Ilic et al. BMC Medical Education 2013, 13:170
http://www.biomedcentral.com/1472-6920/13/170
STUDY PROTOCOL Open Access
Implementation of a blended learning approach
to teaching evidence based practice: a protocol
for a mixed methods study
Dragan Ilic1*, Rusli Bin Nordin2, Paul Glasziou3, Julie K Tilson4 and Elmer Villanueva5
Abstract
Background: Evidence based practice (EBP) requires that health professionals are competent in integrating the
best evidence in their decision making. Being ‘evidence-based’ requires skills and knowledge in epidemiology,
biostatistics and information literacy. EBP is commonly taught in medical and health sciences degrees, yet there is
little evidence to guide educators as to the best teaching modality to increase learner competency in EBP.
Methods/design: This study is mixed methods in design. A randomised controlled trial will examine the
effectiveness of blended learning versus didactic approach of teaching EBP to medical students. The primary
outcome of the RCT is EBP competency as assessed by the Berlin tool. Focus groups will be conducted to explore
student perceptions and attitudes towards implementing a blended learning approach in teaching EBP. A
concurrent triangulation design will be implemented, permitting quantitative data to inform the effectiveness of
the intervention and qualitative data to contextualise the results.
Discussion: This study will provide novel evidence on the effectiveness of blended learning in teaching EBP to a
cohort of undergraduate and graduate-entry medical students.
Background 4. Applying the evidence to the clinical scenario
Evidence Based Practice (EBP), or evidence based medicine (apply); and,
(EBM), has been adopted as a core unit across many 5. Assessing the EBP process as it relates to the clinical
medical schools worldwide, with a particular focus in context (assess) [2].
Australian Universities [1]. The principles of EBP inform
medical decision making by integrating the best available Each step within the EBP process requires a different
evidence with clinical expertise and patient values [2]. level of competency (i.e. integration of knowledge, skill, at-
Adopting an evidence based approach to medicine re- titude and behaviour) from the practitioner [3]. Achieving
quires that practitioners are competent in understand- a high level of competency in EBP can only be achieved
ing and applying the following steps in clinical practice: when the practitioner is able to effectively undertake all
five steps, which incorporate adequate levels of knowledge,
1. Asking a clinical question that is constructed using skills, attitude and behavioural elements [3]. Achieving
the PICO (patient, intervention, comparison, competency in the principles and practices of EBP pro-
outcome) framework (ask); vides the practitioner with the ability to know when
2. Acquiring the evidence via a systematic and efficient and how to make evidence-based medical decisions,
search of the literature (acquire); and also achieve lifelong learning within their medical
3. Appraising the evidence through application of discipline.
critical appraisal techniques (appraise); Each step of the EBP process requires a different
competency to be learnt. This has led to the suggestion
* Correspondence: that different teaching modalities could be used in its
1
Department of Epidemiology & Preventive Medicine, School of Public implementation – be it lecture, tutorial, mini-course,
Health & Preventive Medicine, Monash University, Melbourne, Australia problem based or online [4]. Limited evidence currently
Full list of author information is available at the end of the article
© 2013 Ilic et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication
waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise
stated.
, Ilic et al. BMC Medical Education 2013, 13:170 Page 2 of 5
http://www.biomedcentral.com/1472-6920/13/170
exists in order to inform educators as to the most effective those results addressing issues of ‘how’ and ‘why’ [8].
method of teaching and increasing practitioner compe- The protocol for this current study was informed by a
tency in EBP. A 2004 systematic review identified two pilot study on graduate-entry medical students, which
randomised controlled trials (RCTs) and seven non- has since been accepted for publication by BMC Medical
RCTs that examined the effectiveness of different teach- Education.
ing modalities in EBP [5]. The authors of that review
concluded that standalone teaching improved student
Settings and participants
knowledge, but not skills, attitudes or behaviour in EBP.
Conversely, evidence from the non-RCTs indicated that A multi-campus study will be conducted with medical
integrating teaching of EBP with clinical activities (i.e. students currently enrolled in the MBBS course at Monash
blended learning) was associated with improvements University. Monash University runs undergraduate and
across all four domains (i.e. knowledge, skills, attitudes graduate-entry MBBS programs, in both Australia and
and behaviour) [5]. Malaysia. Students are assigned to one of seven metro-
A 2013 systematic review of the literature identified 9 politan hospitals, or six rural, hospitals in Australia
RCTs that compared the effectiveness of various teaching (with one site in Malaysia). Participants for this study
modalities (lecture, tutorial, self-directed, online, problem- will be third year medical students, who are entering
based, uni and multidisciplinary) in training medical their first year of clinically-based training and first year
students in EBM [6]. The review concluded that train- of formal EBP training.
ing in EBP increased student competency, but identified
a lack of evidence to guide educators on which teaching Quantitative research methodology
modality is best at increasing EBM competency. The following outlines the protocol for the randomised
A variety of factors may dictate how an EBP course is controlled trial aspect of the study.
implemented in medical education – be it student learning
styles, infrastructure or other organisational issues. The
ability to achieve competency in EBP also requires that Recruitment
students have a certain level of mastery in epidemiology, Third year medical students are randomly placed in small
biostatistics, informatics and information literacy. Given tutorial groups for their EBP teaching (approximately 20–
the impact of these factors, and the challenge in achieving 25 in a group). Tutorial groups will be randomised to re-
competency in a variety of areas, teaching EBP requires ceive EBP teaching adopting a blended learning approach,
a multidimensional approach. Blended learning attempts or the traditional didactic small group learning approach.
to create an optimal learning environment by blended a Students not wishing to participate in the study will be
variety of learning approaches (lecture, tutorial, online, taught via the traditional didactic approach and not be
problem-based etc.) [7]. asked to complete an outcome assessment.
Methods/Design Randomisation
Aims
Participants will be randomised according to their tutorial
The aim of this study is to determine the effectiveness group (i.e. cluster) by a researcher independent to the
of blended versus didactic learning of EBP in medical study utilising a simple cluster randomisation procedure
students. The specific study objectives are to; (computerised random numbers). All students will have
access to the blended learning materials at the end of
1. Determine the competency of students in EBP the study period to ensure parity between groups.
receiving EBP training via a blended learning
approach compared to students receiving EBP
training via a didactic approach, and; Control
2. Determine student self-efficacy, perceptions and Students randomised to the control group will receive the
attitudes on EBP teaching delivered through a current didactic model of teaching EBP (lecture/tutorial)
blended learning approach. (Table 1). The didactic model consists of a 10 two-hour
teaching sessions in which formal EBP concepts are deliv-
Design ered by a tutor/lecturer to students. The formal presenta-
This study is a mixed methods study, incorporating a tion is followed up by students performing a small group
randomised controlled trial and a qualitative case study activity to consolidate their learning. This small group
at Monash University. A mixed methods approach will activity is commonly a critical appraisal of an article
permit quantitative data to inform the effectiveness of relating to the study design discussed by the lecturer/
the intervention, whilst qualitative data will contextualise tutor i.e. therapy, harm, prognosis and diagnosis.
http://www.biomedcentral.com/1472-6920/13/170
STUDY PROTOCOL Open Access
Implementation of a blended learning approach
to teaching evidence based practice: a protocol
for a mixed methods study
Dragan Ilic1*, Rusli Bin Nordin2, Paul Glasziou3, Julie K Tilson4 and Elmer Villanueva5
Abstract
Background: Evidence based practice (EBP) requires that health professionals are competent in integrating the
best evidence in their decision making. Being ‘evidence-based’ requires skills and knowledge in epidemiology,
biostatistics and information literacy. EBP is commonly taught in medical and health sciences degrees, yet there is
little evidence to guide educators as to the best teaching modality to increase learner competency in EBP.
Methods/design: This study is mixed methods in design. A randomised controlled trial will examine the
effectiveness of blended learning versus didactic approach of teaching EBP to medical students. The primary
outcome of the RCT is EBP competency as assessed by the Berlin tool. Focus groups will be conducted to explore
student perceptions and attitudes towards implementing a blended learning approach in teaching EBP. A
concurrent triangulation design will be implemented, permitting quantitative data to inform the effectiveness of
the intervention and qualitative data to contextualise the results.
Discussion: This study will provide novel evidence on the effectiveness of blended learning in teaching EBP to a
cohort of undergraduate and graduate-entry medical students.
Background 4. Applying the evidence to the clinical scenario
Evidence Based Practice (EBP), or evidence based medicine (apply); and,
(EBM), has been adopted as a core unit across many 5. Assessing the EBP process as it relates to the clinical
medical schools worldwide, with a particular focus in context (assess) [2].
Australian Universities [1]. The principles of EBP inform
medical decision making by integrating the best available Each step within the EBP process requires a different
evidence with clinical expertise and patient values [2]. level of competency (i.e. integration of knowledge, skill, at-
Adopting an evidence based approach to medicine re- titude and behaviour) from the practitioner [3]. Achieving
quires that practitioners are competent in understand- a high level of competency in EBP can only be achieved
ing and applying the following steps in clinical practice: when the practitioner is able to effectively undertake all
five steps, which incorporate adequate levels of knowledge,
1. Asking a clinical question that is constructed using skills, attitude and behavioural elements [3]. Achieving
the PICO (patient, intervention, comparison, competency in the principles and practices of EBP pro-
outcome) framework (ask); vides the practitioner with the ability to know when
2. Acquiring the evidence via a systematic and efficient and how to make evidence-based medical decisions,
search of the literature (acquire); and also achieve lifelong learning within their medical
3. Appraising the evidence through application of discipline.
critical appraisal techniques (appraise); Each step of the EBP process requires a different
competency to be learnt. This has led to the suggestion
* Correspondence: that different teaching modalities could be used in its
1
Department of Epidemiology & Preventive Medicine, School of Public implementation – be it lecture, tutorial, mini-course,
Health & Preventive Medicine, Monash University, Melbourne, Australia problem based or online [4]. Limited evidence currently
Full list of author information is available at the end of the article
© 2013 Ilic et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication
waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise
stated.
, Ilic et al. BMC Medical Education 2013, 13:170 Page 2 of 5
http://www.biomedcentral.com/1472-6920/13/170
exists in order to inform educators as to the most effective those results addressing issues of ‘how’ and ‘why’ [8].
method of teaching and increasing practitioner compe- The protocol for this current study was informed by a
tency in EBP. A 2004 systematic review identified two pilot study on graduate-entry medical students, which
randomised controlled trials (RCTs) and seven non- has since been accepted for publication by BMC Medical
RCTs that examined the effectiveness of different teach- Education.
ing modalities in EBP [5]. The authors of that review
concluded that standalone teaching improved student
Settings and participants
knowledge, but not skills, attitudes or behaviour in EBP.
Conversely, evidence from the non-RCTs indicated that A multi-campus study will be conducted with medical
integrating teaching of EBP with clinical activities (i.e. students currently enrolled in the MBBS course at Monash
blended learning) was associated with improvements University. Monash University runs undergraduate and
across all four domains (i.e. knowledge, skills, attitudes graduate-entry MBBS programs, in both Australia and
and behaviour) [5]. Malaysia. Students are assigned to one of seven metro-
A 2013 systematic review of the literature identified 9 politan hospitals, or six rural, hospitals in Australia
RCTs that compared the effectiveness of various teaching (with one site in Malaysia). Participants for this study
modalities (lecture, tutorial, self-directed, online, problem- will be third year medical students, who are entering
based, uni and multidisciplinary) in training medical their first year of clinically-based training and first year
students in EBM [6]. The review concluded that train- of formal EBP training.
ing in EBP increased student competency, but identified
a lack of evidence to guide educators on which teaching Quantitative research methodology
modality is best at increasing EBM competency. The following outlines the protocol for the randomised
A variety of factors may dictate how an EBP course is controlled trial aspect of the study.
implemented in medical education – be it student learning
styles, infrastructure or other organisational issues. The
ability to achieve competency in EBP also requires that Recruitment
students have a certain level of mastery in epidemiology, Third year medical students are randomly placed in small
biostatistics, informatics and information literacy. Given tutorial groups for their EBP teaching (approximately 20–
the impact of these factors, and the challenge in achieving 25 in a group). Tutorial groups will be randomised to re-
competency in a variety of areas, teaching EBP requires ceive EBP teaching adopting a blended learning approach,
a multidimensional approach. Blended learning attempts or the traditional didactic small group learning approach.
to create an optimal learning environment by blended a Students not wishing to participate in the study will be
variety of learning approaches (lecture, tutorial, online, taught via the traditional didactic approach and not be
problem-based etc.) [7]. asked to complete an outcome assessment.
Methods/Design Randomisation
Aims
Participants will be randomised according to their tutorial
The aim of this study is to determine the effectiveness group (i.e. cluster) by a researcher independent to the
of blended versus didactic learning of EBP in medical study utilising a simple cluster randomisation procedure
students. The specific study objectives are to; (computerised random numbers). All students will have
access to the blended learning materials at the end of
1. Determine the competency of students in EBP the study period to ensure parity between groups.
receiving EBP training via a blended learning
approach compared to students receiving EBP
training via a didactic approach, and; Control
2. Determine student self-efficacy, perceptions and Students randomised to the control group will receive the
attitudes on EBP teaching delivered through a current didactic model of teaching EBP (lecture/tutorial)
blended learning approach. (Table 1). The didactic model consists of a 10 two-hour
teaching sessions in which formal EBP concepts are deliv-
Design ered by a tutor/lecturer to students. The formal presenta-
This study is a mixed methods study, incorporating a tion is followed up by students performing a small group
randomised controlled trial and a qualitative case study activity to consolidate their learning. This small group
at Monash University. A mixed methods approach will activity is commonly a critical appraisal of an article
permit quantitative data to inform the effectiveness of relating to the study design discussed by the lecturer/
the intervention, whilst qualitative data will contextualise tutor i.e. therapy, harm, prognosis and diagnosis.
