Strengths and limitations
This is the first study to demonstrate that the self-report EBP profile differs with the degree of prior exposure to formal EBP training and with the stages of training (undergraduate and post-graduate) and differs across allied health professional disciplines. While the best teaching practices and processes for EBP remain unclear, the findings in this study support early and repeated exposure to provide the optimal opportunities for reinforcing an EBP approach. The study was not designed to explore why the differences exist (across stages of training and professions and exposures) or to suggest how EBP should be taught but the findings provide a cross-sectional description of predominantly undergraduate allied health EBP profiles in one Australian university. As they are likely to reflect the culture of this university, at this stage the findings should not be generalised to the EBP culture of health professionals at a national or international level. While providing an insight into the EBP profile of a large school within one university at one point in time there is obviously value in conducting future longitudinal studies, comparative studies and studies incorporating larger non-student populations.
Primary variables, pattern and comparison with previous studies
It is possible that the changes in domain scores could be affected by the time that elapses while taking EBP courses, time while progressing through the years of a university program or just getting older. Notwithstanding the possibility of these secular contributions to the cross-sectional findings, the consistent gradients between age, exposure and stage of training, and the domains of Relevance and Terminology, suggest that EBP training can positively affect these domains. Confidence in the skills of EBP demonstrated fewer differences across stages of training. Upton and Upton (2006) reported similar findings and suggested that the actual skills may not match the perception of abilities. In the current study one can only speculate that confidence levels may mask a lack of awareness of limitations in skills in the early years of training on the one hand, and lack of acknowledgement of advancement in skills in the later years of a program on the other hand, that is, 'the more you know, the more you realise you don't know'.
Different professional 'strengths' were reflected in the current study in higher domain scores for attitudes, knowledge and practice of EBP across professions (occupational therapists reported higher scores for Practice, physiotherapists for Relevance, physiotherapists and podiatrists for Terminology). While the Canadian study by Pain et al (2004) focussed on research rather than EBP, speech therapists placed significantly greater value on research and its use in clinical practice than physiotherapists and occupational therapists. In addition, while physiotherapists were least likely to have undertaken formal research training and had the greatest number of years in practice, this did not translate to any difference in time spent on involvement in research activities (eg grant writing, data collection and analysis, and research presentation) when compared to the other professions [17]. In a United Kingdom study, Upton and Upton (2006), reported significant differences in knowledge and use of EBP between 14 professional disciplines including physiotherapists (n = 98), occupational therapists (n = 86), podiatrists (n = 20) and radiographers (n = 70). Confidence in research skills, and application of these in general, rated more poorly in these four professions when compared to professions such as medical physicists and psychologists. There were no data reported by Upton and Upton (2006) on prior exposure to EBP training.
Secondary variables, pattern and comparison with previous studies
Not unexpectedly, older subjects scored higher than younger subjects for each domain of the EBP2 questionnaire. It is likely that with increasing years, greater potential for both formal and informal exposure to EBP training may have occurred. The findings from the two-way factorial ANOVAs suggested that while age and exposure both affected all factors, age-related differences in Confidence and Practice were largely explained by differences in stages of training, and exposure-related differences in Confidence, Practice and Sympathy were largely explained by differences in stage of training. Stage of training, perhaps because it combines maturity and exposure, may be the key variable. To date, gender differences with respect to EBP have not been reported. Our findings indicated that males were significantly more confident in their EBP knowledge and skills while females were more positive in their attitudes and sympathy to EBP.
Interpretation
While a broad measure of prior exposure to EBP training was included in the EBP2 questionnaire, the main limitations to interpreting the findings stem from the lack of detail concerning the nature of this prior EBP exposure. There were significant differences in the EBP profile for participants who had > 20 hours formal training, differences among stages of training for undergraduate students and differences among disciplines. Within the curriculum for each of the disciplines included in this study, EBP training was included in a variety of modes but there was no consistent curriculum or pedagogical approach. For example, at the time of this study, the physiotherapy degree included a core EBP course within the curriculum while all other professional disciplines disseminated EBP training and philosophy across a number of courses. However, each professional discipline demonstrated high scores in at least one of the EBP domains suggesting that knowledge or attitudinal changes resulted from the EBP training curriculum.
It is tempting to suggest that the higher scores in EBP Relevance and in knowledge of EBP Terminology reflect more effective training for these characteristics in current curricula than the characteristics of Confidence and Practice of EBP. It may also be that Confidence and Practice are not able to be effectively taught within the formal university curriculum and change in these domains is more likely to be influenced by consistent immersion in clinical practice. The impact of professional socialisation on undergraduate students' attitudes and experience is difficult to gauge. In concert with exposure to academics within their respective professions, allied health students undertake clinical practice/field work in a range of settings (hospitals, schools, community centres, health centres) and will come into contact with a large variety of people (clinicians, supervisors, administrators, patients). In these encounters, the attitudes and behaviours of individual staff toward evidence-based practice is likely to be highly variable in terms of empathy, approval and understanding of EBP. This again takes us back to the question: "Is EBP taught or caught?" For Confidence, Practice and Sympathy it appears that both may contribute.
What needs to be done now?
These observed cross-sectional relationships need to be complemented by longitudinal studies to allow for separation of genuine self-report changes from those which may be secular patterns. There is a need also to explore the relationship between the nature of EBP training in the undergraduate curriculum (in relation to the total time spent in formal training, the content, the timing of this training through a program, the format, assessment etc) and the characteristics of a self-report profile (Relevance, Knowledge, Confidence, Practice and Sympathy). Once this is known, intervention studies into the effects of training on EBP profiles can be conducted, and it may be possible to identify areas responsive and unresponsive to formal training.