Design, Sampling, and Data Collection

A qualitative, exploratory, and descriptive design was employed using homogenous purposive sampling. Eligible participants were 5th- and 6th-year chiropractic students who were clinically active for a minimum of 4 months. Potential participants were approached or contacted telephonically, and the procedure was explained to them verbally. A minimum number of 12 participants were required to be interviewed, and data were completed when data saturation had been reached. In total, 14 participants were interviewed, of which 8 were in their 5th year and 6 were in their 6th year of study. Interviews were conducted either at the DUT research room or online via Microsoft Teams (Microsoft Corp).

Interviews were conducted using a semi-structured interview guide that consisted of 3 key questions and relevant probes. The guide was developed by the researchers to suit the distinct structure at the DUT CDC. A pilot study was conducted with 1 5th-year and 1 6th-year student to determine if the questions were pertinent and clear. There were no recommended changes to carry out the main study. Demographic information was obtained from the participant verbally. The interview then commenced and was audio recorded.

Data Analysis

The audio recordings were transcribed verbatim and analyzed using Tesch’s method of thematic analysis.¹⁴ The 8 steps are as follows:

1. The researcher transcribed the audio-recorded interviews verbatim.

2. The researcher compared the transcribed data with the audio-recorded data with the use of field notes to confirm certain aspects of the data.

3. The researcher read and reread the transcriptions as many times as needed to fully understand and conceptualize the data.

4. The most informative interview was selected, and notes were made pertaining to that interview. This was repeated for the other interviews as well.

5. Similar topics were identified and clustered.

6. Themes were formulated from these topics.

7. An experienced person in qualitative research (in this case, the research supervisor) checked the data and transcriptions and confirmed the themes identified by the researcher.

8. Merging themes were identified and confirmed by the researcher and the supervisor supported by verbatim statements from the participants. The literature was reviewed to verify findings and draw a conclusion.

Ethical Approvals

Permission to conduct this study was obtained from the institutional research and ethics committee (research ethics clearance number 201/21). Permission to access a class list to identify potential participants was obtained. Permission from the participants was a requirement for inclusion into the study. Participants were required to read a letter of information and sign the informed consent form before commencement of the interview. Participants were reassured that the data would be kept confidential and informed that the interview would be audio recorded. They were allowed to withdraw at any time if they felt uncomfortable. Their personal details were omitted, and they were allocated pseudonyms to ensure confidentiality.

Trustworthiness

Trustworthiness of qualitative research is established by using Lincoln and Guba’s¹⁵ 4 criteria: credibility, confirmability, dependability, and transferability. Credibility was ensured by issuing a letter of informed consent stating that participation was voluntary and participants could discontinue at any given time. Confirmability was elicited by asking the research supervisor to scrutinize the data through independent checking. Dependability was ensured by consistent questions being asked by the researcher during the interview and the supervisor double-checking the transcribed data. Transferability was ensured by providing a detailed description of the research context, settings, and processes utilized in the study.

Theme 1: Perceptions and Necessity Regarding the Roles of EBP

Participants expressed a strong belief in the necessity of EBP in general and its role in the chiropractic profession. However, 1 participant expressed the necessity of EBP alongside a disadvantage.

Theme 2: Undergraduate Education and Its Role in the Implementation of EBP

Most participants had a theoretical understanding of EBP; however, they identified discrepancies between what was taught in the undergraduate program in comparison to what was expected during their clinical practicum. Some students were found to have a general idea of EBP and its importance; however, its implementation could be considered partially neglected.

Theme 3: The Importance of Clinical Experience and the Implementation of EBP

Participants expressed the necessity of clinical experience during their training and its role in implementing EBP. They also had positive and negative views regarding the support structures available during the clinical practicum. In addition, self-perceived limitations were reported.

Theme 4: Implementation of EBP

The participants identified theoretical and practical aspects that hindered their implementation of EBP as well as challenges encountered that affected their efficacy in the implementation thereof.

Theme 1: Perceptions and Necessity Regarding the Roles of EBP

Participants expressed that evidence serves as a guide on how to treat patients for various conditions, and this enhances the credibility of the profession as stated by Thomas et al.⁸ Limited resources in the clinical setting and a discrepancy between what was perceived to be evidence what is evidence were limitations noted. Access to the internet and free online databases are fundamental enablers for the uptake of EBP in a clinical setting, whereas access to critical reviews of research articles was considered a moderately important tool.^16–18

Reported downsides to EBP included the opinion of a lack of literature due to minimal financial gain on pursuing chiropractic research. Although there is a need for more in the literature in this regard, a claim of such nature cannot be fully substantiated. A statement made by Kawchuk¹⁹ implies that there is a distortion of the base of evidence due to financial interests, and this needs to be studied along with its hidden biases in sponsored research. This affects the implementation of EBP because the lack of evidence for certain treatments can serve as a hindrance.

An important aspect highlighted is that chiropractic is believed to be a holistic profession, and to produce evidence-based literature, a method of isolating treatments is necessary, contradictory to chiropractic teaching. Tonelli²⁰ notioned that evidence-based medicine provides an inadequate account of optimal medical practice and a broader understanding of medical knowledge with reasoning is necessary. Tonelli and Callahan²¹ pointed out that complementary alternative medicine approaches to care differ from that of professions within the reductionistic paradigm, and as such, the evidence at the time was linked to randomized controlled trials. Similarly, chiropractic patients are cared for as they present to a practice unlike in hospitals in which preparation takes place prior to patient admission. This brings about the discussion on whether standardizing chiropractic treatment alongside relevant intervention is a possibility²² due to the variability in case presentation and the chosen method for treatment at that consult.

Theme 2: Undergraduate Education and Its Role in the Implementation of EBP

Similar to a study done by Bussières et al,¹⁶ participants expressed a lack of sufficient training on critical appraisal of literature affecting the implementation of EBP. Another hindrance was a lack of practical learning due to SARS-CoV-2 pandemic restrictions by which students had reduced practical classes in comparison to prior years and the usage of certain treatment modalities were limited.

The findings of Malau-Aduli et al²³ and this study align in that a lack of preparation regarding aspects about the clinical environment was found. These included a lack of training on the use of equipment and EBP referencing and research as a whole, and this affected the implementation of EBP.

A void in the chiropractic curriculum was identified with regard to EBP teachings. This can be filled by implementing improvements akin to the findings of Haas et al,⁴ who concluded that implementation of the new EBP curriculum in the 1st year of the undergraduate program was deemed a favorable outcome. This resulted in the chiropractic student’s ability to acquire the knowledge necessary to find and interpret literature, retain and improve EBP skills over a period of time, and enhance self-reported skills in utilizing credible online resources.

There was consensus that the chiropractic training, in general, provided a solid foundation. To facilitate the implementation of EBP, a common suggestion of implementing a journal club much earlier was made, and this was a method used in the study done by Haas et al⁴ with the outcomes deemed favorable.

Another common suggestion was to introduce evidence-based articles supportive of treatments per condition taught. However, it is imperative that pain classifications are understood with regard to musculoskeletal pain syndromes due to variable presentations,²⁴ signifying that conditions can present differently in each patient. A common expected standard between chiropractic regulatory authorities is that undergraduate institutions produce graduates who are capable of making decisions in the best interest of their patients^25–27 and being able to determine indications from contraindications.²⁶ A treatment per condition–based teaching method would limit the abilities of students regarding treatment options given the likely case of encountering a patient with relative contraindications for treatment. Therefore, implementing a teaching method as such could be considered impotent.

Although only 1 participant suggested more practical learning to improve the uptake of EBP, implying that an increase in confidence would amplify proficiency, this is congruent with the findings of Boysen et al²⁸ in which senior students reported an increase in clinical confidence relative to experience. Students perceived that treating patients in a more realistic setting, frequent engagement with technical skills, performing clinical decision making, patient management, and communicating with patients and other health professionals as beneficial.

Theme 3: The Importance of Clinical Experience and the Implementation of EBP

The number and type of cases consulted by students in different clinical settings might be influential on the development of competencies.²⁹ In this study, students suggested that clinical experience aided in competency, and this boosted their confidence. Interaction with patients allowed for exposure to different medical conditions, encouraging more research that aided in the implementation of EBP. The fundamental activity that assisted in developing a sense of professional identity and preparing for a transition into practice was an exposure to patients.³⁰ This study found that the experience of fulfilling the requirements of the internship portfolio amplified practical skills and encouraged research. This is similar to a dominant theme in another study that all clinical experiences prepared students for their transition into practice, but clinical settings other than a university health clinic offered a higher level of preparation.²⁹ As well, Moore et al³⁰ identified that the exclusivity of only 1 type of clinical placement is unlikely to provide optimal preparation professionally.

Multiple studies^31–33 noted that, regardless of the clinical setting, students acknowledged the importance of having good clinical educators, concurrent with this study. Hence, it is crucial to maintain a certain standard of education, and the importance of the clinical practicum cannot be undervalued.

Aspects that indirectly affected the implementation of EBP included challenges regarding the rehabilitation room and excessive administration duties. The implementation of EBP involves more than applying the best literature to a patient. EBP implementation is also influenced by other factors, such as the environment, management structures, and resources.³⁴ There are numerous studies supporting the significance of assessing an institution in its context in order to understand how to best support the implementation of EBP.^33–37 Commonly these studies found that, in addition to an evidence-based protocol implemented at a managerial level, it is imperative to delve into the content, purpose, dynamic, and infrastructure these protocols hold and idealize these elements into context.

Vongsirinavarat et al³⁸ found that respondents considered themselves competent in practicing EBP, yet the frequency of searching and reading literature was relatively low. Similarly, 2 out of the 14 participants in this study reported insufficient reading of literature as a barrier. Only 1 of these 2 participants also reported difficulty referencing and a lack of proficiency that may suggest that these barriers are linked to differing levels of interest. However, findings from various studies^17,38,39 show that insufficient EBP training in the past has led to gaps in skills and application among health care professionals, reinforcing the need for formal training.

Theme 4: Implementation of EBP

Quon et al⁴⁰ suggested that treatment responses could be slightly variable while following clinical practice guidelines, perhaps reasoning with the findings of this study in which students reported variable treatment responses despite adopting an EBP approach.

Participants mentioned that a quick and general EBP reference search was done for the purpose of paperwork. Although a protocol encouraging EBP at the institution is implemented, the findings of this study questions whether this method is sufficient or could be considered futile incidentally to the role that EBP references are intended to fill.

A lack of literature was reported as a hindrance attempting to justify treatment plans. Despite the chiropractic profession shifting away from early theories and hypotheses to a more evidence-based approach,⁴¹ numerous studies report a lack of literature in the profession as a barrier.^17,18,42,43 There is a lack of a developed research culture across the profession,⁴⁴ and observing a consistency in the same report over the last few years reiterates the need for further research.

Students were competent in the implementation of EBP, however, not as proficient as desired. This is relatively consistent with the observation that a passive diffusion of knowledge does not warrant an automatic translation into clinical practice,⁴⁵ emphasizing the importance of high-quality EBP education programs to meet the needs of the chiropractic profession.¹⁷

A lack of supporting literature for content taught was noted to cause confusion in the implementation of desired treatment protocols due to the disparity of what was taught versus the cogency of available evidence. In a similar context, studies from a variety of health professions report that more than half of respondents have concerns of there being a lack of supportive evidence,^38,46–54 reiterating that the preparation of students to inculcate EBP principles is highly dependent on the ability of the faculty to teach and model EBP into clinical training.⁵⁵

Aside from clinicians’ lack of engagement with EBP references intended to justify specific treatment plans, the main concern among students who reported a disparity between clinicians’ views and theirs was that there seems to be a common trend in which the clinicians only approve of treatment plans based on a self-perceived paradigm, which is not always in sync with the students. A teaching environment as such could be considered contrary to the opinion; a teacher in the clinical setting should implement formal and informal strategies of assessment and feedback to enable further learning, thereby assisting the student to progress.⁵⁶ Although participants held a positive attitude toward EBP, the disregard experienced from superiors could later be demotivating, potentially resulting in a negligible method of implementing EBP.

In our study, students found that patient responses to treatment may be different than those reported in the literature. Such cases compelled students to probe into other treatment protocols. This is a common difference between the reality of patient care and concerns about evidence-based treatments.^57–59 The criteria set to carry out treatment research is too specific, and context may differ vastly from patients seen in clinical practice, raising the question on how to generalize the outcomes from the study into clinical practice.⁶⁰