objective of this study was to study KAP of EBP among the clinicians.
| Materials and Methods|| |
This was a cross-sectional questionnaire-based study, where health-care professionals (HCPs) of both genders working in academic institutes or clinical practice were involved.
The questionnaire was developed based on a published article by Silva et al. Content validity was performed by two experts who were not involved in this research. Face validation of the questionnaire was done by sending questionnaire to ten HCPs. The study participants were selected based on convenience sampling. A pre-tested questionnaire was then sent to 300 HCPs via Google Form. The questionnaire consisted of 20 questions regarding KAP related to EBP. Answers to these questions were graded as “Yes,” “No” or “Not sure.” Open-ended questions were avoided in order to avoid bias in interpretations and analysis. Similarly, names or other identifiable information of the participants were not collected for getting unbiased information. Responses were collected over a period of 1 week. For increasing the response rate, two reminders were sent to those persons, who did not respond to the questionnaire. Completed responses were considered for analysis. The study participants were divided into different groups based on their highest level of education, work profile and number of years since graduation. The frequency and percentages of responses for overall study population and different categories were calculated and compared. As this was a cross-sectional study, no follow up was required. The study was approved by the institutional review board (Ref no: DYP/IRB/2018/04/103; Dated March 5, 2019). The study was conducted in March 2019.
As there was no specific hypothesis in the study, formal sample size calculation was not done. Collected data were transferred to Microsoft Excel spreadsheet 2017 for analysis. Missing data were excluded from analysis. Categorical responses are presented as frequency and percentages. Comparison between the groups was performed by Chi-square or Fisher exact test as appropriate. P < 0.05 was considered statistically significant.
| Results|| |
A total of 93 health-care professionals (HCPs) responded to the questionnaire with response rate of 31%. Of the 93 HCPs, 44 (47.31%) were males and 49 (52.69%) were females. Sixty-four (68.82%) study participants were either Doctor of Medicine (MD) or Master of Surgery (MS) and six (06.45%) were Bachelor of Medicine and Bachelor of Surgery [Table 1]. A total of 63 (69.23%) study participants were in clinical practice and 26 (28.57%) were in academic profession [Table 1].
Out of 93 study participants, 13 (14%) had experience of <5 years since the time of graduation, whereas 29 (31.18%) had experience of 5–9 years. Eleven (11.83%), 12 (12.90%), eight (08.60%), and 20 (21.51%) participants had experience between 10 to 14 years, 15–19 years, 20–24 years, and >24 years, respectively [Figure 1].
A total of 87 (93.55%) participants were aware about the term “EBP.” There was no difference in awareness of EBP among participants based on their time since graduation (P = 0.5886), highest level of education (P = 0.3723) or work profile (P = 1). A total of 53 (56.99%) study participants were aware about the core elements of EBP. There was significant difference in the responses based on the level of education [P < 0.0001; [Table 2]], whereas no differences were observed based on time since graduation (P = 0.2871) or work profile of study participants (P = 0.07874). A total of 62 (66.67%) study participants had clear understanding regarding usage of research findings in clinical practice.
Significant difference in the responses was observed based on the level of education [P = 0.003586; [Table 2]], but no differences were observed based on time since graduation (P = 0.1235) or work profile of study participants (P = 0.4307).
A total of 64 (68.82%) and 56 (60.21%) study participants reported clear understanding about different types of study designs and statistical data. No differences in the responses were observed based on their time since graduation, highest level of education or work profile for both responses. A total of 42 (45.16%) study participants reported having no knowledge about performing database searches for literature. Difference in responses was statistically significant based on the level of education (P = 0.03877), but not based on the time since graduation (P = 0.4091) or work profile [P = 0.3302; [Table 2]]. A total of 32 (34.41%) participants reported having sufficient knowledge to implement EBP with significant difference in responses based on level of education (P = 0.04256). A total of 38 (40.86%) study participants reported having lack of ability to critically assess scientific papers with significant difference in responses based on the level of education (P = 0.0068) and work profile of participants (P = 0.0314).
A total of 32 (34.41%) study participants reported that they regularly access online databases for literature search with no difference in responses based on time since graduation (P = 0.4212), level of education (P = 0.8046) or work profile of participants (P = 0.9289). Availability of computer and internet access at workplace to facilitate implementation of EBP was reported by 57 (61.29%) participants. A total of 45 (48.39%) participant reported having discussions at workplace about EBP with significant differences in the responses based on level of education (P = 0.03991) [Table 3].
A total of 71 (76.34%) participants responded that they ask patients about preferences and consider them in decision-making, whereas 86 (92.4%) said that they inform patients about their treatment options and involve them in decision-making. A total of 78 (83.87%) respondents tried to deploy best scientific evidence in clinical practice, whereas 82 (88.17%) respondents believed that EBP improves patient care. There was no significant difference in the responses based on time since graduation, highest level of education, or work profile of the participants (P > 0.05).
A total of 19 (20.43%) respondents mentioned that they received sufficient knowledge during graduation and postgraduation regarding EBP, while 48 (51.61%) reported that the knowledge on EBP received during graduation and postgraduation was not sufficient. Remaining 26 (27.96%) were not sure about it. There was no significant difference in the responses based on the time since graduation (P = 0.4648), highest level of education (P = 0.6147) and profile of participant (P = 0.2156). A total of 82 (88.17%) respondents showed interest in improving knowledge of EBP [Figure 2]. There was significant difference in the responses based on the highest level of education (P = 0.04043).
|Figure 2: Sufficient knowledge received during graduation and postgraduation and willingness in improving knowledge regarding evidence-based practice|
Click here to view
| Discussion|| |
In this study, we evaluated KAP among HCPs related to EBP. Participation of females was slightly more than males, but not considerably different. The study population was dominated by post-graduates with degree of MD or MS and health-care practitioners involved in clinical practice.
Study population had varied number of years of experience since graduation, with highest number of participants having 5–9 years of experience. Most of the study participants were aware of the term “EBP.” Results of our study suggest further scope for improvement in knowledge related to core elements of EBP, different study designs, statistics, performing systemic literature search and skills for critical analysis of scientific papers.
Journals published periodically by academic institutions and professional bodies are the important sources to bridge the gap between research and clinical practice.
A study involving residents of radiology department suggested need for better awareness about sources for evidence-based literature and understanding of complex details in statistics.
In terms of practice, our study results showed routine access of online database by limited number of health-care practitioners. It may be because of time pressure, because of large number of patients or insufficient knowledge and skills to access the online databases. In today's era of technology, availability of computer and internet access at workplace is almost a norm. However, our study suggests scope for improvement for availability of computer as well as internet access.
Similarly, <50% study participants reporting having regular discussions about EBP at workplace also suggests need for a re-look and further improvement.
According to results of a study involving nursing students' self-perceived competence and barriers to EBP, both academicians and hospital administration can play an important role in the successful acquisition of EBP competence. We feel, same can also be true for clinicians, as well as for under-graduate and postgraduate students of modern medicine.
Practice of asking patients about their preferences, informing them about treatment options, involving the patients in decision-making and trying to deploy best scientific evidence in clinical practice was found to be satisfactory. Belief that practice is largely evidence-based may not be necessarily true; given the challenges in correct understanding of the elements of EBP. Some may consider it synonymous with research. Although critical appraisal and the usage of research-based evidence are integral part of EBP, the process is not just limited to the research, but it is beyond these factors and is more patient-centred.
Most important aspect of EBP is nurturing culture of inquiry. Other essential elements include asking a right question for the literature search, searching best evidence for the question in consideration, critical appraisal of the available evidence, integrating the evidence with clinical expertise, patient preferences and values and evaluation of outcomes of clinical practice decisions based on the evidence and dissemination of EBP.
Clinicians' knowledge and skills required for EBP are important. At the same time, culture of the organization is also important for EBP. Availability of resources in the form of computer and internet are necessary for implementation of EBP.
In our study, a total of 61.29% participants reported having computer and internet access at workplace to facilitate implementation of EBP, but only 34.41% of the participants said that they routinely access online databases. Our findings suggest need for both, i.e., improvement of availability of resources at workplace, as well as, proactive usage of available resources by the HCPs. Only availability of internet may not be of use. Internet search skill is another important aspect for implementation of EBP. HCPs should be trained for the correct methods of accessing databases, critically analyze study methodology, results and implications of the same in the clinical practice. Lack of sufficient knowledge and resources may result in perception that EBP is too difficult and time-consuming. Awareness regarding necessary resources and training for gaining skills may be useful for dispelling such myths.
Journal club is a commonly used method for discussion on understanding concepts of EBP for postgraduate students. Incorporating teaching of EBP in journal club presentations can help in improving competencies of postgraduate students in clinical decision-makings. The large gap of discussions about EBP at workplace of our study participants may be explained by the large number of participants from clinical practice rather than academics. A study involving residents of radiology suggested large knowledge gap related to EBP and need to incorporate structured training into the core-curriculum programs.
A systematic review reported moderate to high level of knowledge, skills and attitudes related to EBP among practicing HCPs; however, they did not transform into EBP.
Educational programs may have incorporation of EBP into the curriculum for the development of foundation, but self-development must continue to build on the knowledge and skills gained during curriculum training. Continuing education programs have been evaluated for their usefulness in delivering EBP to hospital nurses. Recently a study from India involving dental under-graduate students and interns reported improvement in the effectiveness of training in improving knowledge, accessing evidence and critical appraisal skills essential for EBP.
A study evaluating curricula of health science universities reported introduction of teaching EBP in physiotherapy programs at the entry level. However, the structure is fragmented. In medical colleges also structured training on EBP is necessary.
In our study, most study participants believed that EBP improves patient care, but only about one fifth participants reported that they have received sufficient knowledge regarding EBP during graduation or postgraduation. The willingness of the study participants to improve their knowledge related to EBP was in line with this finding. Most of the study participants were willing to participate in education programs to improve their knowledge related to implementation of EBP. Willingness to learn more and to improve the EBP skills is also reported by another study involving primary care occupational therapists in Sweden. The existing gap between best practice based on evidence and actual clinical care can be overcome by EBP.
Our study has certain limitations. This was a cross-sectional study with subjective responses. Our study population had more number of postgraduate participants and participants from clinical practice background. Small sample size without any follow up limits the generalization of findings. Studies covering larger population from wider geographical areas are required to confirm these observations.
| Conclusion|| |
In the studied population, although awareness about the term “EBP” was good, there is further scope for improvement in understanding its core elements, methods for literature search, critical analysis of research findings and statistics. Most of the study population showed interest in improving knowledge about EBP. Regular educational activities such as seminars, journal clubs, workshops and group discussions for improving knowledge of EBP may be useful.
The authors of this study wish to thank Dr. Anant Patil for his assistance in writing this manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Beck M, Simonÿ C, Bergenholtz H, Hwiid Klausen S. Professional consciousness and pride facilitate evidence-based practice-The meaning of participating in a journal club based on clinical practice reflection. Nurs Open 2020;7:690-9.
Chiwaula CH, Chinkhata M, Kamera H, Haruzivishe C. Evidence based practice: A concept analysis. Health Syst Policy Res 2018;5,3:75.
Melnyk BM, Fineout-Overholt E, Stillwell SB, Williamson KM. Evidence-based practice: Step by step: The seven steps of evidence-based practice. Am J Nurs 2010;110:51-3.
Leach MJ, Sundberg T, Fryer G, Austin P, Thomson OP, Adams J. An investigation of Australian osteopaths' attitudes, skills and utilisation of evidence-based practice: A national cross-sectional survey. BMC Health Serv Res 2019;19:498.
Sundberg T, Leach MJ, Thomson OP, Austin P, Fryer G, Adams J. Attitudes, skills and use of evidence-based practice among UK osteopaths: A national cross-sectional survey. BMC Musculoskelet Disord 2018;19:439.
Panhale VP, Bellare B. Evidence-based practice among physiotherapy practitioners in Mumbai, India. Educ Health (Abingdon) 2015;28:154-5.
Silva TM, Costa LC, Costa LO. Evidence-based practice: A survey regarding behavior, knowledge, skills, resources, opinions and perceived barriers of Brazilian physical therapists from São Paulo state. Braz J Phys Ther 2015 J 19:294-03.
Mukundan G. Evidence based practice in speech language pathology/audiology in India. S Afr J Commun Disord 2008;55:13-5.
Anuradha C, Jacob KS, Shyamkumar NK, Sridhar G. Evidence-based practice in radiology: Knowledge, attitude and perceived barriers to practice among residents in radiology. Eur J Radiol 2013;82:894-7.
Labrague LJ, McEnroe-Petitte D, D'Souza MS, Cecily HSJ, Fronda DC, Edet OB, et al
. A multicountry study on nursing students' self-perceived competence and barriers to evidence-based ractice. Worldviews Evid Based Nurs 2019;16:236-46.
Cleary-Holdforth J, Leufer T. Essential elements in developing evidence-based practice. Nurs Stand 2008;23:42-6.
Crawford CL, Rondinelli J, Zuniga S, Valdez RM, Cullen L, Hanrahan K, et al
. Testing of the nursing evidence-based practice survey. Worldviews Evid Based Nurs 2020;17:118-28.
Herur A, Kolagi S, Ramadurg U, Hiremath CS, Hadimani CP, Goudar SS. Refining the Journal club presentations of postgraduate students in seven clinical departments for better evidence-based practice. Ann Med Health Sci Res 2016;6:185-9.
] [Full text]
Saunders H, Gallagher-Ford L, Kvist T, Vehviläinen-Julkunen K. Practicing healthcare professionals' evidence-based practice competencies: An overview of systematic reviews. Worldviews Evid Based Nurs 2019;16:176-85.
Duffy JR, Culp S, Marchessault P, Olmsted K. Longitudinal comparison of hospital nurses' values, knowledge, and implementation of evidence-based practice. J Contin Educ Nurs 2020;51:209-14.
Wadgave U, Khairnar MR, Kadu TS, Chadha GK, Wadgave Y. Effect of training on evidence-based practice to undergraduate dental students: Pre and postexperimental study. Int J Evid Based Healthc 2020;18:101-7.
P Panhale V, Bellare B, Jiandani M. Evidence-based practice in Physiotherapy curricula: A survey of Indian Health Science Universities. J Adv Med Educ Prof 2017;5:101-7.
Lindström AC, Bernhardsson S. Evidence-based practice in primary care occupational therapy: A cross-sectional survey in Sweden. Occup Ther Int 2018;2018:5376764. https://pubmed.ncbi.nlm.nih.gov/30538614/
. [Last accessed on 2020 May 15].
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]