Evidence-Based Practice Patterns Among Speech-Language Pathologists and Audiologists in Saudi Arabia

Abstract

The goal of this study was to explore the evidence-based practice (EBP) pattern among speech-language pathologists (SLPs) and audiologists in Saudi Arabia. A total of 48 clinicians working in Saudi Arabia completed a questionnaire that investigated patterns, attitudes, skills, and time and resources at the workplace related to EBP. The results showed that SLPs and audiologists held favorable attitudes toward EBP, and the use of research studies to guide clinical decision making was increased among the participants with previous EBP training. Also, the study found that skills and knowledge related to EBP need to be enhanced, but they were not major barriers to EBP implementation. Limited resources appeared to impose some hindrances, whereas insufficient time at the workplace was found to be a major challenge for EBP implementation. Overall, the findings from this study highlight the importance of increasing the continuing education and professional time for EBP activities in the workplace.

Keywords

evidence-based practices speech-language pathologists audiology

Introduction

Over the past three decades, the research into speech-language pathology and audiology has integrated scientific evidence with clinical experience, and client values and preferences to provide high-quality services. Sackett, Rosenberg, Gray, Haynes, and Richardson (1996) have defined evidence-based medicine as “. . . the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients” (p. 71). The incorporation of evidence-based practice (EBP) into clinical services has become the standard in different health care professions. For example, the American Speech-Language-Hearing Association (ASHA, 2005) has emphasized the integration of EBP into the process of clinical decision making within the practice of speech-language pathology and audiology. Much of focus on EBP in the field of communication sciences and disorders is on EBP guidelines and policy, continuing education and reviews, with less attention paid to other aspects, such as EBP patterns among professionals in school settings (Hoffman, Ireland, Hall-Mills, & Flynn, 2013). Furthermore, the implementation of EBP continues to be problematic, as many clinicians do not routinely integrate EBP research into their clinical decision-making processes (Irwin, Pannbacker, & Lass, 2013). The present study has explored some aspects of EBP implementation among speech-language pathologists (SLPs) and audiologists in Saudi Arabia, and thus will add to the literature about EBP implementation in the practice of speech-language pathology and audiology in Saudi Arabia, a country with developing speech-language pathology and audiology.

The EBP concept is founded on basic but essential principles. The provision of high-quality clinical services and the process of clinical decision making should be based on the integration of the best scientific research evidence with clinical expertise, and client values and preferences (Sackett et al., 1996). In agreement with this decision-making philosophy, ASHA (2005) has stated that SLPs and audiologists are required to “. . . incorporate the principles of evidence-based practice in clinical decision-making to provide high quality clinical care” (p. 1). Clinicians need to evaluate the strength and quality of the evidence behind a particular clinical decision (e.g., assessment, treatment, prevention, and prognosis; Dollaghan, 2004; Nail-Chiwetalu & Ratner, 2006). For example, ASHA has adopted a system to rate the level of evidence for treatment efficacy studies that includes five levels that range from the strongest level of a well-designed meta-analysis to the weakest level of the opinions of authorities based on clinical experience.

Several investigations have examined EBP patterns among SLPs and audiologist (e.g., Hoffman et al., 2013; Meline & Paradiso, 2003; Metcalfe et al., 2001; O’Connor & Pettigrew, 2009; Vallino-Napoli & Reilly, 2004; Zipoli & Kennedy, 2005). For example, Vallino-Napoli and Reilly’s (2004) survey of the EBP patterns among Australian clinicians found that they had a desire to keep up with current clinical information, although this study also reported that the clinicians had insufficient work time to conduct the necessary literature searches. Also, O’Connor and Pettigrew (2009) studied the barriers to EBP implementation in a survey of 39 SLPs working in southern Ireland. They found that the surveyed SLPs favorably perceived EBP. These researchers also identified many barriers that impeded EBP implementation, such as the limited time to conduct and read research, not enough time to implement new assessments and intervention ideas, difficulty in understanding research findings, difficulty in integrating research into practice, and limited access to the literature. In addition, Hoffman et al. (2013) conducted an online survey of 2,762 SLPs in the United States that described the SLPs’ EBP patterns. They reported that the majority of SLPs had formal training from a graduate course or as part of their continuing education activities. Also, they reported that not enough time was available to SLPs to conduct their research-related clinical caseloads. According to Skeat and Roddam (2010), all clinicians face some barriers to implementing EBPs into their practice, such as EBP perception (i.e., attitudes toward implementing EBP), skills and knowledge about research methodology and how to critically review the literature, time to access and search the literature, and access to research resources.

The aim of the current study was to explore some aspects of EBP implementation among SLPs and audiologists in Saudi Arabia, including prior training, patterns, perception, and barriers. Such an investigation was an attempt to add to the growing literature on the integration of EBP into practice and to highlight some important factors related to EBP implementation in a country with developing speech-language pathology and audiology professions. The study used a cross-sectional survey design with a questionnaire form to collect data to address EBP implementation: (a) educational training on EBP implementation, (b) current EBP implementation patterns, and (c) barriers to EBP implementation, including attitudes toward EBP, skills related to EBP implementation, and EBP implementation related to the workplace setting (time and resources). The study obtained ethics approval from the Research Ethics Committee (College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia).

Method

Participants

The inclusive criteria included clinicians who were practicing as a licensed SLP in Saudi Arabia and who were working, or had worked, in Saudi Arabia during the past 5 years. The sample consists of 26 SLPs and 22 audiologists working in Saudi Arabia who were members of the Saudi Society of Speech-Language Pathology and Audiology. With respect to demographic characteristics, 72.9% of the participants were female (45.8% SLP and 27.1% audiologists), and 27.1% of the participants were male (8.3% SLP and 18.8% audiologists). About 46% of the participants were younger than 30 years old, about 35% were 31 to 40 years old, and about 19% were older than 40 years old. With respect to years of experience, 43.7% of the participants had less than 1 to 5 years, and 56.3% had 6 years or more. More than half the participants held a bachelor’s degree (56.2%) and 43.8% held a master’s or a doctorate degree. About 58.3% received a degree abroad. Most participants worked in public hospitals, and very few worked in school settings (4.2%). Initially, 65 clinical professionals responded to the survey, but only a total of 48 completed it. Seventeen respondents were removed from the analysis because they were student interns or did not complete the survey.

Procedure

The survey data were collected using SurveyMonkey Inc. (San Mateo, CA, USA). An email invention to participate—with a link to the survey—was sent to the members of the Saudi Society of Speech-Language Pathology and Audiology. Follow-up notifications were sent twice after the initial email within about a 2-week interval.

Instrument

The questionnaire was based on a review of previous surveys on EBP (Jette et al., 2003; Meline & Paradiso, 2003; Zipoli & Kennedy, 2005). It consisted of four sections with a total of 44 items. Section 1 (10 items) obtained demographic information. Section 2 (seven items) collected information about previous educational training related to EBP implementation using dichotomous responses of yes and no. Section 3 (nine items) collected data about the frequency of usage of information sources related to clinical decision making using a 5-point scale: never (1), rarely (2), sometimes (3), often (4), always (5). Information sources included personal clinical experience, opinions of fellow clinicians, expert opinions, continuing education events at work, continuing education events outside work, clinical practice guidelines, textbooks, Internet resources, and research studies. Section 4 (15 items) collected information related to the barriers to EBP implementation, which included attitudes toward EBP, skills related to EBP implementation, and EBP implementation related to a workplace setting using a 5-point scale: strongly disagree (1), disagree (2), neutral (3), agree (4), strongly agree (5). Section 5 (two items) included two questions that collected information about the time allocated to read and research literature at work and outside work. The five options were none, 0.5-1 hr, 2-4 hr, 5-8 hr, and more than 8 hr.

Although the questionnaire items were designed, in part, on a review of several survey-based works (Jette et al., 2003; Meline & Paradiso, 2003; Vallino-Napoli & Reilly, 2004; Zipoli & Kennedy, 2005), some items were structured according to information from a specific survey. For example, the items of Section 2 (information about previous educational training related to EBP implementation) of the current study were designed with modifications based on Items 10 and 11 of Section I and Item 2 of Section II of the Zipoli and Kennedy (2005) survey. Items 20 to 29 of Section 3 of the current study were adopted from Items 1 to 11 of Section III of the Zipoli and Kennedy (2005) survey. The items of Section 4 (about the time allocated to read and research literature at work and outside work) of the current study were structured based on information from the Jette et al. (2003) survey and the Meline and Paradiso (2003) study.

Research Fidelity

Three experts checked content validity—two held a doctorate degree in audiology and one held a doctorate degree in speech-language pathology. These reviewers were asked to rate each item on a scale of 1 to 5 on which 1 meant highly inappropriate and 5 meant highly appropriate, and they were also asked to provide comments. The survey was modified according to reviewers’ input and feedback.

Data analysis

IBM SPSS Statistics for Windows (Version 24.0., IBM Corp.) was used to run the statistical analyses. First, respondents’ demographic information was provided according to their profession as an SLP or audiologist (Survey Section 1). Second, data about previous training related to EBP were presented in percentages for the whole sample (Survey Section 2). Also, a chi-square test of independence or a Fisher’s exact test was used to examine the association between the respondents’ profession (SLP vs. audiologist), gender, years of experiences (less than 1-5 years vs. 6 years and more), and education background (undergraduate qualification vs. graduate qualification) with respect to their responses (yes vs. no) related to seven questions about previous training related to EBP. Third, data about the information sources used to guide clinical decision making also were presented in percentages for the whole sample (Survey Section 3). The 5-point categories (never, rarely, sometime, often, and always) were clustered into three categories (never/rarely, sometimes, and often/always). Also, Mann–Whitney tests were conducted to examine the effects of previous specific educational training on EBP measured by the respondents’ ratings about the frequency of their uses of EBP information sources for their current clinical decision-making processes (scores ranged from 1 to 5, in which 5 represented frequent uses). Fourth, data about barriers to EBP implementation—including attitudes, skills, time, and resources (workplace settings)—were presented in percentages for the whole sample (Survey Section 4). The 5-point categories (strongly disagree, disagree, neutral, agree, and strongly agree) were clustered into three categories (disagree, neutral, and agree). Also, five independent variables were identified: profession (SLP vs. audiologist), gender, years of experiences (less than 1-5 years vs. 6 years and more), education background (undergraduate degree vs. graduate degree), and specific training on EBP during previous education. Several Mann–Whitney tests were conducted to examine the effects of the independent variables on the respondents’ ratings for barriers to EBP implementation (scores ranged from 1 to 5, in which5 represented high agreement). Only the significant results were reported.

Results

The results are presented in the following order: previous training related to EBP, frequency of usage of EBP information sources related to clinical decision making, and barriers to EBP implementation.

Previous Training Related to EBP

With respect to research training, the majority of the participants of the current study reported that they had completed a research methodology course (93.8%) and were exposed to research articles (87.5%) during their previous education. About 77% of the participants reported an involvement in research activities (e.g., data collection) during their previous education. With respect to EBP experience, only 66.7% of the participants reported that they had specific training related to EBP as a course component or a full course, 75 % said that they were encouraged to use EBP for clinical decision making during their previous education, and 79.2 % reported that they graduated with an understanding and knowledge of EBP. Also, only 62.5% of the participants indicated that they attended training on EBP.

Participants’ responses about previous training related to EBP were compared with those with a graduate degree and those with only an undergraduate degree. Figure 1 shows these group differences. The analyses revealed that a significantly higher proportion of the participants with a graduate degree answered yes compared with the participants with only undergraduate training on the following factors: exposed to research articles during education (p = .029, Fisher’s exact test), involved in research activities during previous education (p = .013, Fisher’s exact test), received specific training on EBP during previous education, χ²(1) = 9.52, p = .002, attended training on EBP, χ²(1) = 5.424, p = .02, and encouraged to use EBP during previous education, χ²(1) = 4.769, p = .029. Also, significant gender differences were found—all the male participants (n = 13) reported that they had completed their study with knowledge about EBP compared with 70 % of the female participants (p = .044, Fisher’s exact test). However, such a finding could be due to having a larger female group compared with a smaller male group. No other significant findings were found.

Figure 1.

Responses of participants with graduate training versus undergraduate training about previous training related to EBP (only the yes responses are shown).

Information Sources Related to Clinical Decision Making

Figure 2 shows the percentages of the participants’ responses related to the frequency of usage of EBP information sources to guide clinical decision making. The highest five sources of information were personal clinical experience, clinical practice guidelines, Internet resources, textbooks, and research studies. Opinions from fellow clinicians were the lowest sources of information. A Mann–Whitney test was performed to assess whether specific training on EBP during previous education increased the frequency of use of EBP information sources for clinical decision making. The findings showed that participants with specific training on EBP during previous education (Mdn = 4) rated using research studies as a source of information more frequently compared with those who indicated no such training (Mdn = 3), U = 151, z = −2.398, p = .016, r = −.35. The other ratings for the two groups were not significantly different (i.e., personal clinical experience, opinions of fellow clinicians, expert opinions, continuing education events at work, continuing education events outside work, clinical practice guidelines, textbooks, and Internet resource).

Figure 2.

Responses of participants about previous training related to the frequency of usage of EBP information sources.

Barriers to EBP Implementation

Table 1 shows participants’ ratings on attitudes toward EBP, skills related to EBP implementation, and EBP implementation related to the workplace setting. With respect to attitudes toward EBP, it was clear that the participants held a positive attitude toward EBP. As shown in Table 1, for example, the item setting aside time for EBP implementation and literature reading is important and the item increased application of EBP should be encouraged received the highest agreement by more than 90% of the participants. About 40% of the participants reported that EBP implantation will increase my workload, whereas 31% of the participants disagreed with that statement. With respect to the skills related to EBP implementation, the majority of participants indicated that they were comfortable with reading research papers; however, only half of them felt confident about their ability to evaluate the quality of the evidence in published studies. Also, it appeared that the application of research findings in practice is challenging, as the participants’ ratings were similar for the three rating categories (disagree, neutral, and agree). With respect to the EBP implementation related to the workplace setting, participants’ ratings showed a less favorable perception of the support related to EBP at work. The majority of participants reported that they did not have enough time to read the research literature at work.

Table 1.

Participants’ Ratings in Percentages With Respect to Attitudes Toward EBP, Skills Related to EBP Implementation, and EBP Implementation Related to Workplace Setting.

Barriers		Disagree	Neutral	Agree
Attitudes toward EBP	Research findings are relevant to my everyday practice.	6.3	33.3	60.4
	Increased application of EBP should be encouraged.	2.1	8.3	89.6
	Setting aside time for EBP implementation and literature reading is important.	2.1	6.3	91.7
	EBP implantation will increase my workload	31.3	27.1	41.7
	Evidence for most of the interventions I use is limited.	41.7	33.3	25.0
	I prefer to use a familiar traditional intervention over a new approach that requires learning it.	56.3	27.1	16.7
Skills related to EBP implementation	I prefer to use textbooks over journal articles to access evidence.	45.8	33.3	20.8
	I am comfortable with reading research papers.	8.3	25.0	66.7
	I am confident about my ability to evaluate the quality of evidence in published studies.	8.3	41.7	50.0
	I find it challenging to apply research findings to my practice.	33.3	29.2	37.5
EBP implementation related to workplace setting	I have enough time to read research literature at work.	60.4	25.0	14.6
	I have enough time to learn and implement research findings in my practice.	41.7	29.2	29.2
	I have the appropriate tools and materials to search online databases for articles at work (e.g., Internet and computer).	20.8	27.1	52.1
	I have access to research literature (e.g., library, a subscription to journal databases).	31.3	29.2	39.6
	I am satisfied with the level of support for formal training related to professional development (continuing education) at work.	33.3	33.3	33.3

Note. EBP = evidence-based practice.

A further examination of the ratings using Mann–Whitney tests showed some significant findings. Gender differences ratings were not found, except for one item related to having enough time to read the research literature at work. Female participants (Mdn = 2) reported having less time compared with male participants (Mdn = 2), U = 136.5, z = −2.205, p = .027, r = −.32. Again, this effect could be due to having a larger female group compared with a smaller male group. With respect to education background, the participants with an undergraduate degree (Mdn = 3) reported high agreement compared with the participants with a graduate degree (Mdn = 2) for the item Evidence for most of the interventions I use is limited—U = 189.5, z = −2.058, p = .040, r = −.30—and for the item I prefer to use a familiar traditional intervention over a new approach that requires learning it—U = 174, z = −2.369, p = .018, r = −.34. Last, the participants with specific training on EBP during previous education (Mdn = 4) reported having more confidence about their ability to evaluate the quality of the evidence in published studies compared with the participants who did not have this kind of training (Mdn = 3), U = 151, z = −2.484, p = .013, r = −.36.

Discussion

The goal of the current study was to investigate EBP implementation among SLPs and audiologists in Saudi Arabia, including previous training related to EBP, frequency of usage of EBP information sources, and barriers to EBP implementation (attitudes, skills, resources, and time). The study results show that more than 90% of the participants completed a research methodology course. This high percentage may reflect adequate research training during the participants’ preprofessional education. Such research training reconciles with the importance of research training for health professionals. For example, the Council on Academic Accreditation in Audiology and Speech-Language Pathology (2017) of ASHA requires education programs to provide students with an understanding and knowledge of research methodology. Also, the results show that only two thirds of the participants reported that they had received specific training related to EBP in their previous educational programs; however, about 80% of the participants indicated that they had completed their studies with an understanding and knowledge of EBP. Further analyses of the responses showed that a significantly higher proportion of the participants with a graduate degree had research exposure and EBP training compared with those who held an undergraduate degree. Specifically, about 90% of the participants with graduate qualifications reported receiving specific training on EBP in their preprofessional education compared with 48% of the participants with an undergraduate qualification. Moreover, the current study shows that receiving specific training on EBP during previous education increases the frequency of usage of research studies for clinical decision making. Thus, it is clear that EBP exposure was insufficient and needs to be enhanced in undergraduate training programs. The importance of teaching EBP was emphasized by the ASHA’s Council on Academic Accreditation in Audiology and Speech-Language Pathology (2017) and by many researchers (Cobus-Kuo & Waller, 2016; Grillo, Koenig, Gunter, & Kim, 2015; Klee, Stringer, & Howard, 2009; Schlosser & Sigafoos, 2009; Spek, Wieringa-de Waard, Lucas, & van Dijk, 2013; Togher et al., 2011).

With respect to the barriers to implementing EBP, it appeared that the participants held a positive attitude toward EBP. More than 90% of the participants agreed that it is important to set aside adequate time for EBP implementation and for reading clinical literature, and that the application of EBP in practice should be encouraged. Also, two thirds of the participants agreed that research findings are relevant to their everyday practice. The finding of a favorable attitude toward research and EBP was consistent with the findings from other studies of speech-language pathology and other allied health professionals (Jette et al., 2003; Metcalfe et al., 2001; Zipoli & Kennedy, 2005). However, about 42% of the participants indicated that EBP implementation would increase their workload, and 27% of the participants were neutral about it (the average rating score was 3.10 out of 5). Such a negative perception of EBP may stem from the fact that many clinicians do not have enough time at work to read and review scientific evidence and implement it into their clients’ care. Hoffman et al. (2013) reported that 91% of their respondents did not have any time allocated for EBP activities, and those who had work time set aside for EBP activities reported a limited time of less than half an hour per week. Thus, it appears that although a large majority of the participants of current study held a positive attitude toward EBP and research, they also perceived that EBP implementation would increase their workload, which may hinder the application of EBP for clinical decision making. Also, it highlights the importance of providing time for EBP activities at work.

With respect to the skills related to EBP implementation, two thirds of the participants of the current study were comfortable with reading research papers, and half of the participants reported being confident about their ability to evaluate the quality of research evidence. Also, the participants with specific training on EBP during previous education were more confident about their abilities compared with the participants who did not have this kind of training. These findings were consistent with similar investigations (Jette et al., 2003; Metcalfe et al., 2001; Zipoli & Kennedy, 2005). In the Jette et al. (2003) study, 55% to 65% of the respondents reported being confident about their skills to conduct research and evaluate the literature. Zipoli and Kennedy (2005) found that only a few respondents (13%) disagreed with the statement about having the knowledge and skills related to literature searching and critically evaluating study designs. However, the current study found that two thirds of its participants agreed (37.5%) or were neutral (33.3%) that it was challenging to apply research findings to practice. Such a challenge may be due, in part, to feeling incompetent with respect to evaluating the level of evidence in the literature.

Furthermore, the challenge of applying research to practice and EBP implementation may stem from factors related to the workplace setting. Participants’ ratings showed a less favorable perception of the support at work related to EBP implementation. Only a third of the participants were satisfied with the support for formal training related to continuing education at work. About 40% to 52% of the participants indicated that they had the appropriate access to tools and materials at work to conduct research related to their practice. Limited resources may interfere with the efficiency to access and retrieve information and the relevant literature that affect EBP implementation (Jette et al., 2003). Also, it is clear that a lack of time is a major barrier to implementing EBP. More than 60.5% of the participants reported not having enough time to read research literature at work. Similar findings were noted by Zipoli and Kennedy (2005)—50% of their surveyed SLPs indicated they did not have enough professional time for EBP—and by the Vallino-Napoli and Reilly (2004) study, in which 69% of their participants indicated such a lack of time. Also, 71.9% of the physical therapists in the O’Connor and Pettigrew (2009) study and 66.3% of the surveyed allied health professionals in the Metcalfe et al. (2001) study reported they did not have sufficient time to read the clinical research.

In summary, the current study shows that SLPs and audiologists in Saudi Arabia have favorable attitudes toward EBP. Receiving specific training on EBP during previous education increased the usage of research studies to guide clinical decision making. Having graduate training appears to prepare clinicians for better EBP implementation. However, the findings of the current study show that relevant skills and knowledge were not major barriers for EBP implementation, and yet, preprofessional training in education programs and ongoing training related to EBP should be enhanced. In addition, limited resources were reported as a barrier, and insufficient time at the workplace is a major challenge for EBP implementation to practice. The findings from the current study suggest that an increase in continuing education and professional development time for EBP activities may contribute positively toward EBP implementation. For a successful application of EBP, clinicians need to have the knowledge, skills, resources, and time necessary to locate and read the scientific literature and to appraise the level of evidence to apply to their clients’ care. Considering the time constrains at the workplace, further investigations are needed to find ways to better integrate EBP into the different settings of speech and hearing services.

Footnotes

Acknowledgements

The author extends his thanks to the Saudi Society of Speech-Language Pathology and Audiology and to the participants who completed the survey. Also, the author appreciates the support from the Research Center at the College of Applied Medical Sciences and the Deanship of Scientific Research at King Saud University.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Abdulsalam Alhaidary

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