Critique: Research Study Radiology
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2. Study Purpose
The following critically reviews a paper by Upton and Upton (2006), concerned with clinical effectiveness (CE) and evidence-based practice (EBP) and the differences between them amongst different professional groups. It compares 14 different groups in terms of how they understand and implement CE and EBP. Evidence-based practice is the application by health care professionals of the most appropriate research evidence to clinical situations, taking into account the whole context in which they operate, including the client’s needs (Hoffman et al 2009). Clinical effectiveness, according to the Department of Health (1996) is “the extent to which specific clinical interventions, when deployed in the field for a particular patient or population, do what they are intended to do” (DoH 1996; cited Hamer and Collinson 2005).Upton and Upton suggest that the differences between these concepts in different fields has, so far, been under researched.
Upton and Upton’s literature review is fairly short, and forms part of the introduction. While it might be slightly clearer to separate this out from other areas covered in the introduction, this seems a fairly standard academic practice. The review does not explain what either CE or EBP are, nor of the history of the terms. While this might be superfluous to the paper, and while the author’s might assume the expected audience will be familiar with the terms already, the term, EBP, for example is, to some extent, ambiguous (Roberts and Yeager 2004), and a statement here, rather than later of the definition used would have been welcome.
The bulk of the review looks at existing research which explores “the views and knowledge of health care professionals toward EBP” (Upton and Upton 2006), pointing out that they mainly concern medical practitioners, with fewer looking at others including McCaughan et al (2002) (nurses) and Iqbal and Glenny (2002) (dental practitioners). They discuss the studies which, like theirs, do compare different professions (Palfreyman et al 2004; Metcalfe et al 2001). These find common features and differences between the groups: nurses, for example, rate their EBP abilities lower than physiotherapists. Not only are existing studies, few, their scope is limited and omits key areas of interest.
As such the literature review provides a good justification for Upton and Upton’s study, by showing the deficit of existing research. However, as an overview of the concepts of EBP and CE it is less successful. In addition it does not suggest a theoretical model to shape and give depth to the study, for example one which predicts differences between professional groups, like that of Gawlinski and Rutledge (2008), who suggest that different models of EBP meet different needs of differing clinical environments.
4. Approach and Methodology
The authors do not explicitly discuss the paradigm under which their research was carried out, and their ‘methodology’ section is only one paragraph. A paradigm is the approach to the research taken by researchers. Johnson and Christensen (2010) suggest that there are three major paradigms, qualitative, quantitative and mixed methods, each of which embraces a set of assumptions about epistemology and the nature of reality. Upton and Upton’s approach is quantitative, empiricist and positivist. Positivism was established by Comte in the early 19th Century, and assumes that the world is objective of human experience, and knowable through our senses.Empiricism is concerned with factual data, and empirical research’s ideal method is the scientific method, whereby clear hypotheses are formulated prior to research and are designed to be tested against empirical evidence. Data is primarily numerical, and outcomes are objective and measurable. This approach contrasts with a qualitative, interpretivist approach, which deals with text, subjectivity and the richness of experience (Tappen 2010). Given that Upton and Upton want to investigate an under-researched area, it is understandable why they used a quantitative approach, as it allows them to investigate a larger data set and draw more generalisable conclusions, and also give scope for assessing statistical significance. However, a qualitative approach would have allowed them to look in more detail at how different types of practitioner experienced EBP and CE, which would have added richness to the study.
Again, there is relatively little detail given by the authors here. They tell us that 1000 members of Allied Healthcare Professions (AHP) and Health Science Services (HSS) were selected, and that the sample represents the proportions of each practicing in the UK. While they assure us that ‘specific statistical methods were used to establish sample size’, there is little discussion of what these were or why they were selected over other possible methods. The authors are informative about the response rate (66.6%), and add that most were female, but there are other details about the sample which are not discussed, and which might have been useful to know. For example, how were participants contacted, and what was the wording used to ask them to take part There is potential for bias here, if the method of contact attracted practitioners who had had either predominantly bad or good experiences of EBP or CE. Postal questionnaires were used, and here the authors do discuss alternative methods, and give a reasonable justification for their choice. In addition, although the authors discuss gender, it might have been interesting to know more about participants. Was there bias towards older or younger respondents, or towards one or other social class They suggest there is a bias towards women, but as this represents the breakdown between men and women in the occupations overall, this does not seem to present a particular problem.
6. Data Collection
Data was collected by questionnaire, distributed by post. The authors used a questionnaire that had already been developed and tested, by Upton and Lewis (1998). Therefore the reliability and validity (whether the questionnaire gives the same results repeatedly, over time, and whether it tests what it sets out to test: Babbie 2008) had already been established. They also distinguish between content and face validity, and confirm that both are good for the questionnaire. Face validity is weaker than content validity, and confirms simply that an instrument seems to measure what it is intended to measure. Content validity covers the “full domain of the concept” and whether it measures all this domain (Rubin 2011). Upton and Upton give a fairly good breakdown of the content of the questionnaire, dividing their discussion into the sections contained in it, including demographics, respondent knowledge of CE and EBP, the extent to which respondents practice different aspects of CE and EBT, and barriers to implementation of EBP. For each, they explain the ways in which each aspect were assessed using an appropriate instrument.What is missing here is any discussion of why these instruments were selected over alternatives, and whether alternatives exist. Although Upton and Lewis’s (1998) instrument seems well regarded, there are also the ‘Evidence-Based Practice Beliefs Scale’ and ‘Evidence-Based Practice Implementation Scale’s (Melnyk et al 2008), and the ‘Evidence-Based Practice Attitude Scale (Aarons, 2004), for example (Rice et al 2010).
The authors give more detail about how participants were contacted here, via a ‘publicity notice’. This might give rise to bias, however, as those who were motivated to take part might well have stronger opinions about EBP and CE and want to express these. Other selection methods might have been considered. There is also no information about the length of time taken to distribute and collect the questionnaires, nor how long the respondents were given to complete them. A longer time might have led to more detailed results, but also to the possibility of other influences effecting responses. Because the questionnaires were distributed by post, there also seems to be little provision for dealing with problems which might be encountered by respondents while completing their forms.
7. Results and Discussion
The authors present their results in some detail, using both tables and written presentation, which makes the data easier to understand.Although they mention that the response rate was high, at 66.6%, some more detail about drop out rates would have been welcome here. For example, did the 66.6% represent the proportion of people who completed the full survey, or just a part of the survey?
The authors divide the discussion by question type, looking in turn at ‘knowledge of concepts and principles of CE and EBP’, ‘Reported use of EBP’, ‘Acting on evidence from a variety of sources’, and ‘barriers to the application of EBP’. This allows clarity in the discussion. They also explain the details of the results well, with a logical pattern of explanation. For example, they say that overall, knowledge of CE and EBP was low, and then give more detail showing there are clear distinctions between different professions, with more psychologists and physiotherapists rating their knowledge in the ‘high’ category than other professions including podiatrists and speech therapists. The authors also back up the intuitive reading of the results with statistical analyses, and note the drawback that small cell numbers in some cases prevent such a confirmation. For reported use of EBP, there are again differences between the professional groups, with a particular link between frequency with which gaps in knowledge are identified and profession. Other key findings in this, and subsequent sections, are clearly reported. There is a separate table for each sub-section of the questionnaire, and each is clear and easy to read. Because the tables (perhaps because of space constraints) summarise information across both the range of professions and for each aspect rated, it is not immediately obvious which professions are ranked higher for each aspect. Also, the tables summarise the aspects rather than using the verbatim wording, for example “monitoring own practice” and “critical analysis”. It might have been interesting to see the actual wording used in the questionnaire. In addition, while statistical information is presented more fully in the text, key information is missing from the tables, for example standard deviation in table 4. Similarly also, the discussion of ‘knowledge of the concepts and principles of CE and EBP’ includes a description of statistical tests including a one-way analysis of variance, but these results are not presented in the tables.
Even though the author’s sample size is relatively high, some cells were so small that certain categories had to be removed from the analysis, for example, orthoptists for ‘reported use of EBP’. This is unfortunate, as it means the full range of professions cannot be assessed for this category.
The authors also present a detailed and intelligent discussion of what the results mean.Their conclusions seem to be backed up by the results, for example, their initial claim that there are “some differences between professional groups in terms of knowledge base and self-reported use of CE and EBP”: this was discussed in the earlier results section. This summary is initially concerned to draw out key themes from the results section. They first suggest that while both HSS and AHP groups have low levels of knowledge, the lowest levels were from professionals from HSS groups. As well as reporting this, they suggest that this is due to the relatively recent introduction of the concept to these professionals, as well as differences in the extent to which each group are involved in day-to-day care of patients.This is interesting, but might the discussion might have had more depth had the differences between HSS and AHP been brought out in more detail during the literature review. They also do not give references for their claims about the differences between HSS and AHP groups, so there is no context for their discussion. However, this is a valuable discussion, as it suggests that part of the problem is the lack of an evidence base for certain professions including radiographers and podiatrists. This insight could be used to generate new practice in these professions.There are similarly useful discussions of other areas of the findings, for example the differences between groups’ ratings of EBP skills. The authors suggest that psychologists, for example, rate their skills higher due to a different emphasis put upon a degree during training. This again throws a useful light upon possible revisions to the way professions are managed. However, Upton and Upton’s discussion here is again marred by lack of reference to any other academic sources. This fruitful area must, surely, have already attracted academic discussion One positive here is that Upton and Upton do not simply stick to one possible explanation, but consider others, for example that respondents rating of their skills does not match their actual skill level.
Their discussions of other areas, for example application of EBP and barriers to its uptake, also display positive and negative features; bringing out key aspects of the results well, and providing interesting interpretations of these results, but with less referencing and relating the results to other academic research than might be useful. Overall, there could have been a little more discussion of overall themes that arose across sections, for example the need for better management of different professions with more uniform integration of EBP, and improved training in its use.
One final, positive point about the results and subsequent discussion is that the authors talk about methodological drawbacks, including those related to postal surveys (respondents may be less honest than with other research methods).They do not, however, consider other possible limitations, for example the lack of any qualitative data, which might have given a richer perspective on what respondents felt emotionally about using EBP and CE. They also do not discuss relationship of the data to any overarching theoretical framework, which might also have added depth to the study.
9. Conclusion and Clinical Implications
The author’s conclusion is perhaps rather short. They simply summarise their key finding, that there are ‘very apparent differences in the knowledge and use of CE and EBP by members of the AHP and HSS’, and that there were other, discipline-related, differences. This brevity is somewhat disappointing. They do not consider any practical implications for the research, nor whether it would be appropriate for AHP and HSS members to show equal levels of awareness and use of CE and EBP. Also, they do not make any suggestions for further research, although as they earlier remarked that there is a lack of study in this area, there is a clear need for such research, perhaps investigating differences between professions further, or looking at ways knowlegge and use of CE and EBP can be increased overall.
To summarise this paper, a critical analysis of a study by Upton and Upton (2006) has been presented, looking at all aspects of their work from introduction to discussion and conclusion. This is a paper with many interesting and well presented areas, but there are some negative points and areas which could be improved.
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