ISSUE
     
Educating Men and Women of Science
Evidence-based Practice: A New Paradigm for Educating Health Professionals
 


By Judith Haber, PhD, APRN, BC, FAAN
The Ursula Springer Leadership Professor in Nursing and Associate Dean for Graduate Programs,NYU College of Nursing

Joan A. Phelan, DDS
Professor & Chair, Department of Oral and Maxillofacial Pathology, Radiology & Medicine, NYU College of Dentistry

Mark S. Wolff, DDS, PhD
Professor & Chair, Department of Cariology & Comprehensive Care and Associate Dean for Predoctoral Clinical Education, NYU College of Dentistry





Informing the Clinical Decision




Knowledge of the Best Hypertension Care
(Shin, et al. CMAS, 1993 r=.54 p=<0.001)








Over the past several decades, there has been a growing trend in the health sciences toward nurturing students and faculty to become “men and women of science,” or as Dean Bertolami defines them, “sophisticated consumers of research.” This trend is in keeping with the recommendation put forth in 2001 by the Institute of Medicine (IOM) that all healthcare providers be educated to work in interdisciplinary teams to provide patient-centered, evidence-based care using quality improvement approaches and informatics. It is predictable that the next step will be for professional organizations and accrediting bodies to mandate these competencies in establishing standards for successful curricula for academic programs.

To prepare the next generation of dentistry and nursing leaders to improve patient outcomes, the NYU Colleges of Dentistry and Nursing, through their unique organizational partnership, have launched a collaborative, evidence-based practice (EBP) initiative, which focuses on using the “best available” evidence, combined with clinical expertise and patient preferences, to inform clinical decision making (Sackett et al, 2000).

Key to the success of this initiative is uniting research faculty and clinical faculty through faculty development and curriculum innovation.

For an EBP culture to take root in a professional school, there must be a shift away from the traditional paradigm of teaching based on subjective judgments and “expert experience” toward one that privileges critical thinking and all that it entails -- i.e., asking clinical questions, determining where and how to find the best evidence, how to read and interpret the evidence, and how to translate the best evidence into clinical practice in order to promote quality outcomes.

Like all entrenched interests, however, educational styles resist change. Indeed, healthcare practitioners historically have faced obstacles to change. In 1847, Semmelweis lost his right to practice for daring to propose that physicians and midwives might be spreading childbed fever -- a frequently fatal infection following childbirth -- by failing to wash their hands between deliveries. When the best available scientific evidence finally gave birth to the “germ theory,” change occurred, first at teaching hospitals and in the medical literature of the day, and then slowly but surely in clinical practice.

The importance of keeping up-to-date regarding “best practices” cannot be overstated. Indeed, Shin and colleagues (1993) report that health professionals experience a significant decline in knowledge about “best practices” that reaches its nadir 20 years following graduation from professional school.

But shouldn’t the information “superhighway” have remedied this situation? On the contrary, while Internet technology has increased information production and access to previously unimaginable levels, this very democratizing process has also made it possible for anyone, regardless of credentials or evidence, to claim scientific expertise. Practitioners can listen to a “detail” person selling them on the benefits of a specific product, or attend a continuing education course featuring an expert who may have little or no research to support her or his presentation. Even within our own educational institutions, our very best curricular efforts can be undermined by clinical faculty and preceptors who insist on teaching according to “the way we do it in practice,” rather than according to the evidence reported in the scientific literature.

Dean Bertolami has argued that only if healthcare professionals become men and women of science will they be able to acquire and assimilate new knowledge and adapt to the changes in clinical practice that the future requires (Bertolami, 2002), including having the intellectual traction to think for themselves, and the willingness to do so, based on credible science. Accordingly, at NYUCD/NYUCN, our aim is to immunize dentists and nurses of the future against junk science propagated by Internet charlatans or others with biased motives by replacing the long-standing paradigm of following tradition and authority in healthcare decision-making with an emphasis on critical thinking. To that end, we are engaged in several important EBP faculty development and curriculum initiatives.

EBP began to emerge as an institutional priority in June 2005, when NYUCD sponsored a culture-change workshop for both nursing and dental faculty. That workshop gave rise to the Evidence-based Practice Steering Committee, cochaired by Drs. Judith Haber and Joan Phelan. But even before the workshop took place, the winds of change had begun to stir. Dr. Ralph V. Katz had already developed a component of the predoctoral dental curriculum that taught students how to appraise the professional literature (see related story on p. 21), and EBP information literacy and critical appraisal skills had been integrated into the nursing undergraduate and master’s programs curricula.

Campuswide awareness of NYUCD/NYUCN’s commitment to EBP was raised when the entire month of April 2007 was designated EBP Month. Sixty-five dental and nursing faculty members received training in EBP competencies related to developing clinical questions, conducting efficient electronic searches appraising the research literature, considering the research evidence in the context of dental or nursing clinical expertise and patient preferences, and applying the results of their findings to patient care. On-site training for a second 55-member faculty group was provided again in spring 2008. In addition, five faculty members attended weeklong EBP intensive training workshops at McMaster University in Toronto and several more faculty members will be attending in June. Two faculty members will be attending an evidence-based dentistry program at Oxford University in England; two additional faculty members have been chosen by the American Dental Association to be EBP Champions, and another to be an Evidence Reviewer for articles concerning EBP themes; and eight nursing faculty have been selected to write critical appraisal commentary responses for the Journal of Evidence-based Nursing.

In addition, the extensive preparation in literature appraisal provided to our dental students by the Department of Epidemiology & Health Promotion is now matched by the Departments of Cariology & Comprehensive Care and of Oral & Maxillofacial Pathology, Radiology & Medicine, which have begun to incorporate EBP competencies and strategies into their didactic and clinical courses. EBP teaching and learning strategies are extensively incorporated into the nursing curriculum through critical appraisal assignments, PICO (Problem, Intervention, Comparison, Outcome) Projects, evidence-based pharmacology treatment plans, EBP clinical journal clubs, and online EBP Grand Rounds.

The NYU Colleges of Dentistry and Nursing have accepted the challenge of teaching our students and faculty the skills required for evidence-based decision making so that they will be prepared for a future in which, despite being bombarded with information, they will be confident in the knowledge that they are providing the best possible patient care based on the best available evidence.