Abstract
Background: To better prepare practitioners for the complex world of clinical decision-making, teaching evidence-based practice needs to move beyond its focus on skills and knowledge to give students an experience and understanding of applying evidence in practice.
Aim: To explore whether incorporating an online values-based tool enhanced learning in a post graduate epidemiology course.
Methods: Having completed a critical appraisal of an epidemiological study, students were asked to then respond to a case scenario, using the analytical frameworks of the Values-Exchange, a software tool that highlights ethical domains in decision-making. The student experience of the Values-Exchange was evaluated using focus groups. Sessions were audiotaped and transcribed. In total, 613 responses were analysed by two independent coders to identify emergent themes.
Results: Three main themes emerged: (1) the Values-Exchange exposed students to new concepts and ideas relating to healthcare decision-making; (2) the diversity of other student values broadened their perspectives and (3) the experience brought reality to what it means to apply evidence in practice.
Conclusion: Adding an online values-based tool to clinical epidemiology teaching was highly valued by students and enabled new understandings of empirical evidence and its application in practice.
Introduction
In 2005, Dawes et al. stated that
Evidence-based practice requires that decisions about health care are based on the best available current, valid and relevant evidence. These decisions should be made by those receiving care, informed by the tacit and explicit knowledge of those providing care, within the context of available resources
This definition expands on earlier definitions, acknowledging that the patient's preferences and values are central, that practitioners also bring ‘tacit’ knowledge and the notion of resource constraints.
The purpose of evidence-based practice (EBP) is to improve outcomes for patients (Sackett Citation2002; Del Mar et al. Citation2004). Key skills for EBP are now considered a fundamental part of training for all healthcare practitioners and are widely taught across all healthcare disciplines (Green Citation1999; Del Mar et al. Citation2004; Kunz et al. Citation2009).
The stated objectives of most EBP teaching is to improve both practitioner knowledge and skills and to change their attitudes and behaviour, so that incorporating epidemiological evidence into clinical decision-making becomes an integral part of routine practice. The instructional model commonly used in both teaching and practicing EBP provides the ‘scaffold’ to help practitioners become self-directed lifelong learners (Davies Citation2000). This model describes a five-step process which forms the core curriculum and defines the learning outcomes for most EBP courses: (1) Ask a focussed clinical question (identify an information need); (2) Access (search) appropriate information sources to locate the relevant literature; (3) critically Appraise it for validity and applicability and then (4) Apply the results in practice. The fifth step is the evaluation of performance (Audit), either that of the student's EBP skills, or the practitioner's performance in applying research evidence in the clinical setting (Dawes et al. Citation2005). This framework closely aligns with information literacy standards (Bundy Citation2004), and is consistent with Bloom's Taxonomy of Learning (Spring Citation2010). This implies that learning at the highest levels of achievement is represented by an ability to synthesise information from multiple sources to create new understanding and translate this into effective action. Furthermore, such action should take account of cultural, ethical, economic, legal and social issues related to the use of that information. In teaching and learning EBP, it is assumed that this learning will lead to evidence being used more effectively. However, there is still a significant gap in translating evidence into practice (McGlynn et al. Citation2003). This raises questions not only about the effectiveness of current approaches in teaching the fourth step in the EBP process, but also whether we in fact fully understand what it means to apply evidence in practice.
New approaches are needed that give students an opportunity to explore the nature of the gap between evidence and practice, and to understand in more depth what factors are at play, thus better preparing them for the complex and unpredictable world of clinical decision-making (Loughlin Citation2009).
With the increasing focus on person-centred healthcare in the twenty-first century, values-based practice as a concept is becoming more prominent in healthcare decision-making (Mila et al. Citation2006). The ‘ten principles of values-based practice’ was initially developed in the domain of mental health, but is recognised as having application across all areas of healthcare (Fulford Citation2011). A fundamental principle is that all healthcare decisions are ‘informed by facts and values’ with an emphasis on the wide range of legitimate values that influence decision-making, not just those oriented specifically to the patient (Mila et al. Citation2006). If we are to bring values into the equation, we first must be able to elicit such values and explore ways of negotiating between facts and values in arriving at healthcare decision in the clinical setting (Mila et al. Citation2006).
The Values-Exchange is a web-based educational tool that has been developed to make individual's values transparent (Seedhouse Citation2009). This tool provides a forum for users to respond to case scenarios and engage in discussion and debate about proposed courses of action. The tool uses an analytical framework that prompts exploration and reflection across a number of ethical domains, including the law, human rights and dignity, equity, risks and benefits. These domains are further stratified by perspectives at an individual patient, health provider and societal levels. The purpose of this tool is to tease out and make transparent the underlying values that are influential in decision-making. This tool is available internationally (www.values-exchange.com/). It has been widely used in both the public arena and in educational institutions across the United Kingdom, Australia and New Zealand to explore ethical and policy issues.
We saw the potential for the Values-Exchange to create a learning environment for students enroled in our postgraduate clinical epidemiology course to explore the gap between scientific evidence and application in practice using a case-based approach. Having completed a critical appraisal of an epidemiological study, students were asked to make a decision for action based on a hypothetical but realistic case scenario, using the evidence from the paper and ethical domains highlighted in the Values-Exchange ()
Table 1. Example of a Values-Exchange activity
Using the framework of the Values-Exchange (see Appendix), students were asked to provide a rationale for their decision and justify their reasoning. Interacting with the Values-Exchange in this way prompted them to reflect on their ethical beliefs and personal values in the context of the evidence they had critically appraised.
Given this was a novel approach both for teachers and students, we wanted to evaluate the impact of the Values-Exchange on student learning. Rather than evaluate changes in EBP knowledge, skills or attitudes, we felt it was more important in the first instance to listen to the students’ experience of learning through their engagement with the Values-Exchange. We, therefore, chose to use a qualitative approach (Barbour Citation2005).
The aim of our study was to explore whether incorporating epidemiological evidence with a tool that rendered individual values more explicit, enhanced learning with respect to applying evidence in practice.
Methods
Setting
This study took place within the School of Population Health, University of Auckland, where a postgraduate course in clinical epidemiology has been taught for 10 years as part of the Masters in Public Health programme. It consisted of a 4-day face-to-face course with online learning elements.
Intervention
We introduced the web-based software package Values-Exchange, specifically modified to augment the critical appraisal assignments and accessible only to class members. Students received an initial orientation to the site where they registered and completed a simple demographic template noting their age group, gender, country of birth and professional training. They could choose to register with their name or as an anonymous user. We set up case scenarios in the Values-Exchange linked to each of the four studies appraised. Each described a scenario and proposed a solution. As part of their assessment process, students responded to the case, either agreeing or disagreeing with the proposal and completing an analysis of the case using the Values-Exchange decision – support frameworks. They were then able to view the reports ‘dashboard’ which provided information about other students’ individual responses and those of the class as a whole (see Appendix). They were asked to use the discussion forum within the Values-Exchange to comment on the class response as a whole, and to discuss and debate the issues with their classmates.
Approach to evaluation
We adopted an action research framework in which an initial reflection about an aspect of teaching and learning identifies an area for improvement, an improvement is planned and carried out and the results evaluated to inform future practice and contribute to theoretical knowledge for the benefit of student learning (Kember & Kelly Citation1993; Norton Citation2008). Students were informed about the research on the first day of class and invited to participate.
For those who consented to participate, focus groups were held on the past day of teaching, facilitated by independent facilitators using a semi-structured interview approach. At this stage students had used Values-Exchange for three of the critical appraisal assignments. Sessions were audiotaped and transcribed. Data collection were augmented by facilitator field notes. Approval was granted by the University of Auckland Human Participants Ethics Committee (Reference number 2010-553).
Analysis
Data analysis used a general inductive approach, similar to grounded theory (Thomas Citation2006). Focus group transcriptions were read to identify emergent theme categories and sub-categories. There were a total of 613 responses. These were categorised into themes that were derived independently by two of the researchers (GR and SW) with consensus regarding five main themes reached subsequently. Because some responses contained more than one thematic category where there were a total of 824 ‘ideas’. Data were then independently double-coded into the themes and reviewed (GR and SW). An adjudication process was available using a third party (FGS) to resolve discrepancies, but because there was high concordance between the two reviewers, this process was not required.
Two themes relating to technical issues, such as student computer problems (n = 170 ‘ideas’), and course delivery issues, such as assignments and timing of teaching block days (452 ‘ideas’), were excluded for the purposes of this article. The remaining three themes that emerged from this analysis comprised 202 ‘ideas’. These themes were: exposure to new concepts and ideas relating to healthcare decision-making (n = 56: 28%), the diversity of other student values broadened their own perspectives (n = 60: 30%) and the experience brought reality to what it means to apply evidence in practice (n = 86: 42%).
Results
Description of the sample
Of the 61 students enroled in the course, 50 (82%) agreed to participate and signed consent forms. Of these, 38 (76%) were available on the past day to take part in one of five focus groups. Twenty-four (63%) were female and 28 (74%) were aged between 20 and 40 (range 20–59). There was a diversity of nationalities and ethnicities among participants. Fifteen students (39%) were from New Zealand, with the remainder coming from 18 other countries. English was a second language for nearly a quarter of the group (n = 9). European was the most common ethnicity (n = 23). Only one person identified as Maori, four as Pacific people, six as Asian and four were other ethnicities. Most of the participants were health professionals (76%). These included 21 doctors, 4 nurses and 4 allied health professionals. The remaining 9 were ‘students’, ‘other’ or ‘not stated’.
Findings
Overall, responses to the Values-Exchange were positive. There was a sense that students had enjoyed the experience and found it had added value to their learning. Furthermore, for some it added a dimension of ‘fun’ and ‘entertainment’ to what was otherwise regarded as a ‘fairly dry topic’. Three key themes emerged.
Exposure to new concepts and ideas
Using the Values-Exchange exposed students to concepts that previously they had not considered influential in healthcare decision-making. As one student commented, by having to interact with the software, the learning was far more effective than being given a blank piece of paper to write down thoughts and feelings. It provided prompts which promoted deeper levels of thinking and engagement. These insights were clearly valuable to many students.
You know, when you had to say, who matters most – say well was it the community or whether it was you or whether it was an individual, if it was somebody else – it made you think about all those different components, which ones sort of have a little bit more weight and which ones make a little bit more difference … Which you don’t really ever see, like I’ve never seen anything like that before. … I enjoyed that
I really like the structure…if you go through, like I do, go through all the options and then go back and prune, you actually do quite a lot of learning in that process about what the different concepts are and when it says, ‘Is justice important here?’ you think, justice, what am I talking about justice for, but you click on justice and you think, oh, for your distribution of resources, access to care, oh yeah,. those things are important to me … that really suited me, I really liked it.
The diversity of values and broadening of perspectives
For the most part, students recognised and were interested in the diversity of other students’ values when arriving at a decision. In particular, there was a sense of surprise and curiosity that given the same evidence, people with a different set of reasons (see Appendix) could arrive at the same conclusion, while people with similar thought process and reasons could arrive at quite different conclusions.
We all are interested it seems in the welfare of the child and the family and the whole community so a very similar thought process, but a totally different outcome. I find that instructive.
It was interesting looking at people who thought the same thing as me at the end but sort of came there through a different path. So they based their opinion on other values than I did but the outcome was the same.
By engaging with the Values-Exchange, students had to reflect on their own values, and for some this helped clarify their own thinking. Reflecting on other students’ values offered them a different way of thinking and broadened their perspective. This meant the focus was less about being right or wrong, but more about appreciating multiple points of view, even if they chose not to change their position.
Well it helped me question my thought processes and that's always a good thing … so it's good to have these things challenged, it broadens the mind a little and once your mind expands to take in another concept you hope never contracts.
It was very interesting to grab those contrasting views and sometimes I think it might need you to change your mind or at least think about it in a different way.
In contrast, for a few students the Values-Exchange was not particularly ‘provocative or evocative’ nor challenging with respect to their own values. They still, however, appreciated their insight into other people's values.
I don’t think I learned anything new about myself by analysing my own values, but separate to this issue, of interest is seeing other people values in the same situation.
The experience brought reality to what it means to apply evidence in practice
It was clear that students’ learning was extended well beyond just gaining more knowledge about EBP and critical appraisal skills. The experiential learning that occurred through interacting with the Values-Exchange added an important dimension to the course. It provoked insights that may not otherwise have occurred through usual teaching methods such as the integration of the learning into real-life decision-making and the reality gap between evidence and practice.
And none of us make any clinical decision removed from our values so I think it's just focusing back on that that it adds a much bigger weight to a lot of our decisions that many of us ever realised I think.
Students developed a more balanced view about the relative roles of evidence and other contextual factors in healthcare decision-making.
The process of going through something that is technically fairly structured and then going to one of the more human factors of this discussion … adds a very important dimension. You can clinically analyse data and evidence and so on … whereas this is more the sort of patient focus or the experience or whatever.
It's always about the contextual evidence, the epidemiological evidence is purely assertive and once we look into it the contextual evidence is in the minds of others and unless you’re exposed to it you don’t get it.
They observed that the critical appraisal process itself is also subject to the influence of values, and that this could have implications for practice:
A lot of the study's information is so inconclusive … it's important to realise that it's really how you read it can make a difference to the interpretation.
It's like a little bit of a key because you actually get that opportunity to look at your values and put them down because you do use them when you are critically appraising but they were all in the background, now you actually have them face on face.
Finally, there was a sense that this learning would also extended beyond the classroom and workplace into their everyday lives. This experience gave them grounding in something that would last a very long-time.
Even if you think you’re someone who's quite comfortable I think it always stretches you every time like you took a leap based on the thinking it made you do and … it makes you ruminate for long after the time you know you’ll flash back to it, I just think it helps you.
It's seldom you get an opportunity in this world to actually say how you feel about something. but to actually be put on the spot to say I feel like this, you know, really grounds it and makes you really … it brings it home a little bit more. So I like that.
In summary, in one student's words:
Yeah, basically the point of doing the critical appraisal of the stuff … wasn’t only to say, Oh, well good, I can critically appraise these articles or these research papers, the point is that now I have got it applied.
Discussion
This study explored whether incorporating epidemiological evidence with a tool that rendered individual values more explicit, enhanced learning with respect to applying evidence in practice. The case-based approach engaged the students in experiential learning. Three key themes emerged: (1) the Values-Exchange exposed students to new concepts and ideas relating to healthcare decision-making; (2) the diversity of other student values broadened their perspectives; and (3) the experience brought reality to what it means to apply evidence in practice.
Students were exposed to ideas and concepts that many had not previously considered influential in the decision-making process in healthcare. By grappling explicitly with ethical issues such as duty and justice at patient, family and community levels, their thinking about how these are related to the case and whether these would alter their decision-making was extended. They were able to observe and articulate ways in which ethical issues might contribute not only to their own decision-making processes but to healthcare decision-making in general.
The interest and curiosity expressed about other students’ reasons seemed to lead to a greater respect for others’ points of views, even though they might not change their own decision. Greater tolerance for multiple points of view is a valuable asset, not only among a diverse group of healthcare professionals, but also when dealing with patients in a multi-ethnic society.
Encouraging students to reflect on and articulate their feelings and reasoning engendered a more explicit approach to decision-making. We believe it brought meaning to that part of the definition of EBP that states patients are ‘informed by the tacit and explicit knowledge of those providing care’.
As far as we are aware, this study is unique in evaluating an innovative e-learning tool that augments critical appraisal teaching in a post graduate setting, using a case-based approach to highlight the role of ethical values in clinical decision-making. We used this approach specifically to enhance learning with respect to the fourth step in the EBP process, namely the application of evidence in practice. This step has proved difficult both to teach and evaluate. This is perhaps due in part to not fully understand the nature of the gap we are trying to bridge.
There are two areas where some of the underlying assumptions about the EBP process may be hindering the effective teaching with respect to the application of evidence in practice. In EBP, the gap is commonly referred to as the evidence-practice gap, implying a linear sequence where ‘appropriate practice’ automatically follows from identifying and appraising evidence. Furthermore, the process whereby such evidence is incorporated into the decision-making process is described as involving ‘synthesising’ or ‘integrating’ evidence with other factors influencing decision-making. Exactly how to do this is not clear.
The casuistic model uses a case-based approach, focusing on the case at hand and recognising the multiple sources of medical knowledge that are applied in decision-making. In this model, various ‘warrants for action’ are described (Tonelli Citation2007). Such warrants for action include not only empirical evidence, but also other types of medical knowledge such as pathophysiology, biological and physiological understanding and clinical experience as well as the values, preferences and practical wisdom of patients and practitioners (Tonelli Citation2007). Importantly, none is considered to have superiority over another. In other words, there is no ‘hierarchy’ of information that informs decision-making.
In contrast to the evidence-practice gap, the gap between facts from clinical research and values involved in decision-making has been better described as an ‘ethical gap’ (Tonelli Citation1998). Furthermore, given that facts and values are derived from two distinct processes, it has been argued that this represents ‘an epistemological gap that can never be bridged’ (Tonelli Citation1998). The process that occurs at this stage is not one of synthesising or integrating, but rather ‘negotiating’ – operationally a far more useful term. Essentially, this is the process of clinical judgement, whereby clinicians, with patients, negotiate the tension between facts and values and apply the proper weighting to arrive at a ‘balanced and appropriate determination’ that will achieve the desired outcome for the patient (Tonelli Citation1998, Citation2009, Citation2010).
Using the Values-Exchange not only brought more transparency to the role of values in healthcare decision, it also effectively incorporated a casuistic approach that gave students an experience of negotiating the balance between facts and values in arriving at a healthcare decision. While this does not replicate clinical practice, enriching their knowledge base in this way fostered deeper reflection and explicit reasoning. The Values-Exchange provided an authentic way of considering evidence and values in decision-making, giving students a grounding with which to cultivate good clinical judgement, the cornerstone of effective practice (Loughlin Citation2009; Goodyear-Smith Citation2011).
Strengths and limitations
A strength of this study is that the majority of students participated in the focus groups and provided information about their experience of the Values-Exchange. The use of independent facilitators meant students were free to express honest opinions about their learning experience. The Values-Exchange was a novel educational tool that most students enjoyed interacting with. They generally felt it was a safe environment and a sense of community developed among students which was evident in the nature of their responses.
There were some challenges. Technical issues, such as navigating the site, proved a barrier for some and in one case a student felt it hindered her participation. There were initial cautions and concerns about expressing their views, but as students became more comfortable using the Values-Exchange, they gained confidence, which was reflected in the tone of their entries as the course progressed. Some students with English as a second language expressed a lack of confidence participating in the discussion forum. Others, however, felt it offered advantages over face-to-face discussion groups in that they were able to take their time reading and responding. A number were irritated by having to justify their values, but at the same time, were able to see the merit in being exposed to different perspectives. For some, the structure of the Values-Exchange imposed restrictions by limiting options and domains. This left them feeling ‘pigeon-holed’ and ‘frustrated’.
There were also challenges from a teaching perspective. Having no previous experience of using the Values-Exchange in a teaching and learning setting, we may not have used it to its full potential. Setting up appropriate cases for each of the critical appraisal assignments proved difficult and may have influenced the way in which students were able to interact with the Values-Exchange and how they chose to respond. This was particularly of concern for students with no clinical background, and for those with English as a second language. Evaluating student contributions also proved challenging, but we were impressed with the quality of the responses and the way in which students engaged with each other in the discussion forum.
Implications with respect to the future development of course
The Values-Exchange has potential to add significant value to our EBP teaching and student learning, particularly, as we are moving to a distance learning format. Several areas have been identified for improvement.
Case development is critical in providing a context that challenges students in their decision-making. Given the diversity of students and learning styles in the class, it may be appropriate to provide a selection of cases to meet the needs of the various groups of students. Another alternative is to have students select and post a case for discussion. This may be something to trial in the future once we have had more experience with the tool.
There are ways we could better utilise the discussion forum to facilitate learning. There is potential to improve the ‘social networking’ aspect of the course by having students interact in ways that promote a strong community of learning, thus ensuring that learning goes well beyond information exchange (Chapman et al. Citation2005). This will be particularly important for the distance learning format, but will require furthering our expertise as ‘moderators’ so that we are able to effectively guide students through the process of becoming productive self-directed learners (Salmon Citation2003; Sloman & Reynolds Citation2003).
In terms of evaluating student contributions, introducing self-assessment and peer assessment may further strengthen student learning and engagement. The challenge is to utilise this in a way that supports student learning, and does not significantly increase their workload, nor that of the lecturers (Hanrahan & Isaacs Citation2001).
Figure 1. Reactions screen of the Values-Exchange.
Figure 2. Reasons screen of the Values-Exchange.
Figure 3. Reports dashboard screen for the Values-Exchange.
Conclusion
This tool is an exciting new innovation that provided an enhanced and enriched postgraduate learning experience. It was evident that students synthesised information from multiple sources, creating new understandings of empirical evidence and its application in practice.
Acknowledgements
The authors thank Iain Doherty and Boaz Shulruf for initial comments on study design. They also thank the facilitators who assisted with conducting the focus groups and their students who generously participated in this research.
Declaration of interest: The authors report no declarations of interest.
Related Research Data
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Appendix
The Values-Exchange uses three frameworks that enable students to explore their values in responding to a case:
The ‘Basic Framework’ asks them to agree or disagree with the proposal and to decide ‘who matters most’ (for example, yourself, the patient, the patient and their family, the family only, the general public, or another group of people). They need to justify this decision.
The ‘Reactions Framework’ is represented in a pie format () where students select from as many of the following six ideas as they consider appropriate (Ideals, Emotions, Hopes, Duty, Fears, Rights). They can adjust the relative weighting of each depending which they consider most important. For each idea included, there are questions to answer and additional prompts to which they can respond with free text.
The ‘Reasons Framework’ () consists of 16 ‘tiles’ (for example, society, evidence, truth, culture, equity, etc) which encourages further exploration of some of the reasons behind their reactions and therefore their decision-making. For each selected tile there are further questions to answer, and again a free text area where students can justify their responses in more depth.
Having completed this process and submitted their responses, they were then able to access the reporting function and explore everyone else's ideas. Values, trends and comparisons for individuals and groups over multiple responses were plotted according to student socio-demographic variables enabling further analysis.
For example, for the cellphone case described, the reports dashboard was able to demonstrate that there was 77% consensus among students with the majority disagreeing with the proposal (Figure 3).