INT J LANG COMMUN DISORD, JULY–AUGUST 2013,VOL. 48, NO. 4, 444–452

Research Report

Teaching evidence-based practice (EBP) to speech–language therapystudents: are students competent and confident EBP users?

B. Spek†, M. Wieringa-de Waard‡, C. Lucas§ and N. van Dijk‡†School of Health Care Studies, Department of Speech–Language Therapy, Hanze University of Applied Sciences, Groningen,the Netherlands‡Department of General Practice/Family Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, theNetherlands§Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam,Amsterdam, the Netherlands

(Received November 2012; accepted March 2013)

Abstract

Background: The importance and value of the principles of evidence-based practice (EBP) in the decision-makingprocess is recognized by speech–language therapists (SLTs) worldwide and as a result curricula for speech–languagetherapy students incorporated EBP principles. However, the willingness actually to use EBP principles in theirfuture profession not only depends on EBP knowledge and skills, but also on self-efficacy and task value studentsperceive towards EBP.Aims: To investigate the relation between EBP knowledge and skills, and EBP self-efficacy and task value indifferent year groups of Dutch SLT students.Methods & Procedures: Students from three year groups filled in a tool that measured EBP knowledge and skills: theDutch Modified Fresno (DMF). EBP self-efficacy and task value were assessed by using a 20-item questionnaire.Both tools were validated for this population. Mean scores for the three year groups were calculated and tested forgroup differences using a one-way analysis of variance (ANOVA) with a post-hoc Games–Howell procedure. Witha multiple linear regression technique it was assessed whether EBP self-efficacy and task value predict learningachievement scores on the DMF. Other possible predictors included in the model were: level of prior education,standard of English, having had mathematics in prior education and the SLT study year.Outcome & Results: A total of 149 students filled in both measurement tools. Mean scores on EBP knowledgeand skills were significantly different for the three year groups, with students who were further along their studiesscoring higher on the DMF. Mean scores on the EBP self-efficacy and task value questionnaire were the samefor the three year groups: all students valued EBP positive but self-efficacy was low in all groups. Of the possiblepredictors, only the year in which students study and EBP self-efficacy were significant predictors for learningachievements in EBP.Conclusions & Implications: Despite a significant increase in EBP knowledge and skills over the years as assessedby the DMF, the integrated EBP curriculum did not raise levels of EBP self-efficacy and task value. This lackof feeling competent might have an impact on students’ willingness actually to use EBP. In curricula, therefore,there should be a focus on how to raise EBP self-efficacy in SLT students. This goes even beyond the educationaldepartment because a professional culture in which professionals are competent and confident EBP users wouldhave a positive effect on EBP self-efficacy in students.

Keywords: behaviour, efficacy, evidence-based practice (EBP), education.

Address correspondence to: Bea Spek, Department of Speech–Language Therapy, Hanze University of Applied Sciences, 9714 EC Groningen,the Netherlands; e-mail: b.spek@pl.hanze.nl

International Journal of Language & Communication DisordersISSN 1368-2822 print/ISSN 1460-6984 online C© 2013 Royal College of Speech and Language Therapists

DOI: 10.1111/1460-6984.12020

Teaching EBP to speech–language therapy students 445

What this paper adds?This paper describes self-efficacy and task value towards evidence-based practice (EBP) in three year groups ofundergraduate speech–language therapy (SLT) students. While year groups differ significantly with regard to EBPknowledge and skills, this does not apply to EBP self-efficacy and task value. All students value EBP as importantfor their future profession; self-efficacy, however, is low in all year groups. This might be an important barrier tostudents’ willingness to use EBP in their decision-making process as a professional.

What is already known on the subject?Motivation is known to be an important force that drives behaviour change. According to social cognitive learningtheory, both self-efficacy and task value are aspects of motivation and highly related to goals that students set forthemselves. They are as such a source of action and predictors of learning achievement. Self-efficacy and task valueare domain specific and should be assessed and tailored to the EBP domain. Both are undervalued in curriculumdevelopment.

Introduction

Evidence-based practice (EBP)

In the early 1990s a first publication on the conceptof evidence-based medicine (EBM) appeared (Guyatt1991). The publication described EBM as a methodof managing the growing bulk of evidence in medicalresearch publications. Sackett et al. (1996: 71) then de-fined EBM as ‘the conscientious, explicit, and judicioususe of current best evidence in making decisions con-cerning the care of individual patients’. Sackett et al.explicitly emphasized the importance of clinical knowl-edge and expertise of the individual clinician when us-ing EBM, with the implication that clinicians shouldbe taught the EBM principles. As a result, nowadaysmany curricula for healthcare professionals include theteaching of EBM. This also applies to speech–languagetherapy, where EBM is taught under the name evidence-based practice (EBP) (Apel and Scudder 2005, Schlosserand Sigafoos 2009, International Association of Logo-pedics and Phoniatrics 2010, Leslie and Coyle 2010,Spek 2010, Guo et al. 2011, Erickson and Perry 2012).

The importance of EBP self-efficacy and task value

While increasing EBP knowledge and skills is an im-portant learning outcome, the ultimate goal of teach-ing EBP is to develop professional behaviour in whichEBP is integrated in the decision-making process ofthe (upcoming) SLT professional (Coomarasamy andKhan 2004, Finn et al. 2005, Ilic 2009a, 2009b, De-lany and Bialocerkowski 2011, McCurtin and Rod-dam 2012). Increasing EBP knowledge and skills onlyleads to behaviour change if it is accompanied by thebelief that such a change is both desirable and at-tainable (Niemivirta 1999). This is in line with Ban-dura’s (1986) social cognitive theory in which Bandurastates that behaviour is strongly associated with bothpersonal and environmental factors. Personal factors

include motivational beliefs, emotions and cognition.Besides socio-economic elements, factors exclusive of thelearning environment—such as peer group, teachers andcurricula—comprise the environmental factors. Thesefactors are strongly interrelated and all are importantvariables in understanding students’ learning achieve-ments and behaviour (Ainley 2006, Linnenbrink 2006,Pekrun 2006, Schulz et al. 2006, Kharrazi and Kareshi2010). We can visualize these relationships in a triad ofhuman functioning (figure 1). All relationships in thetriad are bidirectional and reciprocal (Bandura 1986,2001, Pintrich 1999, Pekrun 2006, Artino et al. 2010).

Without positive emotions, goals and beliefs, a lackof motivation will occur (Schulz et al. 2006). In theteaching of EBP this is problematic because accordingto Kusurkar (2012: 13), ‘motivation is a force that drivesa person to engage in certain behaviour.’ Although theimportance of motivation is recognized in learning andeducation, it is undervalued in curriculum development(Kusurkar 2012). Important aspects of students’ mo-tivational beliefs in learning are perceived self-efficacyor competence, and task value (Bandura 1986, 2001,Schunk 1991, Pelaccia 2009).

The concept of self-efficacy is central to Bandura’ssocial cognitive learning theory. Self-efficacy refers tothe student’s belief in his or her capacities to perform acertain task (Bandura 1986, 2001, Kharrazi and Kareshi2010). Students have to believe they are able to fulfil theactions that are asked of them in order to take the appro-priate action. Students will even avoid actions they feelincapable of performing (Bandura 2001). Partly basedon self-efficacy, students determine what actions theyshould take, how much effort they put into them andhow long they persist when they are difficult (Bandura2001). Self-efficacy, therefore, is strongly related tolearning achievement (Zimmerman 2000, Artino et al.2010). Self-efficacy beliefs are domain specific, whichmeans they have to be assessed in relation to a certaintask; in this study of EBP principles (Parajes 1996,

446 B. Spek et al.

Behaviour

Learning achievement

Performance achievement

Self-regula�on of behaviour

Personal factors

Mo�va�onal beliefs: •self-efficacy •task value •goal se�ng

Emo�ons

Cogni�on

Environmental factors

Socio-cultural factors

Curriculum: •formal •hidden •informal

Figure 1. Triad of human functioning (adapted from Bandura 1986, Pintrich 1999, Pekrun 2006 and Artino et al. 2010).

Zimmerman 2000, Bandura 2001). As Parajes (1996:550) puts it, ‘Self-efficacy judgments should be con-sistent with and tailored to the domain of functioningand/or the task under investigation.’ It is importantto realize that on average self-efficacy increases as afunction of progress in the task (Niemivirta 2006),which confirms that a curriculum can influenceself-efficacy in students.

Besides self-efficacy, outcome expectations and theperceived value of these outcomes, known as task value,are important aspects that influence behaviour (Schunk1991). Task value refers to the student’s personal percep-tion of the importance and utility of the task (Kharraziand Kareshi 2010). Task value is highly related to goalsstudents set for themselves and are as such, like self-efficacy, a source of action (Schunk 1991, Niemivirta1999). Social cognitive theory tells us that individuals’actions reflect their value preferences (Bandura 1986).The theory also stresses that students’ learning takesplace in a social environment. Students are engaged inacquiring the professional role of the SLT, which in-volves acquiring the set of norms and values belongingto the profession. This is known as the process of so-cialization (Merton et al. 1957), implying that students’task value towards EBP, like self-efficacy, evolves duringtheir study.

Aims

Since self-efficacy and positive task value towards EBPare a prerequisite for actual EBP behaviour, it is impor-tant for curriculum developers to know when and howtheir curricula affect these in students. The objectivesof this study were to assess whether SLT students’ self-efficacy and task value towards EBP differ in the various

stages of study and if these predict learning achievementon an EBP knowledge and skills scale.

Methods and procedures

Context

The study was conducted among SLT students ofHanze University of Applied Sciences in Groningen, theNetherlands, during the academic year 2009–2010. TheSLT study is a four-year undergraduate programme. Stu-dents have to acquire professional competences whichare formulated in a national competency frameworkfor the education of SLTs (Nederlandse OpleidingenLogopedie (SRO) 2005). The programme consists of aproblem-based curriculum in which students learn viacontextualized problem sets and situations, so-called ‘au-thentic cases’. Every week students start with a lectureintroducing the case and during the week students workin small groups exploring and discussing the case un-der the guidance of a tutor. At the end of the week allstudents discuss the outcomes in a final lecture with theleading lecturer. In these weekly cycles students are en-couraged to take responsibility for their own learning.During their first five semesters students work on thesecases. During the last three semesters students focus ontemporary clinical assignments and thesis writing. In2006 EBP was integrated into the curriculum.

Participants

Participants were first-, second- and third-year studentsof the SLT Programme. These year groups differ intheir level of previous education in EBP and represent

Teaching EBP to speech–language therapy students 447

the complete spectrum of EBP education: from novices(year 1) to experienced (year 3).

EBP curriculum

The EBP curriculum is based on the five steps of EBP,the so-called ‘five A’s’: formulating an answerable clini-cal question (Asking), finding the best available answerto this question (Acquiring), critically evaluating theevidence (Appraising), applying the evidence to theclient (Applying), and monitoring the performance inrelation to the evidence (Assessing) (Dawes et al. 2005,Spek 2010). In their first year students acquire back-ground knowledge and skills from the broad field of SLT.EBP training focuses on how to use the open internet,formulating learning questions and how to use a refer-ence style. In the second year of study students have toask so-called foreground questions on all authentic casesthey study (McKibbon et al. 2002). EBP training focuseson formulating answerable clinical questions in a PICOformat (Patient, Intervention, Comparison, Outcome),searching for evidence in medical databases and criticallyappraising the evidence. Students receive lectures andtraining sessions on these items and have to apply theirEBP knowledge and skills in small work groups. In thethird year of study students work in project groups anddevelop a clinical EBP guideline. During EBP trainingin this year there is a strong focus on critical appraisal,research methodology and rating the evidence. Studentsintegrate all five EBP steps in their clinical assignmentsin years 3 and 4.

Procedure

In order to assess EBP self-efficacy and task value, a20-item questionnaire was used, which was validatedfor this study (Spek et al. 2013). In the questionnairenine questions focus on perceived EBP self-efficacy and11 focus on the students’ task value regarding EBP(table 1). A seven-point Likert scale was used, rang-ing from totally agree (+3) to totally disagree (–3). Itis an important observation that most items on self-efficacy were stated in the negative, therefore students’answers were re-coded. For this we changed negativescores on self-efficacy items into positive ones, and viceversa, with the implication that a positive score on self-efficacy means that self-efficacy is also positive. Answerson the last two items on task value which are also statedin the negative were also recoded.

EBP knowledge and skills were assessed by using theDutch Modified Fresno (DMF), which is a valid andreliable tool for the assessment of EBP knowledge andskills in Allied Health Care professionals (Spek et al.2012). The DMF consists of 12 items: eight short an-swer questions based on two simple clinical SLT sce-narios, one yes/no answer on the meaning of confident

Table 1. Questionnaire on EBP self-efficacy and task value

Task valueIt is important to use principles of EBP in my daily clinical

routineIt is important for students to have knowledge about recent

scientific studiesI find EBP stimulatingI believe EBP enhances the quality of professional behaviourI intend to search more for scientific evidence in futureI believe it is important to encourage other students to search for

scientific studiesI feel more confident in my professional behaviour due to EBPI expect to make more use of professional guidelines in futureI believe lecturers might expect students to be aware of recent

scientific evidenceI believe EBP is too time-consumingI believe my profession is about people and not about statistics

Self-efficacyI feel uncertain about EBPI often do not know where to find evidence on the InternetI believe my abilities to find scientific evidence are not adequateI am uncertain about my abilities to appraise scientific evidenceI am uncertain about EBP because evidence is published in

EnglishI believe publications in scientific journals are confusingI find EBP difficult because I am not able to understand statisticsI feel I should practice the reading of scientific studies moreI find it difficult to find enough study time to search for evidence

intervals, and three multiple choice questions on the useof study designs. In the DMF students have to formulatePICO’s, design search strategies, justify how to appraiseevidence, and define and calculate diagnostic and thera-peutic outcome measures. The total score on the DMFranges from zero to 220 points. The rating system of theDMF differentiates between excellent, good, adequateand inadequate competence in EBP. The DMF has tobe completed within 40 min. First-year students filledin both the questionnaire and the DMF at the begin-ning of the second semester, having had no EBP trainingwhatsoever. Second-year students did so three monthsafter their EBP training, which consisted of lectures andtraining sessions on PICO and search strategies. Third-year students filled in the questionnaire and the DMFtwo months after their EBP lectures and training ses-sions on critical appraisal. Students responded on levelof prior education, standard of English and whethermathematics had been taken in prior education becausethese were regarded to be potentially important explana-tory variables (table 2). Data from the three year groupswere gathered in the same month and put together byan administrator to ensure the rater (B.S.) was blindedfor the year the students came from.

Ethical considerations

The university management team approved this study.All students were informed of the nature of the study;

448 B. Spek et al.

Table 2. Students’ characteristics

Year 1 Year 2 Year 3SLT (n = 61) SLT (n = 39) SLT (n = 49) Significance

Agea 20.2 (1.9) 20.1 (1.7) 21.6 (1.3) p > 0.05 for years 1—2p < 0.05 for years 1–3 and 2–3*

Female/maleb 58/3 39/0 49/0 p > 0.05**No mathematics in prior education (%) 45.9 35.9 62.5 p < 0.05***Standard of English adequate (%) 78.7 82.1 75 p > 0.05***Level of prior education: entrance/no

entrance to traditional universityb26/35 11/28 21/27 p > 0.05***

Notes: aMean (SD).bFrequency.*One-way ANOVA with Games–Howell; **Chi-square; and ***Kruskal–Wallis.

the fact that participation was voluntary and non-participation had no further consequences. Studentswere invited to come to a lecture room, where partici-pating students submitted a written consent form. Thelecturer (B.S.) remained in the room to answer questionsconcerning the study and to invigilate while the studentsfilled in both the DMF and the questionnaire. Studentdata were stored anonymously, securely, and separatelyfrom consent forms and all other identification.

EBP self-efficacy, task value, EBP knowledge andskills in different year groups

The means of every questionnaire item and the twocomponents self-efficacy and task value, as well as meansor the total score on the DMF, were calculated and testedfor group differences using a one-way analysis of variance(ANOVA) with a post-hoc Games–Howell procedurefor difference in variance and multiple testing. For allstatistical analyses, SPSS16 was used.

The prediction model

A multiple linear regression technique was used to assesswhether EBP self-efficacy and task value predict learningachievement scores on the DMF of the SLT students.Other possible predictors included in the model were:level of prior education, standard of English, whethermathematics had been a part of prior education and theSLT study year. This last variable was considered repre-sentative of the EBP elements in the SLT curriculumfollowed. The other variables were included becausethey might explain possible variance in EBP learningoutcomes. Level of prior education could be importantdue to the fact that in the Netherlands the entry to atraditional university requires a higher level of prior ed-ucation compared with entry to universities of appliedsciences. Lecturers from the SLT department assumedthat students with a higher level of prior education mightpossibly have less difficulty with fundamental EBP prin-ciples. English could be a predictor, because many stu-dents complain about the difficulty of reading research

literature due to language problems. In the literature,language is also described as a barrier when applied toEBP (Letelier et al. 2007, Ubbink et al. 2011). Thestandard of English was defined as adequate if studentspassed the final examination in prior education (e.g. highschool) with sufficient grades in English. In the opinionof the lecturers, mathematics in prior education mightfacilitate the interpretation and calculation of diagnos-tic and therapeutic measures, resulting in a higher totalscore on the DMF. Moreover, students who had nottaken mathematics in prior education might experience‘numerophobia’, which could be an important barrierwhen using EBP (Ben-Shlomo et al. 2004). The totalscore on the DMF was the dependent variable, beingan indicator of learning achievement in EBP knowledgeand skills. The building of the model started with theforced entry of all variables and manually worked back-wards deleting the non-significant variables one by one,considering p < 0.10 a statistically significant difference.For all other analysis apart from the linear regression,p < 0.05 was considered a statistically significant differ-ence. Furthermore, assumptions of linearity, normalityof residuals and multicollinearity were checked.

Results

Response

From a total of 182 invited SLT students 149 (82%)went to the lecture room and completed both the DMFand the questionnaire (table 2). Students from year 3were significantly older than the other year groups. Inthe year 3 group significantly more students also lackedmathematics in prior education.

EBP self-efficacy and task value in different SLTyear groups

Total mean scores on the components self-efficacy andtask value were not statistically different for the threeSLT groups (table 3), indicating no change in taskvalue or self-efficacy beliefs. ANOVA on the meansof the three year SLT groups for task value revealed:

Teaching EBP to speech–language therapy students 449

Table 3. Mean (SD) scores on questionnaire and DMF

Components Year 1 (n = 61) Year 2 (n = 39) Year 3 (n = 49) Significance*

Task value 0.68 (0.68) 0.72 (0.71) 0.62 (0.73) p = 0.776Self-efficacy −0.68 (0.67) −0.75 (0.92) −0.66 (1.06) p = 0.879

DMF 26.3 (12.6) 69.3 (16.3) 89.1 (26.6) p < 0.05

Note: *One-way ANOVA with Games–Howell procedure.

Table 4. Prediction of EBP learning achievement in SLT groups

UnstandardizedVariables coefficients Significance Tolerance VIF

Year 3 63.190 0.000 0.809 1.237Year 2 43.205 0.000 0.808 1.238Reference year 1 30.339 0.000Self-efficacy –5.096 0.007 0.998 1.002

Predictors R2 Adjusted R2 Cook’s distance

Year group 0.665 0.661Year group and self-efficacy 0.683 0.676 0.008 (0.014)

F(2,138) = 0.254, p = 0.776, and for self-efficacy:F(2,136) = 0.129, p = 0.879.

EBP knowledge and skills in different SLT yeargroups

The total score of the SLT students on the DMF in thisstudy ranged from zero to 153, the mean (SD) score was58.3 (34.1). The total score of the DMF differentiatesbetween inadequate, adequate, good and excellent EBPknowledge and skills. The maximum score on the DMFwas 220 points. Mean total scores on the DMF werestatistically different for all three SLT groups (table 3).ANOVA on the means of the three groups for the DMFrevealed: F(2,136) = 0.154, p < 0.001.

Prediction of EBP learning achievement

All assumptions for multiple regression were met. Vari-ance inflation factor (VIF) and Tolerance were close to1.00, indicating no collinearity within the data. Theinitial prediction model with all independent variablesexplained 69.3% of the variance in scoring on theDMF by the SLT students. The final model, with bothyear group and self-efficacy as significant predictors, ex-plained 68.3% (table 4). All other variables did not meetcriteria for significance.

Discussion

The primary aim of this study was to establish if EBPself-efficacy and task value differ in the different yeargroups of SLT students. The task value regarding EBPof SLT students was positive, with scores between 0.62and 0.72, thus slightly above the neutral zero value.This opinion does not significantly differ between the

three year groups. Self-efficacy towards EBP, on the otherhand, is slightly lower in the three SLT year groups. Stu-dents score between –0.66 and –0.75, indicating thatthey tend to feel uncertain. All groups show a simi-lar level of uncertainty about their competence in EBP.Therefore, despite a significant increase in EBP knowl-edge and skills over the years as assessed by the DMF(from a mean score of 26 to one of 89), the integratedEBP curriculum did not raise levels of self-efficacy andtask value. Because feeling competent in learning situ-ations stimulates intrinsic motivation (Kusurkar et al.2011), lack of feeling competent might have an im-pact on students’ willingness to use EBP (Delany andBialocerkowski 2011). Moreover, in a problem-basedcurriculum, students have to construct their own learn-ing questions. Where an active learning attitude is re-quired, low self-efficacy could be a significant barrier. Itis therefore important to include self-efficacy in mod-els of college student learning (Pintrich 2004, Kusurkar2012). McCurtin and Roddam (2012) suggest more at-tention should be paid to the role of EBP educationand critical thinking in SLT education. There shouldalso be more effort put into raising the standard of EBPself-efficacy in SLT students.

Self-efficacy as a social construct

According to Bandura (2001) and Parajes (1996) self-efficacy is both a personal and a social construct. Parajes(1996: 567) describes that a group of students, lecturersand even a department can develop a sense of collec-tive self-efficacy. Translated to EBP a sense of collectiveEBP self-efficacy could empower students to act in anevidence-based manner. A department that clearly wel-comes rather than fears EBP, such as Erickson and Perry

450 B. Spek et al.

(2012: 350) describe, would definitely be helpful. Ina systematic review van Dijk et al. (2010: 1168) con-cluded that ‘a positive learning environment, with staffmembers as EBM role models, might therefore be oneof the most important factors influencing the behaviourof residents’. From the above it follows that EBP curric-ula developers should also pay attention to raising EBPself-efficacy in the learning environment, e.g. lecturersand professionals in the field.

The prediction model

In various studies self-efficacy is mentioned as an im-portant predictor of students’ motivation, learning andbehavioral change (Bandura and Adams 1977, Pintrich1999, 2004, Zimmerman 2000). While self-efficacy isa significant predictor of EBP learning achievements, inthis study the effect was very small. Self-efficacy addedas little as 2% of the variance explained with the predic-tion model. Task value was not a significant predictor ofEBP learning achievements in this study. This is coher-ent with Pintrich’s (2004) statement that self-efficacy isa much better predictor of performance than task value.Most of the variance explained in the prediction model(66%) was due to the SLT year group, which reflectedthe curriculum followed. Other predictors lecturers ex-pected to be important explanatory variables, such aslevel of prior education, mathematics and English, didnot significantly explain the difference in EBP knowl-edge and skills over the subsequent study years. Thiscould be due to the relatively small size of the studypopulation. Furthermore, we defined the standard ofEnglish and mathematics using results from prior edu-cation, though we cannot be sure that these levels havenot changed since then.

Individual items

Although there were no differences in the componentsof the questionnaire between the year groups, therewere a few differences in the individual items whichmight be significant. As their study progresses, morestudents agree with the item ‘I believe EBP is too time-consuming’. This is in line with barriers mentioned inthe literature (Upton and Upton 2006, O’Connor andPettigrew 2009, Delany and Bialocerkowski 2011). Thismight be a very important barrier in teaching the EBPprinciples to SLT students, since as their study progressesother components of the curriculum increasingly putdemands on students’ time. Third-year students experi-enced EBP significantly ‘more stimulating’ than second-and first-year students. A possible explanation could bethat third-year students, when approaching graduation,might appreciate EBP as a guide for continuing educa-tion in practising their future profession. All three yeargroups believed their ‘literature searching skills were

inadequate’, although second- and third-year studentsscored these items at an adequate or a good level on theDMF. This might be the result of their experience infinding little evidence of clinical questions due to thelack of any evidence in this relatively young SLT profes-sion (Pring 2004, Dodd 2007, O’Connor and Pettigrew2009). Another complicating factor is that evidence inthe field is not always indexed in PubMed and Medline,so students have to search in other less well-indexeddatabases which complicate the search process (Nail-Chiwetalu and Bernstein Ratner 2007). All of the abovemake it difficult for students to validate clinically theirstudy subject with evidence, which undoubtedly couldhave an effect on EBP self-efficacy.

Limitations

Some limitations in interpreting the results of this studycould be assumed. Firstly, in this study, the group towhich students belong has been considered representa-tive of the curriculum followed since the groups differin their level of EBP education. It is unknown howeverif other factors, such as socio-cultural factors andpeer-group factors, were comparable in these groups.These unknown factors might have had an effect onlearning achievement as well as on motivation (Artinoet al. 2010).

Secondly, this study assumed that the increase inEBP knowledge and skills due to the EBP curriculumwould have a positive effect on self-efficacy and taskvalue beliefs towards EBP. Relationships between cur-riculum, self-efficacy and task value beliefs, togetherwith learning achievement, however, are complex. Lowself-efficacy can be regarded as a cause of action: moreself-efficacy leads to a higher learning achievement. Self-efficacy can also be interpreted as outcome: better learn-ing achievement, meaning more knowledge and skills,leads to more self-efficacy (Niemivirta 1999). Moreover,in this study third-year students scored adequately on theDMF, but some items on the DMF were problematicfor many students. There was a poor uptake of EBPregarding items on calculating therapeutic measures.This might have had an important impact on EBP self-efficacy. While in this study there was no correlation be-tween total scores on the DMF and EBP self-efficacy, thiscould vary in other populations and needs more research.

Thirdly, students from the final year were not in-cluded in this study. During clinical assignments stu-dents’ motivational beliefs towards EBP might changedue to the effect of role models. The role of colleaguesin the field as a model during assignments has provedto be important in the development of professional be-haviour (Shuval and Adler 1980, Maudsley 2001, Zipoliand Kennedy 2005, Haidet and Stein 2006, Cruess et al.2008, Goldie 2012, Jochemsen-van der Leeuw et al.

Teaching EBP to speech–language therapy students 451

2013). Consequently, the influence from this importantpart of the SLT study, the ‘informal curriculum’ (Cruesset al. 2008), remains unclear.

Fourthly, in this study a quantitative approach isused to study relationships between motivation andlearning achievement. Quality of motivation such asintrinsic or extrinsic motivation however is also impor-tant. There is evidence that a combined approach mightproduce a better understanding of this complex relation-ship (Kusurkar 2012).

Finally, in this study the total score on the EBPknowledge and skills scale (DMF) represents EBP learn-ing achievement. While the authors consider this is animportant learning outcome, it does not guarantee how-ever that students with high scores on the DMF willactually conform to EBP standards. According to thisconcept, the total score is a surrogate outcome for actualEBP behaviour.

Conclusions

Due to the fact that three year groups of Dutch SLT stu-dents differ in the level of EBP knowledge and skills andshow an increasingly practical experience in EBP duringthe study years, self-efficacy and task value beliefs to-wards EBP were expected to differ. Both, however, wereidentical in the three year groups. Overall, the results inthis study show that while SLT students value EBP prin-ciples positively, their EBP self-efficacy is negative. Thiswill pose a barrier when using EBP principles in their fu-ture profession. It is therefore necessary that developersof EBP curricula give explicit attention on how to in-crease EBP self-efficacy in students. Developers shouldalso pay attention to influences from the hidden andinformal curriculum on EBP self-efficacy.

Although motivation, of which self-efficacy is one as-pect, plays an important role in the desired behaviouralchange leading to more EBPs, other aspects both per-sonal and environmental are also important. For exam-ple, in the literature many barriers concerning the useof EBP in clinical practice are mentioned that still haveto be clarified (Zipoli and Kennedy 2005, Dodd 2007,O’Connor and Pettigrew 2009). More research is nec-essary in order to unravel these complex relations.

Acknowledgements

The authors would like to thank all participating students.Declaration of interest: The authors report no conflicts of interest.The authors alone are responsible for the content and writing of thepaper.

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