E‐learning of evidence‐based health care (EBHC) to increase EBHC competencies in healthcare professionals: a systematic review

This Campbell systematic review examines the effectiveness of e‐learning in improving evidence‐based health care (EBHC) knowledge and practice. Compared to no learning, pure e‐learning improves EBHC knowledge and skills but not attitudes and behaviour. Pure e‐learning is no better than face‐to‐face learning in improving any of the primary outcomes. Blended learning is better than no learning for improving EBHC knowledge, skills, attitude and behaviour; and is better than face‐to‐face learning in improving attitudes and behaviour. Compared to pure e‐learning, blended learning improves EBHC knowledge. It is not clear which elearning components are most effective in improving outcomes. However, the included studies were of moderate to low quality, with a small number of studies included in each analysis, and imprecision and inconsistency of results in all comparisons. These shortcomings need to be taken into consideration when interpreting the results Plain language summary Blended learning is most effective in increasing evidence‐based health care competencies of health workers E‐learning is a useful strategy to increase EBHC knowledge and skills, and when combined with face‐to‐face learning, to increase EBHC attitude and behaviour. The review in brief Evidence‐based health care (EBHC) is decision‐making for health care, informed by the best research evidence. Doctors, nurses and allied health professionals need to have the necessary knowledge and skills to apply EBHC. The use of electronic learning (e‐learning) for EBHC training is increasing. E‐learning, compared to no learning, improves EBHC knowledge and skills but not attitudes and behaviour. There is no difference in outcomes when comparing e‐learning to face‐to‐face learning. Combining e‐learning with face‐to‐face learning (blended learning) has a positive impact on EBHC knowledge, skills, attitude and behaviour. What did the review study? Evidence‐based health care (EBHC) involves phrasing questions based on a knowledge gap, searching for research that can answer the question, critically appraising and interpreting the research, applying the results and auditing the process. Electronic learning (e‐learning) has become an increasingly popular method of teaching EBHC. This review assesses the effectiveness of e‐learning of EBHC for increasing EBHC competencies in healthcare professionals. The primary outcomes are EBHC knowledge, skills, attitude and behaviour. What is the aim of this review? This Campbell systematic review examines the effectiveness of e‐learning in improving evidence‐based health care knowledge and practice. What studies were included? Eligible studies were randomised controlled trials (RCTs), cluster RCTs, non‐RCTs, controlled before‐after studies and interrupted time series of any healthcare professional evaluating any educational intervention on EBHC, and that was delivered fully (pure e‐learning) or in part (blended learning) via an electronic platform compared to no learning, face‐to‐face learning or other forms of e‐learning of EBHC. The review included 24 trials, comprising 20 RCTs and four non‐RCTs, with a total of 3,825 participants. Participants were medical doctors, nurses, physiotherapists, physician assistants, athletic trainers and a combination of professionals at all levels of education. The studies included a variety of interventions. What are the main findings of this review? Compared to no learning, pure e‐learning improves EBHC knowledge and skills but not attitudes and behaviour. Pure e‐learning is no better than face‐to‐face learning in improving any of the primary outcomes. Blended learning is better than no learning for improving EBHC knowledge, skills, attitude and behaviour; and is better than face‐to‐face learning in improving attitudes and behaviour. Compared to pure e‐learning, blended learning improves EBHC knowledge. It is not clear which e‐learning components are most effective in improving outcomes. However, the included studies were of moderate to low quality, with a small number of studies included in each analysis, and imprecision and inconsistency of results in all comparisons. These shortcomings need to be taken into consideration when interpreting the results. What do the findings of this review mean? E‐learning of EBHC, whether pure or blended, compared to no learning, improves EBHC knowledge and skills. There is no difference in these outcomes when comparing e‐learning to face‐to‐face learning. Blended learning, which typically comprises multiple interventions, appears more effective than other types of learning in improving EBHC knowledge, skills, attitude and behaviour. Future research should focus on the different components of e‐learning and should adequately report on all the intervention components, the educational context and implementation strategies. How up‐to‐date is this review? The review authors searched for studies published until May 2016. This Campbell Systematic Review was published in March 2017. Executive summary BACKGROUND It is important that all healthcare professionals acquire the knowledge and skills necessary to make healthcare decisions which are informed by the current best research evidence. Evidence‐based health care (EBHC) typically involves phrasing questions based on a knowledge gap, searching for research that can answer the question, critically appraising and interpreting the research, applying the results and auditing the process. Electronic learning (e‐learning) has become an increasingly popular method of teaching EBHC but literature on the effectiveness there of has not been synthesized and it is not clear which e‐learning strategies are most useful. OBJECTIVES The primary objective of this review was to assess the effectiveness of e‐learning of EBHC on increasing EBHC competencies in healthcare professionals. Secondary objectives were to assess the effectiveness of specific dimensions of e‐learning in increasing EBHC competencies, to assess how educational context influences the effectiveness of EBHC e‐learning, and to assess how implementation approaches influence the effectiveness of EBHC e‐learning. SEARCH METHODS We searched MEDLINE, EMBASE, ERIC, CINAHL, CENTRAL, SCOPUS, Best Evidence Medical Education (BEME), Web of Knowledge, PsycInfo and dissertation databases (ProQuest) for relevant studies (24 May 2016). We examined reference lists of included studies and contacted experts in the field. We did not apply any language restrictions. SELECTION CRITERIA We considered randomised controlled trials (RCTs), cluster RCTs, non‐randomised controlled trials (non‐RCTs), controlled before‐after studies (CBAs) and interrupted time series (ITS) of any healthcare professional at any level of education, evaluating any educational intervention that included any or all of the five steps of EBHC and was delivered fully (pure e‐learning) or in part (blended learning) via an electronic platform compared to no learning of EBHC, face‐to‐face learning of EBHC or other forms of e‐learning of EBHC. The primary outcomes were EBHC knowledge, EBHC knowledge and skills, EBHC skills, EBHC attitude and EBHC behaviour. DATA COLLECTION AND ANALYSIS Two authors independently screened search results and assessed eligibility of potentially eligible studies, extracted data and made judgments about risk of bias. Discrepancies were resolved through discussion or consultation of a third author. We contacted study authors in case of missing data. Due to high levels of heterogeneity between studies, we pooled results using random‐effects meta‐analysis and reported on the standardized mean differences (SMD) and 95% confidence intervals for each outcome. RESULTS We included 24 studies (20 RCTs and four non‐RCTs) with a total of 3825 participants in the review. Participants included medical doctors, nurses, physiotherapists, physician assistants, athletic trainers and a combination of professionals at all levels of education. E‐learning interventions were heterogeneous with 17 different intervention components. The interventions of five studies included only one component while the remaining interventions comprised various components in combination and were considered to be multi‐faceted. Overall we judged studies to be at moderate to high risk of selection bias and high risk of attrition bias. Meta‐analyses contained a small number of studies and participants. Results were mostly imprecise and inconsistent. Our confidence in the following results is therefore low. Primary outcomes Pure e‐learning vs no learning (3 studies) Pure e‐learning compared to no learning improved EBHC knowledge (SMD 0.71; 95%CI 0.40 to 1.01; 1 study, n=175) and EBHC attitude (SMD 1.05; 95%CI 0.26 to 1.83; 1 study, n=29). There was no difference between groups for EBHC knowledge and skills (SMD 0.47; 95%CI ‐0.27 to 1.21; 1 study; n=29). Blended learning vs no learning (5 studies) Blended learning compared to no learning improved EBHC knowledge (SMD 0.20; 95%CI 0.13 to 0.86; 1 study; n=119), EBHC knowledge and skills measured at one month post‐intervention (SMD 0.90; 95%CI 0.42 to 1.38; 2 studies; n=241) and 3+ months post‐intervention (SMD 1.11; 95%CI 0.80 to 1.42; 2 studies; n=186) and EBHC behaviour measured at 3+ months post‐intervention (SMD 0.61; 95%CI 0.21 to 1.01; 1 study; n=100). There was no difference between groups for EBHC knowledge and skills measured immediately post‐intervention (SMD 1.40; 95%CI ‐0.06 to 2.85; 2 studies, n=241), EBHC attitude (SMD 0.17; 95%CI ‐0.09 to 0.43; 2 studies; n=226), EBHC attitude measured at 1 month post‐intervention (SMD 0.05; 95%CI ‐0.34 to 0.44; 2 studies; n=241) and 3+ months post‐intervention (SMD 0.32; 95%CI ‐0.02 to 0.67), and EBHC behaviour measured directly post‐intervention (SMD 0.06; 95%CI ‐0.28 to 0.40; 2 studies; n=207) and 1 month post‐intervention (SMD 0.19; 95%CI ‐0.19 to0.56; 1 study; n=109). Pure e‐learning vs face‐to‐face learning (6 studies) We did not find a difference between groups for EBHC knowledge (SMD ‐0.03; 95%CI ‐0.26 to 0.20; 5 studies, n=632), EBHC skills (SMD ‐0.15; 95%CI ‐0.34 to 0.04; 2 studies; n=457) or EBHC attitude (SMD 0.11; 95%CI ‐0.27 to 0.48; 1 study; n=111). Blended learning vs face‐to‐face learning (5 studies) We did not find a difference between groups for EBHC knowledge (SMD 0.28; 95%CI ‐0.23 to 0.79; 1 study; n=146), EBHC knowledge and skills (SMD ‐0.22; 95%CI ‐0.49 to 0.05) and EBHC skills (SMD ‐0.21; 95%CI ‐0.68 to 0.26). Scores for participants in the blended learning group were higher for EBHC attitude (SMD 1.07; 95%CI 0.57 to 1.58; 1 study; n=69) and EBHC behaviour (SMD 2.34; 95%CI 1.72 to 2.96; 1 study; n=69). Blended learning vs pure e‐learning (3 studies) Blended learning compared to pure e‐learning improved EBHC knowledge (SMD 0.69; 95%CI 0.40 to 0.99; 2 studies, n=193). For EBHC skills, results favoured pure e‐learning for the non‐RCT and blended learning for the RCT. There was thus significant heterogeneity between studies and the pooled effect showed no difference between groups (SMD ‐0.53; 95%CI ‐2.31 to 2.25; 2 studies; n=218). Pure e‐learning vs pure e‐learning (3 studies) We found that the interventions improved EBHC skills (SMD 1.30; 95%CI 0.68 to 1.93; 2 studies; n=119). Interventions were heterogeneous. One study compared a DVD containing recorded PowerPoints and tutorials, as well as access to online learning material to a standard online distance learning programme. The other compared an online journal club with an asynchronous discussion list to receiving the articles via email and access to journal articles. Secondary outcomes Secondary outcomes were poorly reported. Attrition rates of learners were high, but did not differ between groups. Four studies reported on satisfaction of learning but results were not conclusive and both advantages and disadvantages of both methods of learning were identified. We were unable to address the secondary objectives of our review, as included studies provided insufficient information on educational context and implementation strategies. Meta‐analyses generally contained a small number of studies, which prevented us from doing subgroup analyses on different dimensions of e‐learning. AUTHORS’ CONCLUSIONS Our findings suggest that e‐learning of EBHC, whether pure or blended, compared to no learning, improves EBHC knowledge and skills. We did not find a difference in these outcomes when comparing e‐learning to face‐to‐face learning, suggesting that both methods of learning can be beneficial. It appears that blended learning, which typically comprises multiple intervention components, could be more effective than other types of learning in improving EBHC knowledge, skills, attitude and behaviour. These findings need to be considered in light of the limited number of studies per outcome in each comparison, risk of bias across studies and heterogeneous interventions, as well as inconsistent and imprecise results. Future research on EBHC e‐learning should focus on the effectiveness of various e‐learning components and should explicitly report on all the intervention components, educational context and implementation strategies.