- Email: [email protected]
Issues in Conducting Research in Chiropractic College Clinics
ISSUES IN CONDUCTING RESEARCH COLLEGE CLINICS
IN
CHIROPRACTIC
Cheryl Hawk, DC, PhD, a Jerrilyn Cambron, DC, PhD, b and Denise Pahmeyer c
ABSTRACT Objective: This study surveyed and interviewed faculty and staff at chiropractic colleges to investigate issues related to conducting clinical research in teaching clinics. Methods: This was a descriptive study using qualitative research methods. It was conducted from May to August 2007 by means of an electronically administered survey using purposive sampling of faculty and administrators at North American chiropractic colleges. Results: A total of 58 surveys were e-mailed to research directors, faculty, and staff at 16 colleges; 2 surveys were returned as undeliverable. Of the 56 successfully delivered surveys, 34 (61%) completed surveys were returned, representing 13 colleges. Not having a separate research clinic was seen by some respondents as positive and by others as negative. Of the 34 respondents, 32 felt there were advantages associated with conducting research within the college's teaching clinics rather than exclusively in a separate research clinic; 33 respondents described challenges to implementing the integration of research into their institution's clinics. The primary themes that emerged as challenges to conducting research in the institutions' teaching clinics were related to administration and policy, resources/facilities, faculty issues, and student issues. Respondents described strategies they had developed to address these challenges, primarily focusing on the challenges related to faculty and students rather than administration and resources. Conclusion: In most chiropractic institutions, the challenges of integrating research into teaching clinics are primarily being addressed by individuals using focused, situation-specific strategies rather than at the level of institutional policy. (J Manipulative Physiol Ther 2008;31:301-307) Key Indexing Terms: Chiropractic; Cross-Sectional Studies; Interviews; Teaching Hospital; Research
lthough research related to chiropractic has been increasing in both quality and quantity, there are still many challenges to be addressed as we move forward in the era of evidence-based practice. The 2006 white paper, “Chiropractic clinical research: progress and recommendations,” reported on progress on this topic since the original 1997 white paper.1-3 Specific recommendations included the development of a “research culture” in
A
a Vice President of Research and Scholarship, Cleveland Chiropractic Research Center, Cleveland Chiropractic College, Kansas City, MO. b Associate Professor, Department of Research, National University of Health Sciences, Lombard Ill. c Student Research Assistant, Cleveland Chiropractic Research Center, Cleveland Chiropractic College, Kansas City, MO. Submit requests for reprints to: Cheryl Hawk, DC, PhD, Vice President of Research and Scholarship, Cleveland Chiropractic College, 6401 Rockhill Rd, Kansas City, MO 64131 (e-mail: [email protected]). Paper submitted October 10, 2007; in revised form November 27, 2007; accepted December 10, 2007. 0161-4754/$34.00 Copyright © 2008 by National University of Health Sciences. doi:10.1016/j.jmpt.2008.03.008
chiropractic education; the maintenance of a critical mass of research faculty within chiropractic educational institutions; and the provision of adequate resources for research personnel and facilities. It was acknowledged that “research in teaching clinics remains challenging because of limited space, competition for patients, and limited capacity.”1 These institutions were urged to make clinical facilities more accessible for conducting experimental studies and to provide incentives to faculty for participating in research projects. The 2006 paper stated that the greatest success in the area of making clinical facilities accessible for experimental studies had occurred through creating dedicated research clinics rather than integrating research into the teaching clinics.1 However, creating and maintaining a separate research facility is a resource-intensive endeavor that may not compete successfully with all the other pressing financial needs in a tuition-dependent institution—particularly if research is not considered an essential part of chiropractic education. Furthermore, the growing need to integrate the concepts of evidence-based practice into chiropractic education suggests that the continued isolation of research activities from chiropractic academic and clinical education may not be in the profession's best interests.4 As Bolton5 301
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stated in a 2005 commentary, “for chiropractic practice to become evidence-based, as espoused by the champions of evidence-based practice, clinicians need to be able to act both as ‘research users’ and as ‘research providers.’ Thus, it is becoming increasingly necessary for chiropractic clinical faculty to become conversant with current research. A 2003 study at a chiropractic college in the United Kingdom indicated that although students thought research was an important part of their training, they felt that faculty were lacking in their involvement in research and also in their use of it in teaching.6 Integration of research as a part of everyday teaching clinic operations is one way to begin to build evidence-based practice into the identity of the chiropractic profession. To gain perspective on the possibility of developing a model in which research is a viable, integral part of chiropractic education, we developed a survey to gather information from chiropractic college faculty and administrators who were involved in research and/or clinical training. The purpose of this project was to survey and interview faculty and staff at chiropractic colleges to investigate issues related to conducting clinical research in teaching clinics.
METHODS This was a descriptive study using qualitative research methods. It was conducted from May to August 2007 by means of an electronically administered survey.
Sample We used purposive sampling, in particular the maximum variation and snowball strategies.7,8 To ensure maximum variation of responses in terms of different institutions, we intended to include respondents from all 18 North American chiropractic colleges belonging to the Association of Chiropractic Colleges (ACC). Using the “snowball” strategy, we asked all college research directors to complete this survey and to then recommend others at their institution who they felt we should include in the sample, prompting them to include the clinic director or clinic faculty if they felt it was appropriate.
Human Subjects and Informed Consent The project was approved by the Institutional Review Boards of the Cleveland Chiropractic College and National University of Health Sciences. The survey was accompanied by an informed consent that respondents signed and returned with their completed survey, which described the measures used to protect confidentiality. Only the investigators were aware of respondents' identity and institutional affiliation and did not link identifiers to any of the data reported. Information containing personal identifiers
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was stored in a secure database only accessible to the investigators.
Survey Instrument and Administration The investigators compiled questions related to the issue of conducting clinical research in chiropractic college teaching clinics and pilot tested them on faculty and staff at 4 different colleges, for a total of 6 completed pilot surveys. The questions were revised according to the pilot test comments. All questions included open-ended response options to ensure that we gathered the most complete information possible. After reviewing responses to the pilot survey, the following questions were included in the survey: • Does your institution have a research clinic facility separate from the teaching clinic(s)? (Yes/No) • If “yes,” do you also conduct research within your college's teaching clinic(s)? (Yes/No) • If “no,” why not? (open-ended) • How do you involve students in research projects? (open-ended) • Are students able to get credit of any type for research involvement? (Yes/No) • If “yes,” please describe: (open-ended) • What do you consider the advantages of conducting research within your college's teaching clinic(s) (in terms of education, practice, research, service, etc.)? (open-ended) • What are the challenges/problems involved in conducting research in your college's teaching clinics? (open-ended) • How have you addressed or attempted to address each one? (open-ended) The survey was administered electronically by e-mail to all respondents, with explicit instructions for opening, completing, and returning the document. It was designed as a protected Word document that allowed responses of unlimited length. The survey was administered in 5 waves. The first wave was sent to research directors, with each subsequent wave sent to potential respondents identified by previous respondents. The first wave, sent to research directors identified through the ACC research directors' group, was followed up twice at 2-week intervals for a total of 3 contacts. Waves 2 to 4 were followed up once at 2-week intervals for a total of 2 contacts. Wave 5 (3 potential respondents) was contacted once.
Data Management Surveys were returned by e-mail to the principal investigator. Each survey was assigned a number, and all identifying information was removed before it was saved into a file and printed for use by the data entry staff to enter
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Hawk et al Issues in Conducting Research
Table 1. Colleges represented in survey by number of respondents (n = 13 colleges) Life University Cleveland Chiropractic College (Kansas City) National University of Health Sciences Southern California University of Health Sciences Canadian Memorial Chiropractic College Northwestern Health Sciences University Parker College of Chiropractic Palmer College of Chiropractic (Davenport) University of Bridgeport Cleveland Chiropractic College (Los Angeles) Logan University New York Chiropractic College Palmer College of Chiropractic (West) Total
n
%
7 6 5 3 2 2 2 2 1 1 1 1 1 34
21 18 15 9 6 6 6 6 3 3 3 3 3 100
the closed-ended and short-answer responses. Contact information was maintained in a separate secure database for use in follow-up mailings. Closed-ended and short-answer responses (b20 characters) were entered into an SPSS (v. 14.0) database, and descriptive statistics (frequencies and proportions) were computed. Open-ended survey responses were pasted verbatim into a single Word document, organized by question and identified by respondent ID and college so that results could be viewed by both individual respondent and by institution.
Analysis After the survey responses were organized by question, 2 of the investigators performed a content analysis, organizing them by theme under each survey question. The principal investigator synthesized these separate analyses, and all 3 investigators reviewed this document and made comments, noting themes that they felt required clarification or reclassification. Finally, the principal investigator incorporated input from the other 2 investigators and organized the data into the identified themes, resulting in the final summary.
RESULTS Sample Population Of the 18 colleges listed as members of ACC, 16 were represented on the ACC's mailing list; research directors for Life West and Palmer Florida were not on the list. A total of 58 surveys were e-mailed to research directors, faculty, and staff at 16 colleges; 2 surveys were returned as undeliverable. Of the 56 successfully delivered surveys, 34 (61%) completed surveys were returned, representing 13 colleges. Table 1 shows the distribution of respondents by college. There was representation of both faculty and professional staff from departments of both research and clinics, as well as 2 faculty who were in positions that served as liaisons
Table 2. Respondents’ positions by department Respondent Research Personnel (n = 24) Research director (including 3 deans, 1 vice president) Liaison between research/academic areas (Director of Faculty Development in Office of Sponsored Research and Scholarly Activity; Coordinator, Research Education) Research faculty Professional staff (2 research coordinators, 1 clinical coordinator) Clinic Personnel (n = 10) Clinic director (including 2 deans and 1 chief of staff) Clinic faculty
Number 10 2
9 3
3 7
Total n = 34.
between the research department and the academic (teaching) division of their institutions. Table 2 summarizes the respondents' positions in their institutions. Of the 10 research directors who responded, the title of 3 was “dean,” and one was “vice president.” Two of the colleges did not have a director or dean of research, which indicated that there was not a separate research department or division at their institution. A total of 24 research personnel and 10 clinic personnel responded to the survey.
Site of Research Project Performance at Respondents' Institutions According to respondents' reports, 4 of the 13 chiropractic institutions represented have a research clinic separate from their teaching clinic(s). All 4 of these institutions also conduct some research in their teaching clinics. Two institutions have a dedicated room for research within their teaching clinic but not a separate facility for research. Of the 13 institutions, 12 conduct some type of research in their teaching clinics. Eleven reported having conducted educational research involving surveys of interns and/or doctors or patient satisfaction. There were 9 who reported investigating outcomes of care related to customary, interndelivered care, and 9 who also reported conducting experimental clinical research unrelated to intern education processes. Six reported conducting other types of research such as health services research, case reports, a best practices pilot, and descriptive studies using file audits. Not having a separate research clinic was seen by some respondents as positive and by others as negative. Some said their institution did not have a research clinic because they did not need one; they felt it was better to integrate their research into the teaching clinic or to develop a model of collaboration with major universities to conduct randomized controlled trials. One respondent described how their institution came to establish a research clinic, which was essentially the result of a failure to integrate research activities into their clinic: “Prior to this we tried a myriad of things including monthly meetings with clinic administrators, staff, and clinicians, getting
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them involved in studies, including them in social events etc. None of this worked despite the best intentions of everyone involved.”
Others, viewing a research clinic as a desirable achievement, cited the reasons for not having one to be budgetary constraints or failure of the administration to make it a priority.
Perceived Advantages of Conducting Research in Teaching Clinics Of the 34 respondents, 32 felt there were advantages associated with conducting research within the college's teaching clinics rather than exclusively in a separate research clinic. Two respondents felt there were only disadvantages, which were confidentiality issues and lack of space. The advantages respondents cited fell into 4 broad themes: improving education both in terms of students and faculty (17 comments), instilling the values of a research culture and evidence-based practice (14 comments), building research capacity (12 comments), and contributing to the community (3 comments). (Respondents were allowed to make as many comments as they wished, so the total number of comments is greater than the total number of respondents.)
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Table 3. Methods for resolving challenges to conducting research in teaching clinics Theme
Methods for resolution
Administrative and policy Research a low priority No policies for conducting research in clinic
• Convince upper level administration of need to establish research culture • Create integrated clinic procedure manual • Standardize forms between research and clinic • Establish policies for easy access to research files
Resources and facilities Competition for space Faculty Time constraints
Lack of interest
Improving Education for Interns and Contributing to Faculty Development. Respondents felt that exposure to research projects during their clinical education contributes to students' clinical skills and hones those of faculty who participate. It also increases the range of cases interns see, providing them with experience with patients with more complex clinical presentations. Some respondents also expressed the importance of providing students with experiential learning about research rather than textbook learning only; for example, “It is one thing to discuss research in a classroom lecture but for some learning styles there is no substitute to seeing research happen and being part of it…Participating and seeing research in action can serve to demystify it and potentially get students excited about it...This will potentially foster both financial and practice based research support in the future.” Promoting Research Culture and Evidence-Based Practice. Integration of research into the teaching clinics was seen as a way to create a culture of research within the institution and the profession. One respondent said, “Research involvement is part of our mission statement. By creating research culture, we provide the best environment to ensure that we graduate DCs who have the idea of best-evidence practice engrained in their professional daily activity.” Building Research Capacity. Advantages related to infrastructure building and increasing availability of personnel included avoiding duplication of personnel and facilities, thus reducing costs; developing the next generation of investigators; and facilitating patient recruitment into research studies. Respondents not only considered the use of students as research subjects, research assistants, or for assisting in treatment to be an educational advantage but also an efficient use of resources and a way to increase their institution's research capacity.
Lack of research training
Students Lack of interest/ competition for patients
• Create research clinic • Move research treatments to underused clinic space • Use research assistants as faculty extenders. • Provide bonus pay and/or supplemental contracts for additional time and service • Engage faculty in discussion and sought their advice and input • Establish incentive policies for publications and grants • Locate research and academic/clinic faculty in proximity • Provide informal training to those interested • Develop clinical research master’s program • Submit grant applications such as R25 • Develop collaborative relationships with established institutions • Conduct faculty in-services focused on research • Fund position to review literature, produce evidence-based reviews, and disseminate to faculty; required faculty to use summaries in classes • Place research representative on new hiring committees • Allow credit for treatment of research patients for certain studies (under supervision of treating clinician) • Allow exam and x-ray credits for research patients • Perform ancillary procedures (e.g. supervised exercise) with research patients • Allow credit for clinic hours while working in research • Allow service credits for participation in research projects • Incorporate experiential learning into required research courses • Develop research patient recruitment plans to reduce competition for patients
Contributing to the Community. Few respondents (3) commented on a value to the community related to integration of research into their teaching clinics. These contributions were cited as being to patients, such as low-income populations able to receive free care in research studies; to the institution,
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by improving its credibility and visibility in the community; and to students by providing them with an opportunity to earn the “community credits” they needed for graduation.
Challenges and Resolution Strategies Related to Conducting Research in Teaching Clinics All respondents provided input, often extensive, on this issue; only 1 of the 34 respondents said that there were no such challenges. The respondent who said there were no challenges was employed at one of the colleges with the largest and most productive research programs. The other respondents' comments nearly all included more than 1 theme. The primary themes that emerged as challenges to conducting research in the institutions' teaching clinics were related to administration and policy, resources/facilities, faculty issues, and student issues. Respondents' reported challenges and strategies for resolving them are summarized in Table 3. Administrative and Policy Challenges. Respondents at 7 of the 13 colleges cited administrative challenges. The college's general administration was seen as giving a low priority to research in institutions that did not have strong research departments. This resulted in not only fewer resources (described below) but also in an absence of or inadequate policies related to research. One respondent said, “…it recently took over 1 year for IRB approval process of a study. This process was enough to deter anyone.” Inadequate attention of clinic administration to defining policies concerning chains of command, authority, responsibility, and liability was also cited. Such a lack was seen to contribute to problems with front desk staff understanding research study schedules and appropriately scheduling doctors or interns for patient care. It was also seen as contributing to the fear that conducting research would interfere with usual clinic operations. Resolution Strategies (Administrative and Policy Challenges). No specific methods of resolution were offered for the low priority given to research by colleges' administration, although one respondent reported that they had convinced their president of the need to establish a culture of research. For clinic-specific administrative challenges, reported methods were finding out how other colleges had handled similar situations; creating procedure manuals for operating an outpatient clinic that integrated research patients into day-today operations while still adhering to CCE requirements; and developing consistency of records between research and teaching clinics and easy access to research files within the teaching clinic. Inadequate Resources and Facilities. Respondents at 7 of the 13 colleges cited challenges related to scarce resources. Competition for scarce space for treating patients and difficulties related to insufficient personnel were cited by respondents in 5 colleges. A respondent at one additional college cited only insufficient personnel, whereas a respon-
Hawk et al Issues in Conducting Research
dent at another college cited a general lack of funds as a challenge. One respondent summarized the resource challenge as follows: “As with any research program, a critical mass must occur. As I am currently one of 2 primary researchers in the college, it is difficult to create a ‘culture of research.’ Most of our full time staff are ‘educators’ and have significant classroom time, which divides up their time to the point where they cannot perform research.” Resolution Strategies (Inadequate Resources and Facilities). Increasing communication from the planning stages forward with clinic staff, including front desk, business office, and clinicians, was cited by a respondent at one of the colleges that has successfully integrated research into their teaching clinic. A respondent from a college that had not adopted a model that integrated research into the clinics reported that their strategy for decreasing antagonism from clinic staff and students was to conduct research patient treatment only in less commonly used areas of the clinic. Faculty Issues. Faculty issues included lack of interest and incentives, lack of time, and lack of training in research methods. Two respondents, at 2 different colleges, cited lack of faculty interest and/or incentives for participation in research as a challenge. One other respondent at another college stated that faculty members were not aware of research projects being conducted. Time constraints on faculty involvement in research due to heavy course loads and resultant scheduling issues were also cited as a challenge by respondents at 6 of the colleges. Resolution Strategies (Faculty Issues). Respondents reported a variety of methods to engage faculty in research and to address their lack of time. Engaging faculty in discussions, asking their advice and input on the conduct of studies, and providing written or oral reports to faculty about research activities were communication methods used. Locating research faculty offices near clinic and academic faculty offices was a method used to physically bring faculty together to facilitate communication. Providing research assistants as “faculty extenders” was one method of offsetting faculty time constraints. Bonus payments, supplemental contracts, and incentive plans for research grants and publications were financial methods used to increase faculty interest in research. Lack of faculty training in research methods was cited as a challenge by respondents at 8 colleges. This not only affects the college's ability to conduct research projects due to lack of trained investigators but also deemphasizes research throughout the institution. As one respondent said, “research concepts and new research are not included in classes other than the research class. This conveys that it is okay to rely on textbooks and that research is not important.” Resolution Strategies (Lack of Faculty Training). Respondents described a variety of strategies designed to increase faculty's research skills (Table 3), ranging from informal training in procedures needed to conduct specific projects
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to submitting a grant application targeting the development of evidence-based health care principles and practice at the institution. Other strategies were to gain buy-in for the concept of building a research culture at the level of the upper administration and to develop collaborative arrangements with local universities. One respondent described a recent concerted movement toward evidencebased practice, which included the following actions: • Convinced upper administration of importance of research culture • Developed faculty scholarship incentive plans • Provided faculty in-services on research • Established program for 2 to 3 faculty each trimester to use release time to work in research department • Funded a full-time position to review literature and provide summaries to the faculty • Required faculty to use these summaries in their classes • Developed an online course on research methods for faculty • Placed a research representative on faculty search committees
Student Issues. Challenges related to interns' lack of interest in or opposition to research were reported by respondents at 5 colleges. Respondents of 3 of these colleges specifically attributed this to lack of a mechanism for assigning credit for student involvement in clinical studies, resulting in students perceiving research studies as competition for patients. Respondents at 2 colleges cited scheduling difficulties due to student turnover and/or their busy schedules. Resolution Strategies (Student Issues). Respondents reported a wide variety of activities that were available at their institutions for involving students in research. Respondents at 3 colleges reported that their institutions required a student-directed research project for graduation. Respondents at 10 colleges said that work study students or paid student research assistants were involved in research projects, assisting with research activities such as data collection, data entry, literature reviews, or patient recruitment and assessment. Because these students were paid, they did not receive course credits. Respondents at 2 colleges reported that students could get credit toward their course grade through “hands-on” participation in research projects under certain circumstances. One of these respondents explained how this was done: the instructor of the required “Research Methods” course announced, at the beginning of each trimester, that students could get credit for serving as an assessor or providing supervised treatment in the instructor's current research project in lieu of doing homework assignments. The instructor then selects several students from those who express interest to serve in this role. The other respondent (at a different college) reported that some instructors allowed homework credit or extra credit for students who “are recruited as participants in research projects.”
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Respondents in 4 colleges reported that students were able to get treatment credits, which counted toward their CCE-specified requirements for graduation, for treating research patients, if they were supervised by a clinic faculty member. Respondents at 2 colleges reported that students could get service credits, which also counted toward graduation requirements, for research involvement; one of these specified that this was for students who participated as subjects in a research study.
DISCUSSION This study was an initial exploration of the issues related to conducting clinical research in chiropractic college teaching clinics. It was not intended to provide definitive solutions to the long-standing challenges facing the chiropractic profession in terms of building its research capacity. Given the dearth of published studies examining this issue, our purpose was to gather and present some material to inform discussions among administrators and faculty who face these challenges on a daily basis. Although our sample size was small (34), it represented 13 of 18 colleges and 61% of the sample population. However, respondents at 3 institutions (Cleveland, NUHS, and Life) represented 54% of the total, so it is possible that results are more representative of these 3 institutions than of all institutions. At all participating institutions, respondents represented faculty and administrators “in the trenches,” with depth of experience with the topic under discussion, and in a variety of institutions, representing breadth of experience as well. Because this was a qualitative rather than quantitative study, we feel that this representative sample of key individuals is useful to provide informative “food for thought.” Nearly all (32 of 34) of our respondents felt there were advantages to conducting research in their teaching clinics. They felt that this would improve students' educational experience and promote the research culture as well as build the institution's research capacity. However, they described, often in considerable detail, the difficulties of integrating research, which is often viewed as an extraneous and even intrusive element, into clinic operations. Respondents reported a number of strategies for overcoming faculty's and students' lack of interest in research. However, none of these strategies were able to address the core issue: research involvement for both faculty and students was, in most institutions, voluntary—that is, not a requirement. Only 3 colleges required students to actually become involved in conducting a research project, and none of the colleges reported that faculty were required to have any research training or experience whatsoever. Research is almost universally viewed by chiropractic college faculty and students as extraneous to their educational experience. In view of the excessively heavy course loads of most chiropractic college faculty, as documented in a 2007 article,
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it is understandable that faculty are reluctant to become involved in “extraneous” activities.9 In viewing the results from a broad perspective, the most striking finding is that the challenges reported by respondents are primarily being addressed from the bottom up: respondents reported a greater number and more ingenious and varied strategies for getting faculty and students interested in participating in research than they did for addressing administrative and resource challenges. This is particularly striking in view of the fact that approximately 40% of respondents were either head of the research department (10) or clinic (3); one might presume that department heads might have greater influence on institutional policies and priorities than faculty or professional staff. Perhaps one explanatory factor might be that 6 of the 10 heads of research were directors rather than deans or vice presidents. In many institutions, employees at the director level are less frequently involved in institution-wide policy development, thus reinforcing the isolation of “research” from the rest of the college. Only one respondent reported a specific, multifaceted institutional plan to address the incorporation of evidence into the institution, demonstrating vertical as well as horizontal integration of research into the institution. When a medical institution implemented a similarly multifaceted program for research training of internal medicine residents, it was highly successful in increasing the level of scholarly activities in this group.10
CONCLUSION To prepare students in training and practitioners already in the field for the “brave new world” of evidence-based practice, the chiropractic profession needs to both increase its research capacity and integrate research into everyday practice. “Evidence-based practice is not about research evidence per se, but, instead, it is about the way in which clinicians use it in their practice on a day-to-day basis.”5 In most chiropractic institutions, the challenges of integrating research into teaching clinics are primarily being addressed by individuals using focused, situation-specific strategies rather than at the level of institutional policy.
ACKNOWLEDGMENT The authors would like to thank all the respondents for contributing their valuable time and thoughts to this project. This project was funded by the Cleveland Chiropractic
Hawk et al Issues in Conducting Research
Research Center and National University of Health Sciences. The authors have no conflicts of interest.
Practical Applications • Conducting research within the college's teaching clinics has educational benefits • The challenges to conducting research in teaching clinics were related to administration and policy, resources/facilities, faculty issues, and student issues. • Challenges of integrating research into teaching clinics are primarily being addressed through focused, situation-specific strategies rather than institutional policy change. • Discussions among administrators and faculty may lead to an improved research capacity.
REFERENCES 1. Haas M, Bronfort G, Evans RL. Chiropractic clinical research: progress and recommendations. J Manipulative Physiol Ther 2006;29:695-706. 2. Nyiendo J, Haas M, Hondras MA. Outcomes research in chiropractic: the state-of-the-art recommendations for the chiropractic research agenda. J Manipulative Physiol Ther 1997;20:185-200. 3. Sawyer C, Haas M, Nelson C, Elkington W. Clinical research within the chiropractic profession: status, needs and recommendations. J Manipulative Physiol Ther 1997;20:169-78. 4. Delaney PM, Fernandez CE. Toward and evidence-based model for chiropractic education and practice. J Manipulative Physiol Ther 1999;22:114-8. 5. Bolton J. Time to (evidence-base) practise what we preach. Clin Chiropr 2005;8:1-4. 6. Newell D, Cunliffe C. Attitudes toward research in undergraduate chiropractic students. Clin Chiropr 2003;6:109-19. 7. Mertens DM. Research and evaluation in education and psychology: integrating diversity with quantitative, qualitative, and mixed methods. Thousand Oaks, CA: Sage; 2005. 8. Patton MQ. Qualitative research and evaluation methods. 3rd ed. Thousand Oaks, CA: Sage; 2001. 9. Ward RW. Separate and distinct: a comparison of scholarly productivity, teaching load, and compensation of chiropractic teaching faculty to other sectors of higher education. J Chiropr Educ 2007;21:1-11. 10. Kanna B, Deng C, Erickson SN, Valerio JA, Dimitrov V, Soni A. The research rotation: competency-based structured and novel approach to research training of internal medicine residents. BMC Med Educ 2006;6:1-8.
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Cheryl Hawk, DC, PhD, a Jerrilyn Cambron, DC, PhD, b and Denise Pahmeyer c
ABSTRACT Objective: This study surveyed and interviewed faculty and staff at chiropractic colleges to investigate issues related to conducting clinical research in teaching clinics. Methods: This was a descriptive study using qualitative research methods. It was conducted from May to August 2007 by means of an electronically administered survey using purposive sampling of faculty and administrators at North American chiropractic colleges. Results: A total of 58 surveys were e-mailed to research directors, faculty, and staff at 16 colleges; 2 surveys were returned as undeliverable. Of the 56 successfully delivered surveys, 34 (61%) completed surveys were returned, representing 13 colleges. Not having a separate research clinic was seen by some respondents as positive and by others as negative. Of the 34 respondents, 32 felt there were advantages associated with conducting research within the college's teaching clinics rather than exclusively in a separate research clinic; 33 respondents described challenges to implementing the integration of research into their institution's clinics. The primary themes that emerged as challenges to conducting research in the institutions' teaching clinics were related to administration and policy, resources/facilities, faculty issues, and student issues. Respondents described strategies they had developed to address these challenges, primarily focusing on the challenges related to faculty and students rather than administration and resources. Conclusion: In most chiropractic institutions, the challenges of integrating research into teaching clinics are primarily being addressed by individuals using focused, situation-specific strategies rather than at the level of institutional policy. (J Manipulative Physiol Ther 2008;31:301-307) Key Indexing Terms: Chiropractic; Cross-Sectional Studies; Interviews; Teaching Hospital; Research
lthough research related to chiropractic has been increasing in both quality and quantity, there are still many challenges to be addressed as we move forward in the era of evidence-based practice. The 2006 white paper, “Chiropractic clinical research: progress and recommendations,” reported on progress on this topic since the original 1997 white paper.1-3 Specific recommendations included the development of a “research culture” in
A
a Vice President of Research and Scholarship, Cleveland Chiropractic Research Center, Cleveland Chiropractic College, Kansas City, MO. b Associate Professor, Department of Research, National University of Health Sciences, Lombard Ill. c Student Research Assistant, Cleveland Chiropractic Research Center, Cleveland Chiropractic College, Kansas City, MO. Submit requests for reprints to: Cheryl Hawk, DC, PhD, Vice President of Research and Scholarship, Cleveland Chiropractic College, 6401 Rockhill Rd, Kansas City, MO 64131 (e-mail: [email protected]). Paper submitted October 10, 2007; in revised form November 27, 2007; accepted December 10, 2007. 0161-4754/$34.00 Copyright © 2008 by National University of Health Sciences. doi:10.1016/j.jmpt.2008.03.008
chiropractic education; the maintenance of a critical mass of research faculty within chiropractic educational institutions; and the provision of adequate resources for research personnel and facilities. It was acknowledged that “research in teaching clinics remains challenging because of limited space, competition for patients, and limited capacity.”1 These institutions were urged to make clinical facilities more accessible for conducting experimental studies and to provide incentives to faculty for participating in research projects. The 2006 paper stated that the greatest success in the area of making clinical facilities accessible for experimental studies had occurred through creating dedicated research clinics rather than integrating research into the teaching clinics.1 However, creating and maintaining a separate research facility is a resource-intensive endeavor that may not compete successfully with all the other pressing financial needs in a tuition-dependent institution—particularly if research is not considered an essential part of chiropractic education. Furthermore, the growing need to integrate the concepts of evidence-based practice into chiropractic education suggests that the continued isolation of research activities from chiropractic academic and clinical education may not be in the profession's best interests.4 As Bolton5 301
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stated in a 2005 commentary, “for chiropractic practice to become evidence-based, as espoused by the champions of evidence-based practice, clinicians need to be able to act both as ‘research users’ and as ‘research providers.’ Thus, it is becoming increasingly necessary for chiropractic clinical faculty to become conversant with current research. A 2003 study at a chiropractic college in the United Kingdom indicated that although students thought research was an important part of their training, they felt that faculty were lacking in their involvement in research and also in their use of it in teaching.6 Integration of research as a part of everyday teaching clinic operations is one way to begin to build evidence-based practice into the identity of the chiropractic profession. To gain perspective on the possibility of developing a model in which research is a viable, integral part of chiropractic education, we developed a survey to gather information from chiropractic college faculty and administrators who were involved in research and/or clinical training. The purpose of this project was to survey and interview faculty and staff at chiropractic colleges to investigate issues related to conducting clinical research in teaching clinics.
METHODS This was a descriptive study using qualitative research methods. It was conducted from May to August 2007 by means of an electronically administered survey.
Sample We used purposive sampling, in particular the maximum variation and snowball strategies.7,8 To ensure maximum variation of responses in terms of different institutions, we intended to include respondents from all 18 North American chiropractic colleges belonging to the Association of Chiropractic Colleges (ACC). Using the “snowball” strategy, we asked all college research directors to complete this survey and to then recommend others at their institution who they felt we should include in the sample, prompting them to include the clinic director or clinic faculty if they felt it was appropriate.
Human Subjects and Informed Consent The project was approved by the Institutional Review Boards of the Cleveland Chiropractic College and National University of Health Sciences. The survey was accompanied by an informed consent that respondents signed and returned with their completed survey, which described the measures used to protect confidentiality. Only the investigators were aware of respondents' identity and institutional affiliation and did not link identifiers to any of the data reported. Information containing personal identifiers
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was stored in a secure database only accessible to the investigators.
Survey Instrument and Administration The investigators compiled questions related to the issue of conducting clinical research in chiropractic college teaching clinics and pilot tested them on faculty and staff at 4 different colleges, for a total of 6 completed pilot surveys. The questions were revised according to the pilot test comments. All questions included open-ended response options to ensure that we gathered the most complete information possible. After reviewing responses to the pilot survey, the following questions were included in the survey: • Does your institution have a research clinic facility separate from the teaching clinic(s)? (Yes/No) • If “yes,” do you also conduct research within your college's teaching clinic(s)? (Yes/No) • If “no,” why not? (open-ended) • How do you involve students in research projects? (open-ended) • Are students able to get credit of any type for research involvement? (Yes/No) • If “yes,” please describe: (open-ended) • What do you consider the advantages of conducting research within your college's teaching clinic(s) (in terms of education, practice, research, service, etc.)? (open-ended) • What are the challenges/problems involved in conducting research in your college's teaching clinics? (open-ended) • How have you addressed or attempted to address each one? (open-ended) The survey was administered electronically by e-mail to all respondents, with explicit instructions for opening, completing, and returning the document. It was designed as a protected Word document that allowed responses of unlimited length. The survey was administered in 5 waves. The first wave was sent to research directors, with each subsequent wave sent to potential respondents identified by previous respondents. The first wave, sent to research directors identified through the ACC research directors' group, was followed up twice at 2-week intervals for a total of 3 contacts. Waves 2 to 4 were followed up once at 2-week intervals for a total of 2 contacts. Wave 5 (3 potential respondents) was contacted once.
Data Management Surveys were returned by e-mail to the principal investigator. Each survey was assigned a number, and all identifying information was removed before it was saved into a file and printed for use by the data entry staff to enter
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Table 1. Colleges represented in survey by number of respondents (n = 13 colleges) Life University Cleveland Chiropractic College (Kansas City) National University of Health Sciences Southern California University of Health Sciences Canadian Memorial Chiropractic College Northwestern Health Sciences University Parker College of Chiropractic Palmer College of Chiropractic (Davenport) University of Bridgeport Cleveland Chiropractic College (Los Angeles) Logan University New York Chiropractic College Palmer College of Chiropractic (West) Total
n
%
7 6 5 3 2 2 2 2 1 1 1 1 1 34
21 18 15 9 6 6 6 6 3 3 3 3 3 100
the closed-ended and short-answer responses. Contact information was maintained in a separate secure database for use in follow-up mailings. Closed-ended and short-answer responses (b20 characters) were entered into an SPSS (v. 14.0) database, and descriptive statistics (frequencies and proportions) were computed. Open-ended survey responses were pasted verbatim into a single Word document, organized by question and identified by respondent ID and college so that results could be viewed by both individual respondent and by institution.
Analysis After the survey responses were organized by question, 2 of the investigators performed a content analysis, organizing them by theme under each survey question. The principal investigator synthesized these separate analyses, and all 3 investigators reviewed this document and made comments, noting themes that they felt required clarification or reclassification. Finally, the principal investigator incorporated input from the other 2 investigators and organized the data into the identified themes, resulting in the final summary.
RESULTS Sample Population Of the 18 colleges listed as members of ACC, 16 were represented on the ACC's mailing list; research directors for Life West and Palmer Florida were not on the list. A total of 58 surveys were e-mailed to research directors, faculty, and staff at 16 colleges; 2 surveys were returned as undeliverable. Of the 56 successfully delivered surveys, 34 (61%) completed surveys were returned, representing 13 colleges. Table 1 shows the distribution of respondents by college. There was representation of both faculty and professional staff from departments of both research and clinics, as well as 2 faculty who were in positions that served as liaisons
Table 2. Respondents’ positions by department Respondent Research Personnel (n = 24) Research director (including 3 deans, 1 vice president) Liaison between research/academic areas (Director of Faculty Development in Office of Sponsored Research and Scholarly Activity; Coordinator, Research Education) Research faculty Professional staff (2 research coordinators, 1 clinical coordinator) Clinic Personnel (n = 10) Clinic director (including 2 deans and 1 chief of staff) Clinic faculty
Number 10 2
9 3
3 7
Total n = 34.
between the research department and the academic (teaching) division of their institutions. Table 2 summarizes the respondents' positions in their institutions. Of the 10 research directors who responded, the title of 3 was “dean,” and one was “vice president.” Two of the colleges did not have a director or dean of research, which indicated that there was not a separate research department or division at their institution. A total of 24 research personnel and 10 clinic personnel responded to the survey.
Site of Research Project Performance at Respondents' Institutions According to respondents' reports, 4 of the 13 chiropractic institutions represented have a research clinic separate from their teaching clinic(s). All 4 of these institutions also conduct some research in their teaching clinics. Two institutions have a dedicated room for research within their teaching clinic but not a separate facility for research. Of the 13 institutions, 12 conduct some type of research in their teaching clinics. Eleven reported having conducted educational research involving surveys of interns and/or doctors or patient satisfaction. There were 9 who reported investigating outcomes of care related to customary, interndelivered care, and 9 who also reported conducting experimental clinical research unrelated to intern education processes. Six reported conducting other types of research such as health services research, case reports, a best practices pilot, and descriptive studies using file audits. Not having a separate research clinic was seen by some respondents as positive and by others as negative. Some said their institution did not have a research clinic because they did not need one; they felt it was better to integrate their research into the teaching clinic or to develop a model of collaboration with major universities to conduct randomized controlled trials. One respondent described how their institution came to establish a research clinic, which was essentially the result of a failure to integrate research activities into their clinic: “Prior to this we tried a myriad of things including monthly meetings with clinic administrators, staff, and clinicians, getting
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them involved in studies, including them in social events etc. None of this worked despite the best intentions of everyone involved.”
Others, viewing a research clinic as a desirable achievement, cited the reasons for not having one to be budgetary constraints or failure of the administration to make it a priority.
Perceived Advantages of Conducting Research in Teaching Clinics Of the 34 respondents, 32 felt there were advantages associated with conducting research within the college's teaching clinics rather than exclusively in a separate research clinic. Two respondents felt there were only disadvantages, which were confidentiality issues and lack of space. The advantages respondents cited fell into 4 broad themes: improving education both in terms of students and faculty (17 comments), instilling the values of a research culture and evidence-based practice (14 comments), building research capacity (12 comments), and contributing to the community (3 comments). (Respondents were allowed to make as many comments as they wished, so the total number of comments is greater than the total number of respondents.)
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Table 3. Methods for resolving challenges to conducting research in teaching clinics Theme
Methods for resolution
Administrative and policy Research a low priority No policies for conducting research in clinic
• Convince upper level administration of need to establish research culture • Create integrated clinic procedure manual • Standardize forms between research and clinic • Establish policies for easy access to research files
Resources and facilities Competition for space Faculty Time constraints
Lack of interest
Improving Education for Interns and Contributing to Faculty Development. Respondents felt that exposure to research projects during their clinical education contributes to students' clinical skills and hones those of faculty who participate. It also increases the range of cases interns see, providing them with experience with patients with more complex clinical presentations. Some respondents also expressed the importance of providing students with experiential learning about research rather than textbook learning only; for example, “It is one thing to discuss research in a classroom lecture but for some learning styles there is no substitute to seeing research happen and being part of it…Participating and seeing research in action can serve to demystify it and potentially get students excited about it...This will potentially foster both financial and practice based research support in the future.” Promoting Research Culture and Evidence-Based Practice. Integration of research into the teaching clinics was seen as a way to create a culture of research within the institution and the profession. One respondent said, “Research involvement is part of our mission statement. By creating research culture, we provide the best environment to ensure that we graduate DCs who have the idea of best-evidence practice engrained in their professional daily activity.” Building Research Capacity. Advantages related to infrastructure building and increasing availability of personnel included avoiding duplication of personnel and facilities, thus reducing costs; developing the next generation of investigators; and facilitating patient recruitment into research studies. Respondents not only considered the use of students as research subjects, research assistants, or for assisting in treatment to be an educational advantage but also an efficient use of resources and a way to increase their institution's research capacity.
Lack of research training
Students Lack of interest/ competition for patients
• Create research clinic • Move research treatments to underused clinic space • Use research assistants as faculty extenders. • Provide bonus pay and/or supplemental contracts for additional time and service • Engage faculty in discussion and sought their advice and input • Establish incentive policies for publications and grants • Locate research and academic/clinic faculty in proximity • Provide informal training to those interested • Develop clinical research master’s program • Submit grant applications such as R25 • Develop collaborative relationships with established institutions • Conduct faculty in-services focused on research • Fund position to review literature, produce evidence-based reviews, and disseminate to faculty; required faculty to use summaries in classes • Place research representative on new hiring committees • Allow credit for treatment of research patients for certain studies (under supervision of treating clinician) • Allow exam and x-ray credits for research patients • Perform ancillary procedures (e.g. supervised exercise) with research patients • Allow credit for clinic hours while working in research • Allow service credits for participation in research projects • Incorporate experiential learning into required research courses • Develop research patient recruitment plans to reduce competition for patients
Contributing to the Community. Few respondents (3) commented on a value to the community related to integration of research into their teaching clinics. These contributions were cited as being to patients, such as low-income populations able to receive free care in research studies; to the institution,
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by improving its credibility and visibility in the community; and to students by providing them with an opportunity to earn the “community credits” they needed for graduation.
Challenges and Resolution Strategies Related to Conducting Research in Teaching Clinics All respondents provided input, often extensive, on this issue; only 1 of the 34 respondents said that there were no such challenges. The respondent who said there were no challenges was employed at one of the colleges with the largest and most productive research programs. The other respondents' comments nearly all included more than 1 theme. The primary themes that emerged as challenges to conducting research in the institutions' teaching clinics were related to administration and policy, resources/facilities, faculty issues, and student issues. Respondents' reported challenges and strategies for resolving them are summarized in Table 3. Administrative and Policy Challenges. Respondents at 7 of the 13 colleges cited administrative challenges. The college's general administration was seen as giving a low priority to research in institutions that did not have strong research departments. This resulted in not only fewer resources (described below) but also in an absence of or inadequate policies related to research. One respondent said, “…it recently took over 1 year for IRB approval process of a study. This process was enough to deter anyone.” Inadequate attention of clinic administration to defining policies concerning chains of command, authority, responsibility, and liability was also cited. Such a lack was seen to contribute to problems with front desk staff understanding research study schedules and appropriately scheduling doctors or interns for patient care. It was also seen as contributing to the fear that conducting research would interfere with usual clinic operations. Resolution Strategies (Administrative and Policy Challenges). No specific methods of resolution were offered for the low priority given to research by colleges' administration, although one respondent reported that they had convinced their president of the need to establish a culture of research. For clinic-specific administrative challenges, reported methods were finding out how other colleges had handled similar situations; creating procedure manuals for operating an outpatient clinic that integrated research patients into day-today operations while still adhering to CCE requirements; and developing consistency of records between research and teaching clinics and easy access to research files within the teaching clinic. Inadequate Resources and Facilities. Respondents at 7 of the 13 colleges cited challenges related to scarce resources. Competition for scarce space for treating patients and difficulties related to insufficient personnel were cited by respondents in 5 colleges. A respondent at one additional college cited only insufficient personnel, whereas a respon-
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dent at another college cited a general lack of funds as a challenge. One respondent summarized the resource challenge as follows: “As with any research program, a critical mass must occur. As I am currently one of 2 primary researchers in the college, it is difficult to create a ‘culture of research.’ Most of our full time staff are ‘educators’ and have significant classroom time, which divides up their time to the point where they cannot perform research.” Resolution Strategies (Inadequate Resources and Facilities). Increasing communication from the planning stages forward with clinic staff, including front desk, business office, and clinicians, was cited by a respondent at one of the colleges that has successfully integrated research into their teaching clinic. A respondent from a college that had not adopted a model that integrated research into the clinics reported that their strategy for decreasing antagonism from clinic staff and students was to conduct research patient treatment only in less commonly used areas of the clinic. Faculty Issues. Faculty issues included lack of interest and incentives, lack of time, and lack of training in research methods. Two respondents, at 2 different colleges, cited lack of faculty interest and/or incentives for participation in research as a challenge. One other respondent at another college stated that faculty members were not aware of research projects being conducted. Time constraints on faculty involvement in research due to heavy course loads and resultant scheduling issues were also cited as a challenge by respondents at 6 of the colleges. Resolution Strategies (Faculty Issues). Respondents reported a variety of methods to engage faculty in research and to address their lack of time. Engaging faculty in discussions, asking their advice and input on the conduct of studies, and providing written or oral reports to faculty about research activities were communication methods used. Locating research faculty offices near clinic and academic faculty offices was a method used to physically bring faculty together to facilitate communication. Providing research assistants as “faculty extenders” was one method of offsetting faculty time constraints. Bonus payments, supplemental contracts, and incentive plans for research grants and publications were financial methods used to increase faculty interest in research. Lack of faculty training in research methods was cited as a challenge by respondents at 8 colleges. This not only affects the college's ability to conduct research projects due to lack of trained investigators but also deemphasizes research throughout the institution. As one respondent said, “research concepts and new research are not included in classes other than the research class. This conveys that it is okay to rely on textbooks and that research is not important.” Resolution Strategies (Lack of Faculty Training). Respondents described a variety of strategies designed to increase faculty's research skills (Table 3), ranging from informal training in procedures needed to conduct specific projects
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to submitting a grant application targeting the development of evidence-based health care principles and practice at the institution. Other strategies were to gain buy-in for the concept of building a research culture at the level of the upper administration and to develop collaborative arrangements with local universities. One respondent described a recent concerted movement toward evidencebased practice, which included the following actions: • Convinced upper administration of importance of research culture • Developed faculty scholarship incentive plans • Provided faculty in-services on research • Established program for 2 to 3 faculty each trimester to use release time to work in research department • Funded a full-time position to review literature and provide summaries to the faculty • Required faculty to use these summaries in their classes • Developed an online course on research methods for faculty • Placed a research representative on faculty search committees
Student Issues. Challenges related to interns' lack of interest in or opposition to research were reported by respondents at 5 colleges. Respondents of 3 of these colleges specifically attributed this to lack of a mechanism for assigning credit for student involvement in clinical studies, resulting in students perceiving research studies as competition for patients. Respondents at 2 colleges cited scheduling difficulties due to student turnover and/or their busy schedules. Resolution Strategies (Student Issues). Respondents reported a wide variety of activities that were available at their institutions for involving students in research. Respondents at 3 colleges reported that their institutions required a student-directed research project for graduation. Respondents at 10 colleges said that work study students or paid student research assistants were involved in research projects, assisting with research activities such as data collection, data entry, literature reviews, or patient recruitment and assessment. Because these students were paid, they did not receive course credits. Respondents at 2 colleges reported that students could get credit toward their course grade through “hands-on” participation in research projects under certain circumstances. One of these respondents explained how this was done: the instructor of the required “Research Methods” course announced, at the beginning of each trimester, that students could get credit for serving as an assessor or providing supervised treatment in the instructor's current research project in lieu of doing homework assignments. The instructor then selects several students from those who express interest to serve in this role. The other respondent (at a different college) reported that some instructors allowed homework credit or extra credit for students who “are recruited as participants in research projects.”
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Respondents in 4 colleges reported that students were able to get treatment credits, which counted toward their CCE-specified requirements for graduation, for treating research patients, if they were supervised by a clinic faculty member. Respondents at 2 colleges reported that students could get service credits, which also counted toward graduation requirements, for research involvement; one of these specified that this was for students who participated as subjects in a research study.
DISCUSSION This study was an initial exploration of the issues related to conducting clinical research in chiropractic college teaching clinics. It was not intended to provide definitive solutions to the long-standing challenges facing the chiropractic profession in terms of building its research capacity. Given the dearth of published studies examining this issue, our purpose was to gather and present some material to inform discussions among administrators and faculty who face these challenges on a daily basis. Although our sample size was small (34), it represented 13 of 18 colleges and 61% of the sample population. However, respondents at 3 institutions (Cleveland, NUHS, and Life) represented 54% of the total, so it is possible that results are more representative of these 3 institutions than of all institutions. At all participating institutions, respondents represented faculty and administrators “in the trenches,” with depth of experience with the topic under discussion, and in a variety of institutions, representing breadth of experience as well. Because this was a qualitative rather than quantitative study, we feel that this representative sample of key individuals is useful to provide informative “food for thought.” Nearly all (32 of 34) of our respondents felt there were advantages to conducting research in their teaching clinics. They felt that this would improve students' educational experience and promote the research culture as well as build the institution's research capacity. However, they described, often in considerable detail, the difficulties of integrating research, which is often viewed as an extraneous and even intrusive element, into clinic operations. Respondents reported a number of strategies for overcoming faculty's and students' lack of interest in research. However, none of these strategies were able to address the core issue: research involvement for both faculty and students was, in most institutions, voluntary—that is, not a requirement. Only 3 colleges required students to actually become involved in conducting a research project, and none of the colleges reported that faculty were required to have any research training or experience whatsoever. Research is almost universally viewed by chiropractic college faculty and students as extraneous to their educational experience. In view of the excessively heavy course loads of most chiropractic college faculty, as documented in a 2007 article,
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it is understandable that faculty are reluctant to become involved in “extraneous” activities.9 In viewing the results from a broad perspective, the most striking finding is that the challenges reported by respondents are primarily being addressed from the bottom up: respondents reported a greater number and more ingenious and varied strategies for getting faculty and students interested in participating in research than they did for addressing administrative and resource challenges. This is particularly striking in view of the fact that approximately 40% of respondents were either head of the research department (10) or clinic (3); one might presume that department heads might have greater influence on institutional policies and priorities than faculty or professional staff. Perhaps one explanatory factor might be that 6 of the 10 heads of research were directors rather than deans or vice presidents. In many institutions, employees at the director level are less frequently involved in institution-wide policy development, thus reinforcing the isolation of “research” from the rest of the college. Only one respondent reported a specific, multifaceted institutional plan to address the incorporation of evidence into the institution, demonstrating vertical as well as horizontal integration of research into the institution. When a medical institution implemented a similarly multifaceted program for research training of internal medicine residents, it was highly successful in increasing the level of scholarly activities in this group.10
CONCLUSION To prepare students in training and practitioners already in the field for the “brave new world” of evidence-based practice, the chiropractic profession needs to both increase its research capacity and integrate research into everyday practice. “Evidence-based practice is not about research evidence per se, but, instead, it is about the way in which clinicians use it in their practice on a day-to-day basis.”5 In most chiropractic institutions, the challenges of integrating research into teaching clinics are primarily being addressed by individuals using focused, situation-specific strategies rather than at the level of institutional policy.
ACKNOWLEDGMENT The authors would like to thank all the respondents for contributing their valuable time and thoughts to this project. This project was funded by the Cleveland Chiropractic
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Research Center and National University of Health Sciences. The authors have no conflicts of interest.
Practical Applications • Conducting research within the college's teaching clinics has educational benefits • The challenges to conducting research in teaching clinics were related to administration and policy, resources/facilities, faculty issues, and student issues. • Challenges of integrating research into teaching clinics are primarily being addressed through focused, situation-specific strategies rather than institutional policy change. • Discussions among administrators and faculty may lead to an improved research capacity.
REFERENCES 1. Haas M, Bronfort G, Evans RL. Chiropractic clinical research: progress and recommendations. J Manipulative Physiol Ther 2006;29:695-706. 2. Nyiendo J, Haas M, Hondras MA. Outcomes research in chiropractic: the state-of-the-art recommendations for the chiropractic research agenda. J Manipulative Physiol Ther 1997;20:185-200. 3. Sawyer C, Haas M, Nelson C, Elkington W. Clinical research within the chiropractic profession: status, needs and recommendations. J Manipulative Physiol Ther 1997;20:169-78. 4. Delaney PM, Fernandez CE. Toward and evidence-based model for chiropractic education and practice. J Manipulative Physiol Ther 1999;22:114-8. 5. Bolton J. Time to (evidence-base) practise what we preach. Clin Chiropr 2005;8:1-4. 6. Newell D, Cunliffe C. Attitudes toward research in undergraduate chiropractic students. Clin Chiropr 2003;6:109-19. 7. Mertens DM. Research and evaluation in education and psychology: integrating diversity with quantitative, qualitative, and mixed methods. Thousand Oaks, CA: Sage; 2005. 8. Patton MQ. Qualitative research and evaluation methods. 3rd ed. Thousand Oaks, CA: Sage; 2001. 9. Ward RW. Separate and distinct: a comparison of scholarly productivity, teaching load, and compensation of chiropractic teaching faculty to other sectors of higher education. J Chiropr Educ 2007;21:1-11. 10. Kanna B, Deng C, Erickson SN, Valerio JA, Dimitrov V, Soni A. The research rotation: competency-based structured and novel approach to research training of internal medicine residents. BMC Med Educ 2006;6:1-8.
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