Scientific Papers

Teaching evidence-based practice to physiotherapy students in Italy: a cross sectional study | Archives of Physiotherapy


This cross-sectional study aimed to map the Italian university context to the prevalence of EBP content in undergraduate degree courses in physiotherapy, given that EBP must now be considered an essential part of every health professional’s basic training [3, 11]. To our knowledge, no studies – both in Italy or other countries – have yet explored the current prevalence of EBP content in undergraduate education and few studies have investigated students’ perspectives without collecting data directly from physiotherapy faculties [23, 24]. Taking our hands-on experience as clinical tutors within Italian BSc courses in physiotherapy as a starting point, we hypothesized that EBP content was currently not adequately represented in undergraduate courses in Italy.

We found a substantially low prevalence of EBP content within undergraduate physiotherapy in Italy when compared to both international (World Physiotherapy) and national (Italian Core Competence) recommendations [6, 11]. The education framework advocated by World Physiotherapy deems EBP a milestone of the curriculum studiorum, which requires specific teaching courses (e.g. research methodology) and to be integrated in all the professional (e.g. physical modalities, exercise) [6]. Also, the Italian Core Competence document recommends what a licensed physiotherapist should gain after the BSc education [11]: again EBP has great importance during all the educational pathway.

Nevertheless, EBP content is present in only about 70% of physiotherapy BSc programs, with a heterogeneous scenario across the country.

These findings could have a twofold interpretation: a likely different approach and weight towards the importance of EBP content within the study plan and a certain independence of each university when drafting the plan of studies [25]. As a consequence, these differences might affect the education of Italian physiotherapists, leading to heterogeneous approaches to EBP, with differences in caring for their patients, in accessing to best and updated effective treatments.

Public universities had a higher prevalence of EBP content compared to private ones – although the low number of private universities raised doubts regarding the validity and reliability of these findings to make a meaningful comparison.

Furthermore, these results require extreme attention about their generalizability, since a substantial uncertainty exists regarding the differences between public and private universities, both in Italy and in an international context [26,27,28,29,30,31,32,33].

Moreover, courses dedicated specifically to EBP comprised 21.4% of total BSc courses, while those containing EBP content comprised 50.0% of total BSc courses. Delivery of EBP content was found to be fragmentary not only on a geographical level but also with regards the modality of delivery, the naming of courses and the relevance of EBP (i.e. the number of CFUs dedicated to specific EBP courses or courses with EBP content) within the degree curriculum.

Such a heterogeneous situation has previously been reported within the context of low-income countries [34] but is not what would generally be expected for a high-income country [35].

Even in the presence of adequate education, various other factors including problems of negative attitude, gaps in knowledge and the presence of cultural barriers may limit the implementation of EBP principles. Previous studies have demonstrated that a positive attitude towards EBP was elicited from groups of both licensed physiotherapists and physiotherapy students but that both also declared concerns over theoretical aspects (such as knowledge and skills), organizational ones (perceived lack of time), and technical aspects (such as lack of resources), all leading to reduced adoption of the tenets of EBP in their current, and above all, future clinical practice [7,8,9, 24, 36,37,38]. Many students and practitioners reported lack of confidence with the principles and practice of EBP [38] and this is surely a problem that needs addressing. Some studies concluded undergraduate education specifically to be the key element in managing this issue [39, 40], with both academic and clinical tutors well placed to aid their students develop a solid foundation in EBP, including those skills necessary for the adequate integration of EBP into their day-to-day practice, [24, 40]. In addition, a positive association between the level of exposure to the principles of EBP and the acquisition of competences by physiotherapy students might also exists: the more the competences on EBP, the more accurate, updated and evidence-based in the health care assistance [39, 41]. Previous studies have highlighted a mismatch between knowledge of the principles of EBP among physiotherapists without exploring the root causes of such a mismatch [9, 12]. Our findings could help in understanding the current situation at Italian university level, hypothesizing an inadequate entry-level EBP educational program as the main cause of lack of knowledge among licensed physiotherapists and a key issue limiting optimal application of EBP in clinical practice.

At the moment, there are no other published studies on EBP content of physiotherapy undergraduate courses from other countries: our preliminary findings could be useful for Italian stakeholders, but probably also for a wider context to investigate if this suboptimal presence/reporting of EBP teaching courses is limited to Italian universities or affecting other European (or extra-European) countries as well.

This issue could be very relevant since EBP content should be a milestone of the physiotherapist curriculum, and any lack could impact both the educational pathway and clinical practice.

Limitations

Our study presents limitations and caution is required to avoid under or overestimation of results. Entry selection criteria for the study were based on the inclusion of declared EBP content within physiotherapy BSc course curricula. We retrieved data from the official website (Universitaly) [19] and then from each university website included in the study. Indeed, educational content can encompass different elements, ranging from the purely theoretical teaching of the concept to the integration and development of critical thinking on practice. This approach may present some limitations in terms of coverage of the educational offer. Fourteen of 42 BSc courses did not report any content or teaching course on EBP: it is therefore possible that some EBP content might have ‘flown beneath the radar’ if it was undeclared on the university websites or included in externally-sourced modules. It is also possible, as some authors have pointed out, that some lecturers might include EBP content during their lessons without this being formally declared at curriculum level [42].

However, Italian universities required professors and lecturers to detail the content of each teaching course, therefore we believe that this choice should provide enough reliable data.

Another limitation could be the “binary” approach to collect information about the presence/absence of EBP content within the plan of study: we are aware that this choice could be simplistic but we considered it as reliable and objective option since other types of data (e.g. characteristics of the teachers, pedagogical approach) would be difficult to retrieve and probably not so informative due to the absence of a reference standard. Additionally, the focus of our study was on the presence of specific EBP courses within curricula studiorium, therefore, given this focus, we believe that our approach is appropriate.

It is important that evidence of poor reporting of university EBP syllabus content be discussed and managed however: we do not expect such a heterogeneous approach to the description of ‘traditional’ course subjects, such as anatomy or physiology.

Definitively, we have no certainties if our findings should be interpreted as a poor reporting, a lack in the educational program, or both about the EBP contents.

Interpretation

Our preliminary findings suggested that EBP needs to gain in relevance within Italian undergraduate degree courses in physiotherapy, including the way in which teaching in this topic is represented on university websites. Ensuring that EBP becomes part of the core of the physiotherapy BSc should be made a priority: it is only through greater knowledge of EBP at grass roots level that practicing physiotherapists will be to effectively respond to the challenges of their profession in a fast-changing world. Practitioners need knowledge of EBP to critically appraise the evidence about the safety and efficacy of their treatments, increase their professional autonomy and respond to the changing requests of their patients [43,44,45].

Strengthening the culture of EBP among undergraduate physiotherapy students may also positively affect post graduate education [46]: with higher knowledge of EBP principles, the basic skills could better fit with the process of knowledge translation for both clinical (e.g. musculoskeletal or respiratory rehabilitation) and non-clinical (e.g. epidemiology) specialistic courses [47]. Indeed, the growing number of Italian physiotherapists attending doctoral programs (i.e. PhD) could suggest the need for a development of EBP culture from the beginning of the educational pathway [48, 49].

All universities should ensure that their website is updated regarding the inclusion of EBP courses. The demand for improvement in the standards of EBP inclusion is also consistent with both daily clinical practice and the Italian regulatory system [50]. Recent Italian legislation includes the application of the so-called Gelli-Bianco Law (Legge 24–2017) which defines certain aspects of the legal responsibilities of health professionals according to the adherence – or lack of it—to evidence-based guidelines and recommendations [17]. Both the improvement of efficacy and the reduction of the clinical risks associated with any treatment cannot be separated from the rigorous application of the principles of EBP [2, 51,52,53].

Methodologies particularly suited to the teaching of EBP might include the examination of case studies or discussions of scientific literature in journal clubs: these tools should be integrated with theoretical coursework to help build the modern and evidence-based physiotherapist [46].



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