using best evidence to inform healthcare decisions is widely recognized as a key 
 competency for all healthcare professionals .
academic institutions are implementing evidence - based healthcare 
 ( ebhc ) as part of learning in the curriculum of healthcare professionals .
these 
 curricula usually cover critical enquiry and formulating clear questions when faced with 
 a scenario of uncertainty , finding best research evidence applicable to the problem , 
 critically appraising the evidence for validity , clinical relevance and applicability , 
 interpreting and applying the findings in the clinical setting and evaluating the 
 performance .
clinically integrated teaching and learning , with a focus on learning linked to 
 real - world problems in the clinical setting and learning by doing , as modelled by 
 sackett are considered to be the 
 more effective approaches for improving ebhc knowledge , skills and attitudes .
successful teaching and learning depends 
 on factors related to the learner , the educator / lecturer , and on having a supportive 
 environment with teaching and learning opportunities .
educators play a critical role in 
 the delivery and facilitation of ebhc teaching and learning , in encouraging critical 
 enquiry , in fostering reflective practices and in being role models for the practice of 
 ebhc in the clinical setting . within the clinical setting ,
clinician lecturers / educators who have received ebhc 
 training are more likely to teach the application of ebhc .
a study in new zealand among clinical teachers found that 
 those who received training in ebhc are more likely to teach its application in the 
 clinical setting and are more comfortable to engage students on topics and issues 
 related to ebhc , and this was more 
 often seen among general practitioners than specialists . among nurse educators ,
melnyk 
 et al . found 
 significant relationships between educators knowledge of ebhc and their beliefs 
 about the value of ebhc , the ability to practice ebhc and the relationship between 
 teaching ebhc and advancing the profession and their comfort in teaching ebhc .
the 
 create framework , which provides an 
 international consensus statement on ebhc assessment tools , defines self - efficacy as the 
 individual 's judgments regarding their ability to perform a certain activity and 
 notes that educators confidence in their ability may increase their likelihood 
 to engage in practicing the various ebhc steps .
internationally , training initiatives 
 thus focus on training trainers in ebhc to enhance their capacity to integrate ebhc 
 teaching and learning in the clinical setting . also on the increase are initiatives to build confidence in 
 teaching and learning principles and theories .
in south africa , the colleges of medicine of south africa includes critical appraisal 
 skills in curricula for medical specialist training while the medical and dental 
 professions board of the health professions council of south africa states in its 
 regulations for registration of students , undergraduate curricula and professional 
 examinations in medicine and dentistry that : the emphasis in teaching should be on fundamental principles and methods that 
 promote understanding and problem - solving skills and not only on the purely 
 factual knowledge which , in any event , becomes outdated  .
they should be 
 taught at all times to be critical of old and new knowledge and to evaluate data , 
 statistics , thinking and methods objectively .
the emphasis in teaching should be on fundamental principles and methods that 
 promote understanding and problem - solving skills and not only on the purely 
 factual knowledge which , in any event , becomes outdated  .
they should be 
 taught at all times to be critical of old and new knowledge and to evaluate data , 
 statistics , thinking and methods objectively .
the health professions council of south africa used the canmeds framework to define the desired graduate 
 attributes of a newly qualified healthcare professional .
this now serves as a guide to 
 the essential abilities of a newly qualified health professional to optimize patient 
 outcomes and defines the attributes of the graduate according to seven interdependent 
 roles : medical expert , scholar ( which includes ebhc ) , professional , communicator , 
 collaborator , manager and health advocate . at stellenbosch university
an ongoing project aims to develop and implement 
 undergraduate ebhc teaching and learning to medical undergraduates in an integrated 
 manner . to inform curriculum development ,
an assessment of the medical curriculum was 
 conducted , including a document review of the 2011 curriculum , a survey of recent 
 graduates and interviews with 
 faculty .
this found that ebhc is covered to varying degrees with teaching in specific 
 modules , which it was not explicitly integrated in a stepwise fashion and did not 
 progress from foundational knowledge to the acquisition of skills and practical 
 competencies throughout the curriculum .
recent graduates felt that they lacked ebhc 
 skills and proposed that ebhc teaching and learning be integrated into clinical 
 rotations , making use of relevant examples in different disciplines .
as educators play a key role in facilitating the teaching and learning of ebhc , 
 especially within the clinical setting , the study reported here assessed 
 educators confidence in practicing , and their attitude , to ebhc , as well as 
 their confidence in teaching ebhc and the barriers they had experienced , or perceived , 
 to practicing and teaching ebhc .
the study population included all 
 faculty members involved in teaching on the undergraduate medical curriculum across the 
 10 departments at the stellenbosch university faculty of medicine and health sciences . 

all those employed by the university , and those on joint appointments , whose role 
 included teaching of undergraduate medical students were invited to participate by 
 e - mail , and provided with a link to the online questionnaire .
the structured questionnaire sought information regarding demographics and training 
 received , experience in teaching and learning , and previous exposure to ebhc ( training 
 received , research conducted , etc . ) .
we used validated tools for assessing confidence in 
 practicing , and attitude to , ebhc . 

confidence in practicing ebhc was assessed using the evidence - based practice 
 confidence scale and questions 
 were included to assess attitude . 

visual analogue scales measured attitudes to , and confidence in , teaching ebhc and open - ended questions explored barriers 
 to practicing and teaching ebhc .
the 
 afrikaans version was back translated by a person independent of the research team , and 
 the original english and the back - translated version compared to ensure that the meaning 
 of the questions was not lost .
stata 12 ( statacorp lp , college station , texas , usa ) was used for quantitative data 
 analysis .
categorical data 
 were summarized using proportions . for questions on knowledge we assessed consistency 
 and found high cronbach 's alphas ( 95% ) and therefore combined all 16 items into 
 one knowledge score .
the highest score was allocated to the best level of knowledge , 
 giving a knowledge score with a maximum 80 . for questions on attitude to practicing ebhc 
 we reversed the scores of the negatively phrased items , for example 
i rarely 
 formulate questions about patients and then added all the items together to get 
 an overall score between 10 and 50 ( cronbach 's alpha 57% ) . for confidence in 
 practicing ebhc
we grouped the 
 scores into five categories aligned with the five steps in practicing ebhc namely ask 
 clear questions , search for research evidence , appraise and interpret the evidence , 
 apply the evidence and audit practices .
scores for self - perceived confidence in teaching 
 ebhc were also combined into an overall score ( maximum 55 ) .
bivariate analysis of 
 associations between factors such as demographics , education and exposure to ebhc , and 
 outcomes such as attitude and confidence to practice and teach ebhc were assessed using 
 correlation analysis , analysis of variance testing , pearson 's 
  analysis and t tests as appropriate .
responses 
 to open - ended questions on barriers , and proposed strategies to overcome these , to 
 practicing and teaching ebhc were coded and analysis and interpretation were done by the 
 investigators , using thematic content analysis to identify key emerging themes .
we 
 linked these to the conceptual framework for integrated teaching and learning of ebhc , 
 developed following semistructured interviews with 24 ebhc programme coordinators from 
 around the world , which revolves around the engagement between the learner and the 
 educator within the institutional context .
the study proposal was approved by the stellenbosch 
 university health research ethics committee ( s12/10/262(c ) ) . to enhance response rate , 
 we had a lottery for respondents , with a sponsored conference registration , for a 
 conference of their choice , to the value of r5000 as the prize .
participants who wanted 
 to enter the lottery had to provide their cell phone numbers , which were only be used to 
 notify the winner .
forty two ( 19% ) of 227 faculty members involved in teaching undergraduate medical 
 students responded .
they worked across various departments , were mainly senior lecturers 
 and offered teaching to all years of medical students ( table 1 ) .
about 75% had attended training on research methodology ( mainly 
 epidemiology , research proposal writing , biostatistics , systematic reviews and 
 qualitative research methods ) , and to a lesser extent training on knowledge translation 
 and change management .
most participants had conducted primary research , with only a few 
 conducting systematic reviews .
more than half ( 57% ) indicated that they had done some 
 training in ebhc in the past 5 years by attending short courses , workshops / seminars , 
 online courses , journal clubs or by reading articles on ebhc .
these activities mainly 
 addressed enabling competencies such as epidemiology , biostatistics , research 
 methodology and the basic principles of ebhc .
most ( 85% ) had attended teaching and 
 learning training events that had content such as teaching and learning strategies , 
 assessment , curriculum planning , teaching ebhc , supervision and promoting active 
 learning .
participants described ebhc as : supporting clinical decision - making by combining best available evidence with own 
 experience , patient preference and local factors and  healthcare 
 practices ( of any nature 
e.g. prevention , diagnosis , treatment , prognosis 
 etc . ) that are informed by evidence as far as possible ; and recognising where 
 there is inadequate / insufficient evidence to inform these practices .
it implies 
 ongoing changes to healthcare practice when new evidence becomes available . supporting clinical decision - making by combining best available evidence with own 
 experience , patient preference and local factors and  healthcare 
 practices ( of any nature  e.g. prevention , diagnosis , treatment , prognosis 
 etc . )
that are informed by evidence as far as possible ; and recognising where 
 there is inadequate / insufficient evidence to inform these practices .
profile of survey responders ebhc , evidence - based healthcare ; iqr , interquartile range .
some emphasised use of research evidence and did not include reference to combining this 
 with clinical experience and patient preferences .
participants self - reported 
 understanding of ebhc - related terms is described in table 2 . using the overall knowledge score for the 16 items , maximum score 
 80 , the median
the knowledge scores 
 were not significantly associated with training , highest qualification , years since 
 qualifying , position , academic department or age .
self - reported understanding of evidence - based healthcare - related terms often used 
 in research articles figure 1 graphically depicts responses to the 
 questions on attitude to practicing ebhc .
the items were framed both positively , for 
 example  ebhc is useful on a daily basis and negatively , for example 
  i rarely formulate questions about patients. most felt that ebhc is a 
 realistic option in their practice and that lifelong learning is important . however , 
 more than 50% felt that literature searches are too time - consuming to undertake in 
 the clinic and that questions can be answered faster by referring to a textbook or a 
 consultant .
the overall mean score was 38 ( sd 5 ) ( maximum score 50 ) .
data were 
 normally distributed , so we compared the independent variables to attitude score 
 using t tests and analysis of variance .
training in ebhc and 
 research methods , qualification , time since qualification , faculty position , age , 
 conducting systematic reviews and years of teaching were not significantly associated 
 with attitude .
lecturers confidence in practicing ebhc is summarized in table 3 , highlighting levels of confidence that are 
 high overall but with lower levels for interpreting statistics .
they raised various 
 barriers , relating to the individual or the context , to practicing ebhc . by far
the 
 most common were lack of time , clinical workload , limited access to internet and 
 resources , knowledge and skills.no simple solution to increase time - clinicians responsibilities in 
 the hospital , including patient and student load will only be addressed if more 
 posts are made available .
no simple solution to increase time - clinicians responsibilities in 
 the hospital , including patient and student load will only be addressed if more 
 posts are made available .
educators self - perceived confidence in practicing evidence - based 
 healthcare ( n  =  42 ) they made suggestions on how this could be addressed , calling for more staff and 
 dedicated time for research and for faculty development .
they proposed capacity 
 development opportunities to especially enhance their capacity to interpret and 
 understand biostatistics , searching skills , how to read papers and on time 
 management .
support group to assist each other . 
 to create an enabling environment , they suggested widely available and reliable 
 internet access and wifi , access to relevant literature and having evidence informed 
 clinical guidelines available at the point of care . furthermore , they suggested using 
 auditing and feedback to enhance practices .
this was done 
 through lectures , small group tutorials , teaching at the bedside , online learning and 
 including ebhc concepts in assessments .
the content covered in these sessions focused 
 on the enabling competencies ( epidemiology , biostatistics ) , basic ebhc principles and 
 searching skills . the overall mean score for self - perceived confidence in teaching 
 ebhc was 40 ( sd 11 ) of a maximum of 55 
 ( n  =  42 ) .
most ( 38 ) of the 42 respondents indicated that they were confident to help medical 
 students find relevant articles in medline ( or other bibliographic databases ) , and to 
 guide critical review of articles ( 60% or higher on the visual analogue scale ) .
fewer 
 ( 30 ) indicated that they were confident to assist students phrase a clear question 
 following a clinical encounter with a patient , and to guide students in considering 
 the application of the results of their critique of articles to the patient 's 
 care .
twenty seven selected 60% or higher on the visual analogue scale for confidence 
 in evaluating students ebhc knowledge .
2 . confidence in teaching evidence - based healthcare ( ebhc ) per 
 department . using total score 
 ( maximum  =  55 ) .
educators raised a number of perceived barriers to teaching ebhc , which relate to the 
 students , the context and the educators .
they felt that the curriculum is full , that 
 students are subjected to information overload , that there is no scaffolding of ebhc 
 learning over the course of the degree and that ebhc is not integrated in practice . 

lack of internet access , especially at point - of - care , was commonly listed . with 
 respect to students the size of student groups , immaturity and lack of interest of 
 students
were seen as barriers to ebhc learning while competing priorities and lack 
 of time (  am involved with too many other activities ) , as well as 
 limited ebhc knowledge and skills (  i need to upgrade and maintain my 
 knowledge of ebhc ) and the tendency to stick to habits influence how 
 educators facilitate ebhc learning .
suggestions for addressing these challenges included improving departmental internet 
 access , exploring wifi access for the whole faculty , and easy point - of - care access to 
 databases and resources .
respondents stressed the importance of increasing awareness 
 of the value and utility of ebhc (  demonstrate to them the value of 
 ebhc ) and thus the need for ebhc teaching .
they also emphasized building 
 capacity to both practice and facilitate learning of ebhc , and expressed the need for 
 more time to devote to teaching students (  get somebody to take over my 
 postgraduate activities .
furthermore , they called for 
 promotion of critical thinking among students , incorporating the teaching and 
 learning of ebhc from the start of the curriculum , and making  ebhc applicable 
 and relevant to students. respondents felt that there needs to be dedicated 
 time to apply ebhc principles especially within the clinical setting , and that it 
 should be integrated in assessments . to support each other ,
educators requested help 
 from others who are particularly proficient , for example  a working group 
 supporting educators , and highlighted the need for evaluation and ongoing 
 refinement of teaching approaches and material .
the items were framed both positively , for 
 example  ebhc is useful on a daily basis and negatively , for example 
  i rarely formulate questions about patients. most felt that ebhc is a 
 realistic option in their practice and that lifelong learning is important . however , 
 more than 50% felt that literature searches are too time - consuming to undertake in 
 the clinic and that questions can be answered faster by referring to a textbook or a 
 consultant .
the overall mean score was 38 ( sd 5 ) ( maximum score 50 ) .
data were 
 normally distributed , so we compared the independent variables to attitude score 
 using t tests and analysis of variance .
training in ebhc and 
 research methods , qualification , time since qualification , faculty position , age , 
 conducting systematic reviews and years of teaching were not significantly associated 
 with attitude .
lecturers confidence in practicing ebhc is summarized in table 3 , highlighting levels of confidence that are 
 high overall but with lower levels for interpreting statistics .
they raised various 
 barriers , relating to the individual or the context , to practicing ebhc . by far
the 
 most common were lack of time , clinical workload , limited access to internet and 
 resources , knowledge and skills.no simple solution to increase time - clinicians responsibilities in 
 the hospital , including patient and student load will only be addressed if more 
 posts are made available .
no simple solution to increase time - clinicians responsibilities in 
 the hospital , including patient and student load will only be addressed if more 
 posts are made available .
educators self - perceived confidence in practicing evidence - based 
 healthcare ( n  =  42 ) they made suggestions on how this could be addressed , calling for more staff and 
 dedicated time for research and for faculty development .
they proposed capacity 
 development opportunities to especially enhance their capacity to interpret and 
 understand biostatistics , searching skills , how to read papers and on time 
 management .
support group to assist each other . 
 to create an enabling environment , they suggested widely available and reliable 
 internet access and wifi , access to relevant literature and having evidence informed 
 clinical guidelines available at the point of care .
this was done 
 through lectures , small group tutorials , teaching at the bedside , online learning and 
 including ebhc concepts in assessments .
the content covered in these sessions focused 
 on the enabling competencies ( epidemiology , biostatistics ) , basic ebhc principles and 
 searching skills .
the overall mean score for self - perceived confidence in teaching 
 ebhc was 40 ( sd 11 ) of a maximum of 55 
 ( n  =  42 ) .
most ( 38 ) of the 42 respondents indicated that they were confident to help medical 
 students find relevant articles in medline ( or other bibliographic databases ) , and to 
 guide critical review of articles ( 60% or higher on the visual analogue scale ) .
fewer 
 ( 30 ) indicated that they were confident to assist students phrase a clear question 
 following a clinical encounter with a patient , and to guide students in considering 
 the application of the results of their critique of articles to the patient 's 
 care .
twenty seven selected 60% or higher on the visual analogue scale for confidence 
 in evaluating students ebhc knowledge .
2 . confidence in teaching evidence - based healthcare ( ebhc ) per 
 department .
educators raised a number of perceived barriers to teaching ebhc , which relate to the 
 students , the context and the educators .
they felt that the curriculum is full , that 
 students are subjected to information overload , that there is no scaffolding of ebhc 
 learning over the course of the degree and that ebhc is not integrated in practice . 

lack of internet access , especially at point - of - care , was commonly listed . with 
 respect to students the size of student groups , immaturity and lack of interest of 
 students
were seen as barriers to ebhc learning while competing priorities and lack 
 of time (  am involved with too many other activities ) , as well as 
 limited ebhc knowledge and skills (  i need to upgrade and maintain my 
 knowledge of ebhc ) and the tendency to stick to habits influence how 
 educators facilitate ebhc learning .
suggestions for addressing these challenges included improving departmental internet 
 access , exploring wifi access for the whole faculty , and easy point - of - care access to 
 databases and resources .
respondents stressed the importance of increasing awareness 
 of the value and utility of ebhc (  demonstrate to them the value of 
 ebhc ) and thus the need for ebhc teaching .
they also emphasized building 
 capacity to both practice and facilitate learning of ebhc , and expressed the need for 
 more time to devote to teaching students (  get somebody to take over my 
 postgraduate activities .
furthermore , they called for 
 promotion of critical thinking among students , incorporating the teaching and 
 learning of ebhc from the start of the curriculum , and making  ebhc applicable 
 and relevant to students. respondents felt that there needs to be dedicated 
 time to apply ebhc principles especially within the clinical setting , and that it 
 should be integrated in assessments . to support each other ,
educators requested help 
 from others who are particularly proficient , for example  a working group 
 supporting educators , and highlighted the need for evaluation and ongoing 
 refinement of teaching approaches and material .
this is one of only a few studies conducted in south africa to assess one or more of the 
 following : undergraduate educators confidence in practicing and teaching ebhc , 
 attitudes to ebhc and to practicing and teaching ebhc .
this study links to ongoing work 
 at stellenbosch university supporting the implementation of graduate attributes , 
 specifically linked to developing and implementing clinically integrated ebhc teaching 
 and learning for medical undergraduates , a process within which educators play a 
 critical role . despite respondents having a high self - reported level of 
 knowledge and understanding of ebhc concepts attitudes towards ebhc varied ( fig .
those who were teaching ebhc focused the curricula content on 
 enabling competencies of ebhc , basic ebhc principles and searching skills , rather than 
 on reading , interpreting and considering the application of different types of articles . 

as educators are faced with various competing priorities the need was expressed for 
 dedicated faculty development and a community of practice to provide support in the 
 implementation of ebhc teaching and learning .
similar studies among south african psychiatrists and general practitioners with a 
 special interest in mental health , 
 general practitioner and specialist educators in new zealand and nurse educators in the united states found that those who had attended ebhc 
 courses were more likely to teach ebhc .
barriers to teaching ebhc , resonating with our 
 survey , were centred around lack of time , lack of support , lack of evidence in some 
 clinical areas and the need for more training in teaching ebhc .
findings of this survey 
 also resonate with a curriculum assessment , which found that there is no scaffolding of ebhc learning over 
 the course of the degree and that ebhc is not integrated in practice .
a supportive enabling institutional , and health sector , environment is important for 
 advancing ebhc learning .
educators need to be confident and competent to facilitate the 
 learning and , to this end , require opportunities to enhance their capacity in ebhc and 
 in how to facilitate learning .
furthermore , through working together , 
 building on each other 's strengths , sharing best practices and lessons learnt , in 
 a supportive community of practice can build the critical mass of educators needed to 
 facilitate learning across the various disciplines .
our survey had limited the power to 
 assess associations between confidence to practice and teach ebhc and variables such as 
 attitude and training .
the low response rate might also mean that those who took part 
 are not representative of the target population .
the nonresponders may have different 
 levels of confidence to practice and teach ebhc , their attitude may vary and they could 
 be experiencing different challenges . to assess this we conducted brief follow - up survey 
 of nonresponders , to which 14 educators responded .
they described ebhc in a similar way 
 to responders and listed lack of time , length of the survey , limited involvement with 
 undergraduate teaching and that ebhc is irrelevant to their practice as reasons for not 
 participating .
educators play a critical role in facilitating learning not just in the classroom , but 
 also in practice .
this survey , despite low response rate , shows that even for those with 
 high levels of self - reported knowledge and understanding of ebhc ; adequate support , 
 training and development and an enabling environment are important for educators to be 
 the role models future healthcare professionals need .
 abstractaim : medical student educators play critical roles in evidence - based healthcare ( ebhc ) 
 teaching and learning and as role models practicing ebhc . 
 this study assessed 
 their confidence to practice and teach ebhc , their attitude to ebhc and barriers 
 to practicing and teaching ebhc.methods:we conducted a cross - sectional online survey of educators of undergraduate medical 
 students at a south african academic institution . 
 stata 12 was used for 
 quantitative data analysis . 
 responses to open - ended questions were coded , and 
 further interpretation done using thematic content analysis.results:forty two ( 19% ) educators from various departments responded to the invitation 
 sent to everyone formally involved in teaching undergraduate medical students . 
 
 they had high levels of knowledge and understanding of ebhc . 
 many had received 
 training in teaching and learning approaches , although ebhc training received was 
 mainly on enabling competencies . 
 limitations to practicing ebhc included lack of 
 time , clinical workload , limited access to internet and resources , knowledge and 
 skills . 
 one quarter of the respondents indicated that they teach ebhc . 
 perceived 
 barriers to teaching ebhc reported related to students ( e.g. lack of interest ) , 
 context ( e.g. access to databases ) and educators ( e.g. competing priorities ) . 
 
 respondents suggestions for support included reliable internet access , 
 easy point - of - care access to databases and resources , increasing awareness of 
 ebhc , building capacity to practice and facilitate learning of ebhc and a 
 supportive community of practice.conclusion:educators play a critical role in facilitating ebhc learning not just in the 
 classroom , but also in practice . without adequate support , training and 
 development , 
 they are ill equipped to be the role models future healthcare 
 professionals need . 
Background
Methods
Results
Attitude to evidence-based healthcare
Practicing evidence-based healthcare
Teaching evidence-based healthcare
Discussion
Conclusion