The occupational therapy students scored highly on the Beliefs Scale but had low scores on the Implementation Scale. The students believed that EBP results in the best clinical care for patients; however, they lacked confidence related to their own EBP competence (Table 2). The scores were highest for the question “I [have] used evidence to change practice” and “[I have] accessed [the] Cochrane Database of Systematic Reviews”. Interestingly, they reported not sharing evidence from research with patients or team members (Table 4). Accordingly, assessing the students with the EBP work file during clinical placements did not strengthen their EBP competence. On the contrary, cohort 5, who completed the EBP work file, had statistically lower scores on the implementation scale than cohort 1, who had not been given additional instruction.
Results obtained from the EBP Beliefs Scale indicated that occupational therapy bachelor’s-level students had a positive attitude towards EBP, with a mean total score of 56.8. Similar average scores in other studies vary from 53.0 to 64.1 (20). In the present study, students believed that EBP results in the best clinical care for patients; that critical appraisal is an important step in the EBP process; that EBP guidelines improve clinical care; and that implementing EBP improves patient care. However, they reported low skills in EBP due to their assumption that EBP is difficult to learn and takes too much time (Table 2). The students believed that EBP is important for patient care, although they did not think they possessed the necessary competence. This indicates that EBP teaching should be targeted at enabling students to overcome these barriers. As Young et al. (10) report, teaching needs to be multifaceted, related to clinical issues and should include assessment of students. In the present study, the authors found that the EBP work file as an assessment is insufficient to enable occupational therapy students to engage in EBP during clinical placements. The assessment needs to be introduced and pursued during clinical placements, with the active involvement of clinical instructors. In terms of student learning outcomes, it is important that clinical instructors have the possibility to collaborate with students during the EBP process. This is in line with previous research indicating that students have trouble retaining and using EBP skills beyond the classroom (1, 9).
Comparison of the cohorts revealed no statistical difference in terms of the EBP Beliefs Scale, regardless of whether students had completed the EBP work file or not (Table 3). Students had low scores on the questions “I believe that EBP is difficult” and “I believe that EBP takes too much time (Table 2). Several other studies have reported lack of knowledge, time and support from clinical instructors as being barriers to students’ EBP in their clinical placement (1, 6, 9, 21). This may be one of the reasons why students experience difficulties applying EBP. Additionally, the lack of teaching strategies to assist students in closing the gap between their theoretical studies and clinical placements is crucial (9). EBP teaching for occupational therapy students at OsloMet and HVL seems to concentrate on searching for, finding and critically appraising evidence, with less emphasis on integrating and using research evidence together with clinical and user experiences. It is important to enable students to apply all the steps of the EBP process (3) and to integrate EBP into clinical practice.
The results of cohorts 4 and 5 at OsloMet revealed that students had similar scores, irrespective of whether they were introduced to the EBP work file or not. This may be due to the students in both cohorts experiencing demands related to EBP during clinical placements. The students were expected to formulate a question relevant to their clinical placement, together with their clinical instructor. After finding an article, they presented the results to their clinical instructor and occupational therapy colleagues at the placement. This may be a strategy to reduce the gap between theoretical studies and clinical placements, making all relevant parties at the clinical placement aware of the demands related to EBP. According to our experience, it appears to be easier for students and clinical instructors to use and develop EBP competencies during placements, when clinical instructors collaborate with students on their assignment. Being able to contribute by way of EBP may make clinical placements more motivating and meaningful for students (18). This approach accords with the recommendation for teaching to be related to clinical issues and assessments (10).
In our study, the occupational therapy bachelor’s-level students obtained an average score of 15.8 on the EBP Implementation Scale. In the study by Stokke et al. (22), healthcare professionals obtained an average score of 7.8. Snibsøer et al. (20) reported that, in American studies, the average score of healthcare professionals ranged from 11.4 to 40.9. Our study has congruent results, with slightly higher scores than those reported by Stokke et al. (22). This may indicate that implementation of EBP is difficult for healthcare professionals and that the scores in our study are not actually that low. The translation of evidence and implementation of EBP in clinical placements is influenced by several factors, such as being aware of the evidence, deciding on its applicability and the need for habits to change. Change takes time, and translation of high-quality evidence into practice may not always happen (10).
The authors have considered whether the questionnaires may have been difficult to answer due to the role of students in clinical placements, especially questions related to implementation, for example, “[I have] [u]sed evidence to change my clinical practice”. However, this was the question that students scored most highly on out of all the implementation questions, with a mean score of 2.0 (Table 4). A barrier to working in an evidence-based way is insufficient autonomy to be able to change practice (8). Occupational therapy bachelor’s-level students would not be expected to change their practice while on placement, but they could if they chose to (in consultation with their clinical instructor). The students responded to the questionnaires after their second-year clinical placement so naturally scored poorly on this and similar claims. Prior to clinical placement and completion of questionnaires, the students in our study had been exposed to low or medium levels of EBP teaching, as defined by Olsen et al. (6). It is possible that they would have answered differently if they had been asked to rate their competency using the EBP Beliefs and EBP Implementation Scales on completion of their education or after graduation.
Comparison of the cohorts showed that students in cohort 5 (who received additional EBP instruction in relation to their clinical placement) had statistically lower scores than students in cohort 1(who did not receive additional instruction) (Table 5). A possible explanation for this is that when students engage in EBP teaching and learn more about the concept, they might understand that they do not know that much about EBP after all. Targeted teaching is required to adequately support students’ EBP learning. Faculty members need to highlight what kinds of difficulties the students may encounter when aiming to implement research in practice. Crabtree et al. (9) suggested overcoming real-world barriers by adopting teaching strategies such as role playing with credible practice scenarios and bringing practitioners into the classroom to identify issues relevant to their practice.
Olsen et al. (5) highlighted that competing demands, learning new routines and gaining practical skills are more than enough for students to handle during clinical placements. They found that both students and clinical instructors believed students should prioritize practice skills over EBP (5). This might indicate why the students had low scores in relation to their perceived ability to engage in and implement EBP after completing their clinical placement. In particular, the students had low scores for questions about sharing evidence with patients or team members (Table 4). Given the assignment based on the EBP work file (necessitating presentation of a research article to the clinical instructor), this result is surprising. This may be due to students only presenting the article to their clinical instructor and not to patients or other team members.
Implications for occupational therapy education
This study has revealed that the teaching of EBP should be multifaceted, related to clinical issues and should include assessments (10, 11). There is still a question over which strategies are optimal for EBP exposure throughout the curriculum, in terms of content, timing, and the amount and type of training (6, 11). We would argue that including an EBP-based assessment during clinical placements is insufficient to boost students’ confidence in engaging with EBP. Teaching and assessment of EBP must be thoroughly evaluated and requested. It is important to include clinical instructors in the planning and delivery of EBP curricular activities during clinical placements (9). For example, it is important to discuss with clinical instructors how students can be given opportunities to present and discuss the results of research articles and implement EBP in their clinical placements.
Participants in this study included bachelor’s students from two different occupational therapy programmes in Norway, giving a broader picture of students’ self-reported attitude, skills, use and implementation of EBP. This study’s limitations include a limited sample size and the lack of a control group. This may have led to differences in the results according to confounding variables. However, the use of ANOVA with Bonferroni correction has controlled for confounding variables. Some items in the questionnaires were probably difficult for students to answer, which might have affected the results. The occupational therapy students answered the questionnaires after their clinical placement (approximately midway through their bachelor’s-level education). The actual timing probably affected the students’ answers and hence the results. They attended about 10–16 hours of EBP teaching prior to their second-year clinical placement. Still, it is important to teach students the concept of EBP early on in a bachelor’s programme in order to help them become evidence-based practitioners after graduation. Acquiring the ability to apply and implement EBP in a clinical context takes time.