Generic capability 5

Healthcare should use the best available evidence. This simple statement presents several challenges. What constitutes the best, who judges it, and how? As a rehabilitation professional, how do you find it and then evaluate it? Moreover, healthcare professionals are expected to support research in their service. These requirements depend on the clinician’s sufficient understanding of research and research methods to evaluate published articles or participate in a research study. However, clinicians are not expected to initiate or undertake research studies, though they may. The knowledge and skills that underlie the generic capability are also invaluable when undertaking audit and quality improvement projects. The common theme is identifying the data needed, discovering how to collect it and ensuring a systematic approach, and then knowing the most appropriate statistical analytic methods and how to interpret the results. Indeed, the distinction between well-designed and executed quality improvement or audit projects and research is indistinct, not black and white but shades of grey. This capability also leads professionals to question some of the certainties they acquired in undergraduate education and early postgraduate training. The MindMap below, downloaded here, shows the significant points.

Generic capability in research knowledge and skill

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. Still, the person will likely be able to select, understand and use proper research, identify and reject invalid research, and support research by others.

Context - reducing uncertainty, challenging beliefs

There are no certainties in healthcare, except one: there are no certainties in healthcare! (A philosophical conundrum we will ignore!) When starting independent professional work, this must be revealed to the student or learner. I suspect that some of those educating and training professionals still believe that at least some of their teachings are absolute and the only correct course to follow. When someone is ready to acquire rehabilitation-specific expertise, they will realise that taught certainties are rarely accurate. 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 all patients are different. 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 practices are not based on evidence. In the 1970s, the standard approach discouraged children with 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 firmly 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 firm believers and critics. The differences in opinion primarily 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 indeed addressed. The second important class of evidence is knowledge and expertise of local resources. For example, phenol nerve injection would be a good, evidence-based treatment for a patient with severe spasticity, but if no one is available, it cannot be delivered. Or, more practically, knowledge of local day services would be substantial evidence when considering referral to a day service.

Because evidence is an essential part of all clinical practice, and because the evidence is constantly accumulating, a professional must be able, when needed, to find and evaluate potentially relevant research. It is also vital 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 only sometimes generalisable. This is clinical improvement activity, sometimes termed an audit.

The knowledge and skills needed for research and audit are similar and overlap.

Attitude

The critical 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 the approach;
prepared to admit uncertainty and to look for evidence to reduce uncertainty;
commitment to the importance of research, both as an activity and as a source of evidence

Behaviours

The behaviours associated with this capability are exhibited by a curious and critical person 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, unreasonable, and excessive questioning. A balance is needed between passive acceptance of the status quo and obsessional examination of every item. Furthermore, the attitude required extends beyond simple curiosity; it requires the person to satisfy that curiosity and 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 and be able to evaluate it and use it or ignore it as appropriate. Very importantly, the professional needs research skills in designing and undertaking projects that depend upon data collection and analysis 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 communicate the assessment’s outcome.
Discusses the implementation of research findings 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 a commitment to the acquisition of new and better evidence.
Collects, handles, and analyses data (audit, research, clinical) effectively, showing an understanding of the processes needed in research, both how to collect and analyse data. It also helps 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 an understanding of data handling laws and rules within the organisation.
Considers and complies with ethical and Good Clinical Practice guidance (here) when collecting data.

Research Knowledge and Skills

All professionals should acquire the knowledge required, but they need more. It is taught in undergraduate and postgraduate courses. Still, the teacher or the learner often perceives it as something different, a knowledge belonging to researchers who are usually considered ‘a race apart’. Thus, although learned to pass an exam, the relevance to daily clinical work must be 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, challenging activity undertaken by others and not relevant to everyday clinical practice to being perceived as essential knowledge both for day-to-day clinical practice (e.g. evaluating change associated with 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 regarded as audits 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 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 following:

the laws and recommendations concerning the 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 most robust evidence available and (b) so many trials are both poorly designed and 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 outstanding expertise. It is essential 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 only concerns a few ‘special’ people who ‘do research’. Most of these skills involve evaluating published research, but they will almost inevitably 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 essential to other team members;
Use simple database and data analysis software, such as a spreadsheet (e.g. Excel).

Conclusion

This page has outlined generic capability five, which focuses on data collection, analysis, interpretation and use. The abilities are usually considered to be related to research, but the same skills are essential in clinical practice. For example, they are helpful when evaluating whether a treatment is helping a patient and necessary 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 seen below and downloaded here.