The fifth generic capability of a rehabilitation professional is “is able to assess critically, and interpret clinically published research, is able to use findings in their clinical practice, and is able to encourage and support any research undertaken in their service.” It is not expected that the person will be an expert researcher, but it is expected that the person will be able to select, understand and use valid research, identify and reject invalid research, and support research by others. The skills needed will also improve the person’s ability in all quality improvement activities. Indeed the distinction between good quality improvement projects and research is indistinct – ‘shades of grey’. (here) The capability requires a willingness to question everything, especially earlier teaching which stated that some action was ‘what had to be done. The normal expectation given in much early training is that ‘this is the correct, and the only course of action in this situation. This early inculcation of fixed ideas needs to be overruled for success in this capability. A MindMap is available here.
There are no certainties in healthcare, except one: there are no certainties in healthcare! (A philosophical conundrum we will ignore!) When starting professional work, this is not revealed to the student or learner. I suspect that some of those educating and teaching professionals still believe that at least some of their teaching is absolute, and is the only correct course to follow. By the time someone is ready to acquire rehabilitation-specific expertise, they will have realised that taught certainties are rarely true. However, that does not necessarily mean that the person has changed their practice – or been allowed to. This capability is concerned with learning and changing practice.
Healthcare is complex, and no two patients are the same. One way to handle complexity is to develop routines with standard, default ways of managing and reacting. A person presenting with acute chest pain, shortness of breath, and sweating is initially treated as someone with acute myocardial infarction until better information is available. That routine is based on evidence. Other routines are not based on evidence. In the 1970s the routine was to discourage children who had cerebral palsy from undertaking strength training. The evidence now shows that strength training improves function. (here) Acquiring that evidence required brave therapists to challenge a strongly held belief.
One term for this approach is evidence-based medicine (EBM), now more appropriately called evidence-based practice (EBP). The former has been defined as “the conscientious, explicit and judicious use of current best evidence, combined with individual clinical expertise and patient preferences and values, in making decisions about the care of individual patients.” (here) The latter has been described, in a nursing context, as as a “problem-solving approach to the delivery of health care that integrates the best evidence from well-designed studies and patient care data, and combines it with patient preferences and values and nurse expertise.” (here). Both emphasise that evidence must be interpreted and used as part of the decision-making process; evidence alone does not dictate what should be done.
Evidence-based practice, a less profession-specific term, is an approach that has its own strong believers and its own critics. The differences in opinion largely relate to the interpretation of the term. The practice should be based on evidence, not dictated by evidence.
Evidence comes primarily but not only from research. Other evidence includes personal experience and the experience of others. This should be considered and used critically and certainly not ignored. The second and important class of evidence is knowledge and experience of local resources. For example, it might be that phenol nerve injection would be a good, evidence-based treatment for a patient with severe spasticity, but if there is no one available, then it cannot be delivered. Or, more practically, knowledge of local day services would be important evidence when considering referral to a day service.
Because evidence is an important part of all clinical practice, and because the evidence is constantly accumulating, it is important that a professional is able, when needed, to find and evaluate potentially relevant research. It is also important to support the acquisition of better evidence. This may be from research, which is generalisable to other settings. It can also be focused on local practice, which is not usually generalisable. This is clinical improvement activity, sometimes termed audit.
The knowledge and skills needed for research and audit are similar and overlap.
The key attitudes required for this capability are:
- willingness to question any existing clinical practice;
- openness to considering how any new evidence put forward or found might alter practice;
- prepared to admit uncertainty, and to look for evidence to reduce uncertainty;
- commitment to importance of research, both as an activity and as a source of evidence
Behaviours associated with capability
The behaviours associated with this capability are those exhibited by a curious and critical person, someone who is unwilling to accept assumptions or standard procedures without checking their veracity and appropriateness. On the other hand, this critical attitude should not extend to continuous or unreasonable and excessive questioning. A balance is needed between passive acceptance of the status quo and obsessional questioning of every item. Furthermore, the attitude required extends beyond simple curiosity; it requires the person to satisfy that curiosity themselves, and to expect others to do so.
The capability does not require the professional to be a successful, active researcher nor is a high level of expertise in undertaking research needed.
Instead, the capability concerns an active interest in and some knowledge about research as an activity, being able to appreciate its importance. The professional should know about research, should be able to evaluate it and use it or ignore it as appropriate. Very importantly, the professional needs the research skills in designing and undertaking projects that depend upon data collection and anlysis because these skills, which are identical in nature, are central to effective quality improvement activities.
Some indicative behaviours expected are that the rehabilitation professional:
- Undertakes critical evaluation of published research, discussing it with others. This requires both the ability to evaluate research, and to communicate the outcome of the evaluation.
- Discusses implementation of research finding with the team. This demonstrates a commitment to acting on evidence, rather than simply knowing it.
- Collaborates willingly with and actively supports research at all times. This demonstrates commitment to the acquisition of new and better evidence.
- Collects, handles and analyses data (audit, research, clinical) effectively, which shows an understanding of the processes needed in research, both how to collect and how to analyse data. It also help improve the quality of any audit or other service development where data are collected and used.
- Uses appropriate clinical measures when collecting data. This depends upon understanding how to select simple measures relevant to clinical practice.
- Complies with and shows understanding of data handling laws, and any rules within the organisation.
- Considers and complies with ethical and Good Clinical Practice guidance (here) when undertaking data collection.
Knowledge and skills
The knowledge required should be acquired by all professionals, but unfortunately is not. It is taught in undergraduate and postgraduate courses, but either the teacher or the learner often perceives it as something different, a knowledge that belongs to researchers who are usually considered ‘a race apart’. Thus, although learned to pass an exam, the relevance to daily clinical work is not taught or learned. Somehow, in training, the knowledge needs to be embedded into normal, expected knowledge required for professional practice, not something other.
In other words, knowledge about research needs to change from being perceived as knowledge about an esoteric, difficult activity undertaken by others and not relevant to normal clinical practice to being perceived as essential knowledge both for day to day clinical practice (e.g. evaluating change associated with a treatment) and, most importantly, for all service audit and quality improvement activities.
That research and quality improvement projects are similar is apparent when considering, for example, ethics, and the need for approval. First, there is a large grey area, where projects may be consider as either audit or research. Second, it is quite possible to undertake audit projects that carry risks to patients, without any requirement for approval or scrutiny. (See examples given here.)
Therefore, all professional clinicians should consider the acquisition of knowledge, which is currently badged as being relevant to research, as an integral part of their professional education and learning, not as an optional extra simply needed to pass an exam. The knowledge will help them in their daily work, for example when evaluating the response of individual patients, or when undertaking sound quality monitoring and improvement projects.
The rehabilitation professional should know:
- the laws and recommendations concerning handling of personal, clinical data, so that they comply with them;
- a systematic approach to evaluating research; (see here)
- basic principles underlying randomised trials, and data analysis in trials. This is essential because (a) randomised trials provide the strongest evidence available and (b) so many trials are both poorly designed and/or analysed and, also, incorrectly interpreted by the researchers; (see here)
- basic principles underlying statistical testing of hypotheses. This is only learned through use, and all clinicians should practice on clinical data collected;
- where to find expert help on research or data analysis, when needed, both online and in person. It is unrealistic to expect to have great expertise. It is important to acknowledge this fact, and to seek and use help from others.
The skills needed are also skills that should be considered integral to day-to-day clinical activities, and should not be considered optional and something that really only concerns a few ‘special’ people who ‘do research’. Most of these skills concern the evaluation of published research, but they will, almost inevitably, also translate into skills that can be used when collecting and analysing data.
The rehabilitation professional should be able to:
- undertake a critical evaluation of both quantitative and qualitative studies. Though most training relates to quantitative studies, qualitative studies can give invaluable information and an ability to evaluate qualitative studies is vital;
- recognise which statistical methods are appropriate for specific data-sets and analyses;
- search and use computer databases of research (e.g. PubMed) efficiently;
- recognise or detect common methodological flaws in research studies;
- explain why research is important to other team members;
- Use simple data-base and data analysis softeware, such as a spreadsheet (e.g. Excel).
This page has outlined generic capability five, which focuses on the collection, analysis, interpretation and use of data. The abilities are usually considered to be related to research, but the same abilities are essential in clinical practice. For example, they are useful when evaluating whether a treatment is helping a patient, and they are essential in audit and quality improvement activities. The only additional features that relate specifically to research are (a) finding relevant research, and (b) evaluating the quality of the research. A summary MindMap can be downloaded here.