Summary of main findings and comparison with existing literature
There is not sufficient information to draw any conclusions about the effectiveness or acceptability of the modules in nurses or nurse practitioners; any conclusions drawn will only apply to GPs. Also, as it was impossible to collect data from clinicians visiting the site who did not complete a module, there is no information from those who chose not to start or not to finish a module. Findings are therefore limited to those who chose and worked through a module.
Evidence suggests that to give the modules and guidelines presented here the very best chance of resulting in change in practice, they should be studied by teams together, who would accept the recommendations, discuss barriers, plan implementation, and monitor adherence; this is not feasible in British primary care because each module would require a session of protected time. However, if key individuals study and then are able to share their learning with their teams, discuss, and introduce plans for change, effective change will occur.
In planning educational interventions, thought should be given to clinicians who find attending conventional educational sessions problematic. This study has been able to show that, for some clinicians, modification of traditional PBL structure to allow individuals to interact with a computer rather than colleagues is acceptable, and can result in reported change in practice. The results suggest a high level of acceptability among practitioners choosing this type of resource. Practitioners liked the fact that they could study where and when they wished, they liked the patient-orientated approach, found the topics interesting, and appreciated the ease of use of the modules.
Participants had been asked to stop, consider, and write down learning needs, and complete a written management plan. The majority of participants did not actually write, thus gains appear to be independent of actually writing in some of this group of clinicians.
Most participants reported intention to change practice; learners who studied urinary tract infections and coeliac disease frequently reported that they had changed their practice; others had not actually changed because they were not working in a situation where they currently managed the problem themselves. Some learners studying chronic kidney disease said they had not changed practice because they had studied and developed a management plan for this condition before studying the module; however, they did gain confidence from their study. Financial incentives can help reduce resistance to implementation in relation to hypertension treatment within the Quality and Outcomes Framework in the UK;16,17 this study suggests that the same applies to chronic kidney disease.
Change in practice was confirmed by all participants interviewed on urinary tract infection and coeliac disease modules reporting examples of change; these were particularly numerous and varied for the urinary tract infection module, possibly reflecting the frequency with which practitioners deal with urinary infections.
Participants did not identify barriers to implementing change on a personal level, but two felt that colleagues studying the modules would help their practice team to implement change. Carlsen and colleagues recently published a meta-synthesis of studies of GPs' attitudes to guidelines, and identified a number of barriers to implementation.18 These include questioning of the guideline; the fact that patients are often more complicated than they appear in guidelines, and have their own views which can be impediments; fear of affecting the doctor–patient relationship; fear of ‘missing a diagnosis’ in guidelines that seek to limit investigations; time, skills, and resource limitations; and complex guidelines format. Most of these issues were not reflected in the current study; this may in part be a function of the PBL format prompting participants to consider these issues.
Practical issues was the only category represented as a barrier in this study, and these practical issues related to personnel. Some participants had shared learning with their teams; this is pleasing but may say more about the individuals, and the nature of their teams, than about the modules. However, it can be concluded that for participants who were prepared to share learning with their teams, the modules provided a useful stimulus to team learning.
It was not possible to demonstrate an increase in knowledge except possibly in the coeliac disease module; this is surprising in the light of acceptability, change data, and annoyance of interviewees on not improving. It may be that EMQ tests are less reliable in this group of learners than in students19 (in whom most evaluations of EMQs have been undertaken), and difference may be a function of familiarity and of the difference between busy professionals seeking to improve themselves, and students seeking to pass important examinations.
Limitations of the study
Agreement to be interviewed was obtained by only 10 doctors or 22% of participants. All participants were invited to participate in interviews, but only volunteers could be interviewed, so interviewees were self-selecting; this is likely to result in a positive bias for the modules and means that it is only possible to draw conclusions that some participants achieved the reported advantages. Therefore further work is needed to verify any conclusions. Sufficient data were not obtained to allow any conclusions to be drawn about use of modules by nurses in primary care, and further work should address these groups. Additionally, there is no information about clinicians who chose not to use this method of learning; conclusions can only be drawn for participants choosing this method of study.
This study lacks hard evidence of change. Widespread geographical locations of participants made this information impossible to collect. Reported change is never as reliable as hard evidence; however, interviews provided the opportunity to request that participants describe changes which provided additional collaboration and the opportunity to explore attitudes and any barriers to change.
EMQ tests were used because of reported benefits; however, these benefits had not been substantiated in this type of learner, multiple choice questions would provide a more-familiar and easier-to-use format for further studies.
