The results indicate that the occupational therapy students believed that EBP is important, but they had problems applying EBP to their clinical practice. There was no difference between the cohorts regarding their EBP believes. Accordingly, assessing the students with the EBP work file during clinical placements did not strengthen their self-perceived EBP belief and attitude. On the contrary, cohort 5, who completed the EBP work file, had statistically lower scores on the EBP Implementation Scale (attitude) than cohort 1, who had not been given additional instruction.
Results of EBP Belief Scale indicates that occupational therapy bachelor’s-level students believed that EBP results in the best clinical care for patients, although they thought EBP takes too much time and perceived difficult to apply. Similar barriers are found in previously research (1, 4-7). The average scores in other studies of EBP behaviour vary from 53.0 to 64.1 (maximum 80) (19), which is similar to our results. To support and increase the EBP belief of the students, it seems relevant to target the EBP teaching. A multifaceted teaching approach is recommended, including assessment of the students (10, 11). In the present study, the authors found that the EBP work file as an assignment was insufficient to enable occupational therapy students to engage in EBP during clinical placements. In terms of student learning outcomes, it is important that clinical instructors have the possibility to collaborate and guide the students during the EBP process. It is essential that the student's time spent in relation to literature and critical inquiry is perceived useful and relevant to both students and instructors. If not, it can be perceived as taking unnecessary time away from clinic, and therefore difficult to prioritize time on EBP. Supporting the students to apply EBP over a longer period of time can also contribute to students being more comfortable with EBP during clinical placement (11).
The attitude towards EBP was low for the occupational therapy students. Our study has congruent and slightly better results of the EBP Implementation Scale than reported in the study by Stokke et al. (20), where Norwegian nurses obtained an average score of 7.8. Snibsøer et al. (19) reported that, in American studies, the average score of healthcare professionals ranged from 11.4 to 40.9 (maximum 72). This may indicate that implementation of EBP is difficult for healthcare professionals, thus, making it difficult being EBP role models for students. It is therefore not surprising that occupational therapy students find it difficult applying EBP. 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 (10). Change takes time, and translation of high-quality evidence into clinical practice may not always happen. Resistance to change is regarded a significantly barrier to apply EBP (7). Given the difficulties and barriers related to the process of changes, students will probably face problems implementing EBP.
The EBP work file may have been perceived as a school assignment and less seen as a regular activity during clinical placement. When assignments are regarded different and separated from clinical practice, the translation of EBP is not assured (9). Previous research indicates that students have trouble retaining and using EBP skills beyond the classroom (1, 8). Crabtree et al. (8) 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. These suggestions may support students to close the gap between theoretical and practical knowledge, although it does not ensure EBP integrated to the student’s clinical work. The assignment needs to be introduced and pursued during clinical placements, with an active involvement of clinical instructors (4) which support the students to translate evidence to practice (9). Potentially, an online tracking of the student’s work would enable teachers and clinical instructors to assist students to implement EBP during clinical placement.
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). Several other studies have reported lack of knowledge, time and support from clinical instructors as EBP barriers to students in their clinical placement (1, 5, 8, 22). EBP teaching for occupational therapy students at OsloMet and HVL seems to concentrate on the first four steps of EBP, e.g. searching for, finding and critically appraising evidence (Table 2), with less emphasis on integrating and using research evidence together with clinical and user experiences. The use and translation of research evidence into clinical practice needs to be prioritized (9, 11), including enabling students to apply all the steps of the EBP process (3). More emphasis on the last step of the EBP process, integrating and using research evidence, could boost student’s motivation. For them to see and acknowledge that EBP makes a difference in relation to best practice. That EBP give new knowledge of relevant topics, strengthen clinical practice and promote better treatment for patients.
Comparison of the cohorts showed that students who received additional EBP instruction in relation to their clinical placement (cohort 5) had statistically lower scores than students who did not receive additional instruction (cohort 1) (Table 5). A possible explanation may be that when students engage in EBP teaching and learn more about the concept, they might understand their lack of EBP competence. This is in line with Nieman et al. (23): “… students become more realistic about their self‑efficacy in using EBP”. 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.
Implications for occupational therapy education
There is still questions of optimal strategies for EBP exposure throughout the curriculum, in terms of content, timing, and the amount and type of training (5, 11). We would argue that including an EBP-based assignment during clinical placements is insufficient to boost students’ confidence in engaging with EBP. EBP teaching and assignments have to be thoroughly evaluated and requested, and it seems important to include clinical instructors in the planning and delivery of EBP curricula activities during clinical placements (8). For example, it is important for faculty to discuss with clinical instructors how students can be given opportunities to present and discuss the results of research articles and implement EBP into clinical placements. The involvement of clinical instructors in teaching EBP may contribute closing the gap between theoretical teaching and practice, enabling students of the translation of research evidence and potentially practice change (9). Clinical placement gives a unique opportunity to learn the implementation of EBP to patient treatment and can promote motivation for lifelong learning.
Study strengths and limitations
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.
The 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.
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”. A barrier to working in an evidence-based way is insufficient autonomy to be able to change practice (7). Occupational therapy bachelor’s-level students would not be expected to change the practice of the institution while on placement, but they could be engaged in the process of change in consultation with their clinical instructor. Therefore, a possible change of the question could be appropriate when used with students, for example “I have used evidence and changed practice together with my clinical instructor”
The translation to Norwegian language of the two questionnaires has been in accordance with the WHO’s process of translation and adaptation of instruments (19). However, the questionnaires have not been tested for cross culture validity, which may be a potential limitation to this study. Future research could use control groups and interviews with both students and clinical instructors to investigate further how to implement EBP teaching strategies during clinical placements.