Email updates

Keep up to date with the latest news and content from HRH and BioMed Central.

This article is part of the series Improving the efficiency, effectiveness and sustainability of health worker in-service training: Closing the gaps between evidence, practice and outcomes.

Open Access Research

Effective in-service training design and delivery: evidence from an integrative literature review

Julia Bluestone1*, Peter Johnson1, Judith Fullerton2, Catherine Carr1, Jessica Alderman3 and James BonTempo1

Author Affiliations

1 Jhpiego Corporation, 1615 Thames Street, Baltimore, MD 21231, USA

2 Independent Consultant, San Diego, CA, USA

3 Research Assistant, Baltimore, MD, USA

For all author emails, please log on.

Human Resources for Health 2013, 11:51  doi:10.1186/1478-4491-11-51


The electronic version of this article is the complete one and can be found online at: http://www.human-resources-health.com/content/11/1/51


Received:8 August 2012
Accepted:2 May 2013
Published:1 October 2013

© 2013 Bluestone et al.; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

In-service training represents a significant financial investment for supporting continued competence of the health care workforce. An integrative review of the education and training literature was conducted to identify effective training approaches for health worker continuing professional education (CPE) and what evidence exists of outcomes derived from CPE.

Methods

A literature review was conducted from multiple databases including PubMed, the Cochrane Library and Cumulative Index to Nursing and Allied Health Literature (CINAHL) between May and June 2011. The initial review of titles and abstracts produced 244 results. Articles selected for analysis after two quality reviews consisted of systematic reviews, randomized controlled trials (RCTs) and programme evaluations published in peer-reviewed journals from 2000 to 2011 in the English language. The articles analysed included 37 systematic reviews and 32 RCTs. The research questions focused on the evidence supporting educational techniques, frequency, setting and media used to deliver instruction for continuing health professional education.

Results

The evidence suggests the use of multiple techniques that allow for interaction and enable learners to process and apply information. Case-based learning, clinical simulations, practice and feedback are identified as effective educational techniques. Didactic techniques that involve passive instruction, such as reading or lecture, have been found to have little or no impact on learning outcomes. Repetitive interventions, rather than single interventions, were shown to be superior for learning outcomes. Settings similar to the workplace improved skill acquisition and performance. Computer-based learning can be equally or more effective than live instruction and more cost efficient if effective techniques are used. Effective techniques can lead to improvements in knowledge and skill outcomes and clinical practice behaviours, but there is less evidence directly linking CPE to improved clinical outcomes. Very limited quality data are available from low- to middle-income countries.

Conclusions

Educational techniques are critical to learning outcomes. Targeted, repetitive interventions can result in better learning outcomes. Setting should be selected to support relevant and realistic practice and increase efficiency. Media should be selected based on the potential to support effective educational techniques and efficiency of instruction. CPE can lead to improved learning outcomes if effective techniques are used. Limited data indicate that there may also be an effect on improving clinical practice behaviours. The research agenda calls for well-constructed evaluations of culturally appropriate combinations of technique, setting, frequency and media, developed for and tested among all levels of health workers in low- and middle-income countries.

Keywords:
In-service training; Continuing professional education; Continuing medical education; Continuing professional development

Background

The need to increase the effectiveness and efficiency of both pre-service education and continuing professional education (CPE) (in-service training) for the health workforce has never been greater. Decreasing global resources and a pervasive critical shortage of skilled health workers are paralleled by an explosion in the increase of and access to information. Universities and educational institutions are rapidly integrating different approaches for learning that move beyond the classroom [1]. The opportunities exist both in initial health professional education and CPE to expand education and training approaches beyond classroom-based settings.

An integrative review was designed to identify and review the evidence addressing best practices in the design and delivery of in-service training interventions. The use of an integrative review expands the variety of research designs that can be incorporated within a review’s inclusion criteria and allows the incorporation of both qualitative and quantitative information [2]. Five questions were formulated based on a conceptual model of CPE developed by the Johns Hopkins University Evidence-Based Practice Center (JHU EPC) for an earlier systematic review of continuing medical education (CME) [3]. We asked whether: 1. particular educational techniques, 2. frequency of instruction (single or repetitive), 3. setting where instruction occurs, or 4. media used to deliver the instruction make a difference in learning outcomes; and, 5. if there was any evidence regarding the desired outcomes, such as improvements in knowledge, skills or changes in clinical practice behaviours, which could be derived from CPE, using any mixture of technique, media or frequency.

Methods

Inclusion/exclusion criteria

Articles were included in this review if they addressed any type of health worker pre-service or CPE event, and included an analysis of the short-term evaluation and/or assessment of the longer-term outcomes of the training. We included only those articles published in English language literature. These criteria gave priority to articles that used higher-order research methods, specifically meta-analyses or systematic reviews and evaluations that employed experimental designs. Articles excluded from analysis were observational studies, qualitative studies, editorial commentary, letters and book chapters.

Search strategy

A research assistant searched the electronic, peer-reviewed literature between May and June 2011. The search was conducted on studies published in the English language from 2000 to 2011. Multiple databases including PubMed, the Cochrane Library and Cumulative Index to Nursing and Allied Health Literature (CINAHL) were utilized in the search. Medical subject headings (MeSH) and key search terms are presented below in Table 1.

Table 1. Medical subject headings (MeSH) and key search terms

Study type, quality assessment and grade

An initial review of titles and abstracts produced 244 results. We identified the strongest studies available, using a range of criteria tailored to the review methodology. Initial selection criteria were developed by a panel of experts. Grading and inclusion criteria are presented in Table 2. The grading criteria were adapted from the Oxford Centre for Evidence-Based Medicine (OCEMB) levels of evidence model [4]. Grading of studies included within systematic reviews was reported by authors of those reviews and was not further assessed in this integrative review. Therefore, reference to quality of studies in our report refers to those a priori judgments. Only tier 1 articles (grades 1 and 2) were included in our analysis.

Table 2. Grading criteria

After prioritization of the articles, 163 tier 1 articles were assessed by a senior public health professional to determine topical relevance, study type and grade. A total of 61 tier 1 studies were selected to be included in the analysis following this second review. An additional hand search of the reference lists cited in published studies was conducted for topics that were underrepresented, specifically on the frequency and setting of educational activities. This search added eight articles for a total of 69 studies, including 37 systematic reviews and 32 randomized controlled trials (RCTs), see inclusion process for articles included in analysis, Figure 1.

thumbnailFigure 1. Inclusion process for articles included in the analysis.

A data extraction spreadsheet was developed, following the model offered in the Best Evidence in Medical Education (BEME) group series [5] and the conceptual model and definition of terms offered by Marinopoulos et al. in the JHU EPC earlier review of CME [3]. Categorization decisions were necessary in cases when the use of terminology was inconsistent with the Marinopoulos et al. definitions of terms for CPE [3]. For example, an article that analysed 'distance learning’ as a technique and used the computer as the medium to deliver an interactive e-learning course was coded and categorized as an 'interactive’ technique delivered via 'computer’ as the medium of instruction. See illustration of categorization terminology in panels A, B, and C, Figure 2, for an illustration of how terminology was used to categorize and organize articles for analysis.

thumbnailFigure 2. Illustration of categorization terminology in panels a-c.

Results

Selected articles that best represent common findings and outcomes (effects) of CPE are discussed in the results and discussion sections; the related tables present all the articles analysed and categorized for that topic, and each article is included only once. Relevant information obtained from educational psychology literature is referenced in the discussion.

Techniques

The articles or studies that specifically addressed educational techniques are summarized in Table 3. Technique refers to the educational methods used in the instruction. Technique descriptions are based on the Marinopoulos et al. definitions of terms [6] and reflect the approaches defined in the articles analysed.

Table 3. Summary of articles focused on techniques

Case-based: use of created or actual clinical cases that present materials and questions

Though case-based learning was not specifically compared with other techniques in the literature reviewed, it was often noted as a method in articles that discussed interactive techniques. Case-based learning was also noted as a technique used for computer-delivered CPE courses. Triola et al. compared types of media utilized for case-based learning and found positive learning outcomes both with the use of a live standardized patient and a computer-based virtual patient [7].

Didactic/lecture: presenting knowledge content; facilitator determines content, organization and pace

Lecture was often referred to in the literature as traditional instruction, lecture-based or didactic teaching. Didactic instruction was not found to be an effective educational technique compared with other methods. Two studies [8,9] found no statistical difference in learning outcomes, and three studies found didactic to be less effective than other techniques [10-12]. Reynolds et al. compared didactic instruction with simulation. The study was limited by small sample size (n = 50), but still demonstrated that the simulation group had a significantly higher mean post-test score (P <0.01) and overall higher learner satisfaction [12].

Several systemic reviews that compared didactic instruction to a wide variety of teaching approaches also identified didactic instruction as a less effective educational technique [13-15].

Feedback: providing information to the learner about performance

Multiple articles identified feedback as important for outcomes [16-18]. Herbert et al. compared individualized feedback in the form of a graphic (a prescribing portrait based on personal history of drug-prescribing practices) to small group discussion of the same material and found that both the feedback and the live, interactive session were somewhat effective at changing physician’s prescribing behaviours [16]. The Issenberg et al. systematic review of simulation identified practice and feedback as key for effective skill development [17]. A Cochrane review of the evidence to support CPE suggested the importance of feedback and instructor interaction in improving learning outcomes [18].

Games: competitive game with preset rules

The use of games as an instructional technology was addressed in one rigorous systematic review. The authors found only a limited number of studies, which were of low to moderate methodological quality and offered inconsistent results. Three of the five RCTs included in the review suggested that educational games could have a positive effect on increasing medical student knowledge and that they include interaction and allow for feedback [19].

Interactive: provide for interaction between the learner and facilitator

Five articles specifically compared interactive CPE to other educational techniques. De Lorenzo and Abbot found interactive techniques to be moderately superior for knowledge outcomes than didactic lecture [10]. Two other studies found interactive techniques were more effective when feedback from chart audits was added to the intervention [16,20].

Three systematic reviews and one meta-analysis specifically noted the importance of learner interactivity or engagement in learning in achieving positive learning outcomes [21-24] (refer to summary of articles focused on outcomes).

Point-of-care (POC): information provided as needed, at the point of clinical care

Two articles and one systematic review specifically addressed point-of-care (POC) as a technique. The systematic review included three studies and concluded that while the findings were weak, they did indicate that POC led to improved knowledge and confidence [25]. In an examination of media, Leung et al. determined that handheld devices were more effective than print-based, POC support, although outcome measures were self-reported behaviours [26]. You et al. found improved performance on a procedure among surgical residents who received POC mentoring via a video using a mobile device, compared with those who received only didactic instruction [27].

Problem-based learning (PBL): present a case, assign information-seeking tasks and answer questions about the case; can be facilitated or non-facilitated

Four articles specifically compared problem-based learning (PBL) to other methods. One study identified PBL as slightly better [11], and two studies indicated it to be relatively equal to didactic instruction [8,9]. A systematic review of 10 studies on PBL reported inconclusive evidence to support the approach, although several studies reported increased critical thinking skills and confidence in making decisions [28].

Reminders: provision of reminders

The Zurovac et al. study conducted in Kenya found that using mobile devices for repetitive reminders resulted in significant improvement in health care provider’s case management of paediatric malaria, and these gains were retained over a 6-month period [29]. Intention-to-treat analysis showed that correct management improved by 23.7% (95% confidence interval (CI) 7.6 to 40.0, P <0.01) immediately after intervention and by 24.5% (95% CI 8.1 to 41.0, P <0.01) 6 months later, compared with the control group [29]. Reminders were also noted as an effective technique by two of the systematic reviews [13,14].

Self-directed: completed independently by the learner based on learning needs

This term was difficult to extract for analysis due to widely varying terminology. Some authors used the term 'distance learning’, and some used it to define the medium of delivery, rather than technique. This analysis specifically discusses articles that were consistent with the description for self-directed learning, even if the authors used different terminology.

A recent systematic review identified that moderate-quality evidence suggests a slight increase in knowledge domain compared with traditional teaching, but notes that this may be due to the increased exposure to content [30]. One RCT found modest improvements in knowledge using a self-directed approach, but noted it was less effective at impacting attitudes or readiness to change [31].

Multiple studies focused on use of the computer as the medium to deliver instruction and noted that self-directed instruction was equally (or more) effective as instructor-led didactic or interactive instruction and potentially more efficient.

Simulation may include models, devices, standardized patients, virtual environments, social or clinical situations that simulate problems, events or conditions experienced in professional encounters [17]. Simulation was noted as an effective technique for promotion of learning outcomes across the systematic reviews, particularly for the development of psychomotor and clinical decision-making skills. The systematic reviews all highlighted inconclusive and weak methodology in the studies reviewed, but noted sufficient evidence existed to support simulation as useful for psychomotor and communication skill development [32-34] and to facilitate learning [35]. The systematic review by Lamb suggests that patient simulators, whether computer or anatomic models, are one of the more effective forms of simulations [36].

Outcomes of the four separate RCTs indicated simulation was better than the techniques to which they were compared, including interactive [37,38], didactic [12] and problem-based approaches [35]. A study by Daniels et al. found that although knowledge outcomes were similar between the interactive and simulation groups, the simulation team performance in a labour and delivery clinical drill was significantly higher for both shoulder dystocia (11.75 versus 6.88, P <0.01) and eclampsia (13.25 versus 11.38, P = 0.032) at 1 month post-intervention [38].

Simulation was also found to be useful for identifying additional learning gaps, such as a drill on the task of mixing magnesium sulfate for administration [39]. A systematic review focused on resuscitation training identified simulation as an effective technique, regardless of media or setting used to deliver it [40].

Team-based: providing interventions for teams that provide care together

Articles discussed here focused on the technique of providing training to co-workers engaged as learning teams. One systematic review of eight studies found that there is limited and inconclusive evidence to support team-based training [41]. Two of the articles reporting on the same CPE study did not identify any improvements in performance or knowledge acquisition with the addition of using a team-based approach [39,42].

Frequency

This review included consideration of frequency, comparing single versus repetitive exposure. The findings regarding frequency are summarized in Table 4.

Table 4. Summary of articles focused on frequency

The three articles focused on frequency all support the use of repetitive interventions. These studies evaluated repetition using the Spaced Education platform (now called Qstream), an Internet-based medium that uses repeated questions and targeted feedback. The evidence from these three articles demonstrated that repetitive, time-spaced education exposures resulted in better knowledge outcomes, better retention and better clinical decisions compared with single interventions and live instruction [43-45].

The use of repetitive or multiple exposures is supported in other systematic reviews of the literature, as well as one RCT conducted in Kenya that used repeated text reminders and resulted in a significant improvement in adherence to malaria treatment protocols [29].

Setting

Setting is the physical location within which the instruction occurs. We identified three articles that looked specifically at the training setting. The findings regarding setting are summarized in Table 5. Two of them stemmed from the same intervention. Crofts et al. specifically addressed the impact of setting and technique (team-based training) on knowledge acquisition and found no significant difference in the post-score based on the setting [42]. A systematic review of eight articles evaluating the effectiveness of team-based training for obstetric care did not find significant differences in learning outcomes between a simulation centre and a clinical setting [41].

Table 5. Summary of articles focused on setting

Coomarasamy and Khan conducted a systematic review and compared classroom or stand-alone versus clinically integrated teaching for evidence-based medicine (EBM). Their review identified that classroom teaching improved knowledge, but not skills, attitudes or behaviour outcomes; whereas clinically integrated teaching improved all outcomes [46]. This finding was supported by the Hamilton systematic review of CPE, which suggests that teaching in a clinical setting or simulation setting is more effective (Table 1), as well as the Raza et al. systematic review of 23 studies to evaluate stand-alone versus clinically integrated teaching. This review suggested that clinically integrated teaching improved skills, attitudes and behaviour, not just knowledge [18].

Media

Media refers to the means used to deliver the curriculum. The majority of RCTs compared self-paced or individual instruction delivered via computer versus live, group-based instruction. The findings regarding media are summarized in Table 6.

Table 6. Summary of articles focused on media used to deliver instruction

Live versus computer-based

Live instruction was found to be somewhat effective at improving knowledge, but less so for changing clinical practice behaviours. When comparing live to computer-based instruction, a frequent finding was that computer-based instruction led to either equal or slightly better knowledge performance on post-tests than live instruction. One of the few to identify a significant difference in outcomes, Harrington and Walker found the computer-based group outperformed the instructor-led group on the knowledge post-test and that participants in the computer-based group, on average, spent less time completing the training than participants in the instructor-led group [47].

Systematic reviews indicate that the evidence supports the use of computer-delivered instruction for knowledge and attitudes; however, insufficient evidence exists to support its use in the attempt to change practice behaviours. The Raza Cochrane systematic review identified 16 randomized trials that evaluated the effectiveness of Internet-based education used to deliver CPE to practicing health care professionals. Six studies showed a positive change in participants’ knowledge, and three studies showed a change in practice in comparison with traditional formats [18]. One systematic review noted the importance of interactivity, independent of media, in achieving an impact on clinical practice behaviours [48].

Mobile

One article assessed the use of animations against audio instructions in cardiopulmonary resuscitation (CPR) using a mobile phone and found the group that had audiovisual animations performed better than the group that received live instruction over the phone in performing CPR; however, neither group was able to perform the psychomotor skill correctly [49]. Leung et al. found providing POC decision support via a mobile device resulted in slightly better self-reporting on outcome measures compared with print-based job aids, but that both the print and mobile groups showed improvements in use of evidence-based decision-making [26].

Print

The systematic review of print-based materials conducted by Farmer et al. did not find sufficient evidence to support the use of print media to change clinical practice behaviours [50]. A comparison of the use of print-based guidelines to a live, interactive workshop indicated that those who completed live instruction were slightly better able to identify patients at high risk of an asthma attack. However, neither intervention resulted in changed practice behaviours related to treatment plans [51].

Multiple systematic reviews caution against the use of print only media, concluding that live instruction is preferable to print only. Another consistent theme was support for the use of multimedia in CPE interventions.

Outcomes

Outcomes are the consequences of a training intervention. This literature review focuses on changes in knowledge, attitudes, psychomotor, clinical decision-making or communication skills, and effects on practice behaviours and clinical outcomes. All of the articles that focused on outcomes were systematic reviews of the literature and are summarized in Table 7.

Table 7. Summary of articles focused on outcomes: knowledge, attitudes, types of skills, practice behaviour, clinical practice outcomes

The weight of the evidence across several studies indicated that CPE could effectively address knowledge outcomes, although several studies used weaker methodological approaches. Specifically, computer-based instruction was found to be equally or more effective than live instruction for addressing knowledge, while multiple repetitive exposures leads to better knowledge gains than a single exposure. Games can also contribute to knowledge if designed as interactive learning experiences that stimulate higher thinking through analysis, synthesis or evaluation.

No studies or systematic reviews looked only at attitudes, but CPE that includes clinical integration, simulations and feedback may help address attitudes. The JHU EPC group systematic review evaluation of the short- and long-term effects of CPE on physician attitudes reviewed 26 studies and, despite the heterogeneity of the studies, identified trends supporting the use of multimedia and multiple exposures for addressing attitudes [6].

Several systematic reviews looked specifically at skills, concluding that there is weak but sufficient evidence to suggest that psychomotor skills can be addressed with CPE interventions that include simulations, practice with feedback and/or clinical integration. 'Dose-response’ or providing sufficient practice and feedback was identified as important for skill-related outcomes. Other RCTs suggest clinically integrated education for supporting skill development. Choa et al. found that neither the audio mentoring via mobile nor animated graphics via mobile resulted in the desired psychomotor skills, reinforcing the need for practice and feedback for psychomotor skill development identified in other studies [49].

Two systematic reviews focused on communication skills and found techniques that include behaviour modeling, practice and feedback, longer duration or more practice opportunities were more effective [52,53]. Evidence suggests that development of communication skills requires interactive techniques that include practice-oriented strategies and feedback, and limit lecture and print-based materials to supportive strategies only.

Findings also suggest that simulation, PBL, multiple exposures and clinically integrated CPE can improve critical thinking skills. Mobile-based POC support was found to be more useful in the development of critical thinking than print-based job aids.

Several systematic reviews specifically looked at CPE, practice behaviours and the behaviours of the provider. These studies found, despite reportedly weak evidence, that interactive techniques that involved feedback, interaction with the educator, longer durations, multiple exposures, multimedia, multiple techniques and reminders may influence practice behaviours.

A targeted review of 37 articles from the JHU EPC review on the impact of CPE on clinical practice outcomes drew no firm conclusions, but multiple exposures, multimedia and multiple techniques were recommended to improve potential outcomes [6]. Interaction and feedback were found to be more useful than print or educational meetings (systematic review of nine articles) [24], but print-based unsolicited materials were not found to be effective [50]. The systematic review of live, classroom-based, multi-professional training conducted by Rabal et al. found 'the impact on clinical outcomes is limited’ [54].

Discussion

The heterogeneity of study designs included in this review limits the interpretations that can be drawn. However, there is remarkable similarity between the information from studies included in this review and similar discussions published in the educational psychology literature. We believe that there is sufficient evidence to support efforts to implement and evaluate the combinations of training techniques, frequency, settings and media included in this discussion.

Avoid educational techniques that provide a passive transfer of information, such as lecture and reading, and select techniques that engage the learner in mental processing, for example, case studies, simulation and other interactive strategies. This recommendation is reinforced in educational psychology literature [55]. There is sufficient evidence to endorse the use of simulation as a preferred educational technique, notably for psychomotor, communication or critical thinking skills. Given the lack of evidence for didactic methods, selecting interactive, effective educational techniques remains the critical point to consider when designing CPE interventions.

Self-directed learning was also found to be an effective strategy, but requires the use of interactive techniques that engage the learner. Self-directed learning has the additional advantage of allowing learners to study at their own pace, select times convenient for them and tailor learning to their specific needs.

Limited evidence was found to support team-based learning or the provision of training in work teams. There is a need for further study in this area, given the value of engaging teams that are in the same place at the same time in an in-service training intervention. This finding is especially relevant for emergency skills that require the collaboration and cooperation of a team.

Repetitive exposure is supported in the literature. When possible, replace single-event frequency with targeted, repetitive training that provides reinforcement of important messages, opportunities to practice skills and mechanisms for fostering interaction. Recommendations drawn from the educational psychology literature that address the issue of cognitive overload [56] suggest targeting information to essentials and repetition.

Select the setting based on its ability to deliver effective educational techniques, be similar to the work environment and allow for practice and feedback. In this time of crisis, workplace learning that reduces absenteeism and supports individualized learning is critical. Conclusions from literature in educational psychology reinforce the importance of 'situating’ learning to make the experience as similar to the workplace as possible [57].

Certain common themes emerged from the many articles that commented on the role of media in CPE effectiveness. A number of systematic reviews suggest the use of multimedia in CPE. It is important to note that the studies that found similar knowledge outcomes between computer-based and live instruction stated that both utilized interactive techniques, possibly indicating the effectiveness was due to the technique rather than the media through which it was delivered. While the data on use of mobile technology to deliver CPE were limited, the study by Zurovac et al. indicated the potential power of mobile technology to improve provider adherence to clinical protocols [29]. Currently, there is unprecedented access to basic mobile technology and increasing access to lower-cost tablets and computers. The use of these devices to deliver effective techniques warrants exploration and evaluation, particularly in low- and middle-income countries.

CPE can positively impact desired learning outcomes if effective techniques are used. There are, however, very limited and weak data that directly link CPE to improved clinical practice outcomes. There are also limited data that link CPE to improved clinical practice behaviours, which may influence the strength of the linkage to outcomes.

Limitations

The following limitations apply to the methodology that we selected for this study. An integrative review of the literature was selected because the majority of published studies of education and training in low- and middle-resource countries did not meet the parameters required of a more rigorous systematic review or meta-analysis. The major limitation of integrative reviews is the potential for bias from their inclusion of non-peer-reviewed information or lower-quality studies. The inclusion of articles representing a range of rigor in their research design restricts the degree of confidence that can be placed on interpretations drawn by the authors of those articles, with the exception of original articles that explicitly discussed quality (such as systematic reviews). This review did not make an additional attempt to reanalyse or combine primary data.

Therefore, for purpose of this article, we also graded all articles and included only tier 1 articles in the analysis. This resulted in restriction of information on certain topics for this report, although a wider range of information is available.

We faced an additional limitation in that many articles included in the review were neither fully transparent nor consistent with terminology definitions used in other reports. This is due in part to the fact that we went beyond the bio-medical literature, to include studies conducted in the education and educational psychology literature, as was appropriate to the integrative review methodology. Certain topics were underdeveloped in the literature, which limits the interpretation that can be drawn on these topics. Other topics are addressed in studies conducted using lower-tier research methodologies (for example observational and/or qualitative studies) that were not included in this article. In addition, the overwhelming majority of studies focused on health professionals in developed or middle-income countries. There were very few articles of sufficient rigor conducted in low- and middle-income countries. This limits what we can say regarding the application of these findings among health workers of a lower educational level and in lower-resourced communities.

Conclusions

In-service training has been and will remain a significant investment in developing and maintaining essential competencies required for optimal public health in all global service settings. Regrettably, in spite of major investments, we have limited evidence about the effectiveness of the techniques commonly applied across countries, regardless of level of resource.

Nevertheless, all in-service training, wherever delivered, must be evidence-based. As stated in Bloom’s systematic review, 'Didactic techniques and providing printed materials alone clustered in the range of no to low effects, whereas all interactive programmes exhibited mostly moderate to high beneficial effect. … The most commonly used techniques, thus, generally were found to have the least benefit’ [14]. The profusion of mobile technology and increased access to technology present an opportunity to deliver in-service training in many new ways. Given current gaps in high-quality evidence from low- and middle-income countries, the future educational research agenda must include well-constructed evaluations of effective, cost-effective and culturally appropriate combinations of technique, setting, frequency and media, developed for and tested among all levels of health workers in low- and middle-income countries.

Abbreviations

BEME: Best Evidence in Medical Education; CI: Confidence interval; CINAHL: Cumulative Index to Nursing and Allied Health Literature; CME: Continuing medical education; CPE: Continuing professional education; CPR: Cardiopulmonary resuscitation; EBM: Evidence-based medicine; JHU EPC: Johns Hopkins University Evidence-Based Practice Center; MeSH: Medical subject headings; OCEMB: Oxford Centre for Evidence-Based Medicine; PBL: Problem-based learning; POC: Point-of-care; RCT: Randomized controlled trial.

Competing interests

The authors declare they have no competing interests.

Authors’ contributions

JB performed article reviews for inclusion, synthesized data and served as primary author of the analysis and manuscript. PJ conceived the study, participated in its design and coordination, and provided significant input into the manuscript. JF provided guidance on the literature review process, grading and categorizing criteria, and quality review of selected articles, and participated actively as an author of the manuscript. CC and JBT contributed to writing of the manuscript. JA searched the literature, performed initial review and coding, and contributed to selected sections of the manuscript. All authors read and approved the final manuscript.

Acknowledgments

We thank the Jhpiego Corporation for support for this research. We thank Dana Lewison, Alisha Horowitz, Rachel Rivas D’Agostino and Trudy Conley for their support in editing and formatting the manuscript. We also thank Spyridon S Marinopoulos, MD, MBA, from the Johns Hopkins University School of Medicine, for his initial input into the study and links to relevant resources. The findings, interpretations and conclusions expressed in this paper are those of the authors and not necessarily those of the Jhpiego Corporation.

References

  1. Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, Fineberg H, Garcia P, Ke Y, Kelley P, Kistnasamy B, Meleis A, Naylor D, Pablos-Mendez A, Reddy S, Scrimshaw S, Sepulveda J, Serwadda D, Zurayk H: Health professionals for a new century: transforming education to strengthen health systems in an interdependent world.

    Lancet 2010, 376(9756):1923-1958. PubMed Abstract | Publisher Full Text OpenURL

  2. Wittemore R, Kanfl K: The integrative review: updated methodology.

    In J Adv Nursing 2005, 52(5):546-553. Publisher Full Text OpenURL

  3. Marinopoulos SS, Baumann MH: American College of Chest Physicians Health and Science Policy Committee: Methods and definition of terms: effectiveness of continuing medical education: American College of Chest Physicians Evidence-Based Educational Guidelines.

    Chest 2009, 135(3 Suppl):17S-28S. PubMed Abstract | Publisher Full Text OpenURL

  4. Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence Working Group: The Oxford 2011 Levels of Evidence. Oxford: Centre for Evidence Based Medicine; 2011.

    http://www.cebm.net/?O=1025 webcite

    OpenURL

  5. Best Evidence in Medical Education (BEME):

    Appendix 1-BEME Coding Sheet. 2011.

    http://www.medicalteacher.org/MEDTEACH_wip/supp%20files/BEME%204%20Figs%20%20Appendices/BEME4_Appx1.pdf webcite

    OpenURL

  6. Marinopoulos SS, Dorman T, Ratanawongsa N, Wilson LM, Ashar BH, Magaziner JL, Miller RG, Thomas PA, Prokopowicz GP, Qayyum R, Bass EB: Effectiveness of continuing medical education. Evidence Report/Technology Assessment, No. 149, (Prepared by the Johns Hopkins Evidence-based Practice Center, under Contract No.290-02-0018) AHRQ Publication No. -7-E006. Agency for Healthcare Research and Quality: Rockville, MD; January 2007. OpenURL

  7. Triola M, Feldman H, Kalet AL, Zabar S, Kachur EK, Gillespie C, Anderson M, Griesser C, Lipkin M: A randomized trial of teaching clinical skills using virtual and live standardized patients.

    J Gen Intern Med 2006, 21(5):424-429. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  8. Smits PB, De Buisonje CD, Verbeek JH, Van Dijk FJ, Metz JC, Ten Cate OJ: Problem-based learning versus lecture-based learning in postgraduate medical education.

    Scand J Work Environ Health 2003, 29(4):280-287. PubMed Abstract | Publisher Full Text OpenURL

  9. White M, Michaud G, Pachev G, Lirenman D, Kolenc A, FitzGerald JM: Randomized trial of problem-based versus didactic seminars for disseminating evidence-based guidelines on asthma management to primary care physicians.

    J ContinEduc Health Prof 2004, 24(4):237-243. Publisher Full Text OpenURL

  10. De Lorenzo RA, Abbott CA: Effectiveness of an adult-learning, self-directed model compared with traditional lecture-based teaching methods in out-of-hospital training.

    Acad Emerg Med 2004, 11(1):33-37. PubMed Abstract | Publisher Full Text OpenURL

  11. Lin CF, Lu MS, Chung CC, Yang CM: A comparison of problem-based learning and conventional teaching in nursing ethics education.

    Nurs Ethics 2010, 17(3):373-382. PubMed Abstract | Publisher Full Text OpenURL

  12. Reynolds A, Ayres-de-Campos D, Pereira-Cavaleiro A, Ferreira-Bastos L: Simulation for teaching normal delivery and shoulder dystocia to midwives in training.

    Educ Health (Abingdon) 2010, 23(3):405. OpenURL

  13. Alvarez MP, Agra Y: Systematic review of educational interventions in palliative care for primary care physicians.

    Palliat Med 2006, 20(7):673-683. PubMed Abstract | Publisher Full Text OpenURL

  14. Bloom BS: Effects of continuing medical education on improving physician clinical care and patient health: a review of systematic reviews.

    Int J Technol Assess Health Care 2005, 21(3):380-385. PubMed Abstract OpenURL

  15. Satterlee WG, Eggers RG, Grimes DA: Effective medical education: insights from the Cochrane Library.

    Obstet Gynecol Surv 2008, 63(5):329-333. PubMed Abstract | Publisher Full Text OpenURL

  16. Herbert CP, Wright JM, Maclure M, Wakefield J, Dormuth C, Brett-MacLean P, Legare J, Premi J: Better Prescribing Project: a randomized controlled trial of the impact of case-based educational modules and personal prescribing feedback on prescribing for hypertension in primary care.

    Fam Pract 2004, 21(5):575-581. PubMed Abstract | Publisher Full Text OpenURL

  17. Issenberg SB, McGaghie WC, Petrusa ER, Lee Gordon D, Scalese RJ: Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review.

    Med Teach 2005, 27(1):10-28. PubMed Abstract | Publisher Full Text OpenURL

  18. Raza A, Coomarasamy A, Khan KS: Best evidence continuous medical education.

    Arch Gynecol Obstet 2009, 280(4):683-687. PubMed Abstract | Publisher Full Text OpenURL

  19. Akl EA, Pretorius RW, Sackett K, Erdley WS, Bhoopathi PS, Alfarah Z, Schunemann HJ: The effect of educational games on medical students’ learning outcomes: a systematic review: BEME Guide No 14.

    Med Teach 2010, 32(1):16-27. PubMed Abstract | Publisher Full Text OpenURL

  20. Laprise R, Thivierge R, Gosselin G, Bujas-Bobanovic M, Vandal S, Paquette D, Luneau M, Julien P, Goulet S, Desaulniers J, Maltais P: Improved cardiovascular prevention using best CME practices: a randomized trial.

    J Contin Educ Health Prof 2009, 29(1):16-31. PubMed Abstract | Publisher Full Text OpenURL

  21. Forsetlund L, Bjorndal A, Rashidian A, Jamtvedt G, O’Brien MA, Wolf F, Davis D, Odgaard-Jensen J, Oxman AD: Continuing education meetings and workshops: effects on professional practice and health care outcomes.

    Cochrane Database Syst Rev 2009, 2:CD003030. PubMed Abstract | Publisher Full Text OpenURL

  22. Mansouri M, Lockyer J: A meta-analysis of continuing medical education effectiveness.

    J Contin Educ Health Prof 2007, 27(1):6-15. PubMed Abstract | Publisher Full Text OpenURL

  23. Perry M, Draskovic I, Lucassen P, Vernooij-Dassen M, Van Achterberg T, Rikkert MO: Effects of educational interventions on primary dementia care: A systematic review.

    Int J Geriatr Psychiatr 2011, 26(1):1-11. Publisher Full Text OpenURL

  24. Rampatige R, Dunt D, Doyle C, Day S, Van Dort P: The effect of continuing professional education on health care outcomes: lessons for dementia care.

    Int Psychogeriatr 2009, 21(Suppl 1):S34-S43. PubMed Abstract | Publisher Full Text OpenURL

  25. Blaya JA, Fraser HS, Holt B: E-health technologies show promise in developing countries.

    Health Aff (Millwood) 2010, 29(2):244-251. Publisher Full Text OpenURL

  26. Leung GM, Johnston JM, Tin KY, Wong IO, Ho LM, Lam WW, Lam TH: Randomised controlled trial of clinical decision support tools to improve learning of evidence-based medicine in medical students.

    BMJ 2003, 327(7423):1,090. OpenURL

  27. You JS, Park S, Chung SP, Park JW: Usefulness of a mobile phone with video telephony in identifying the correct landmark for performing needle thoracocentesis.

    Emerg Med J 2009, 26(3):177-179. PubMed Abstract | Publisher Full Text OpenURL

  28. Yuan H, Williams BA, Fan L: A systematic review of selected evidence on developing nursing students’ critical thinking through problem-based learning.

    Nurse Educ Today 2008, 28(6):657-663. PubMed Abstract | Publisher Full Text OpenURL

  29. Zurovac D, Sudoi RK, Akhwale WS, Ndiritu M, Hamer DH, Rowe AK, Snow RW: The effect of mobile phone text-message reminders on Kenyan health workers’ adherence to malaria treatment guidelines: a cluster randomised trial.

    Lancet 2011, 378(9793):795-803. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  30. Murad MH, Coto-Yglesias F, Varkey P, Prokop LJ, Murad AL: The effectiveness of self-directed learning in health professions education: a systematic review.

    Med Educ 2010, 44(11):1,057-1,068. OpenURL

  31. Young JM, Ward J: Can distance learning improve smoking cessation advice in family practice? A randomized trial.

    J Contin Educ Health Prof 2002, 22(2):84-93. PubMed Abstract | Publisher Full Text OpenURL

  32. Harder BN: Use of simulation in teaching and learning in health sciences: a systematic review.

    J Nurs Educ 2010, 49(1):23-28. PubMed Abstract | Publisher Full Text OpenURL

  33. McGaghie WC, Siddall VJ, Mazmanian PE, Myers J: American College of Chest Physicians Health and Science Policy Committee: Lessons for continuing medical education from simulation research in undergraduate and graduate medical education: effectiveness of continuing medical education: American College of Chest Physicians Evidence-Based Educational Guidelines.

    Chest 2009, 135(3 Suppl):62S-68S. PubMed Abstract | Publisher Full Text OpenURL

  34. Sturm LP, Windsor JA, Cosman PH, Cregan P, Hewett PJ, Maddern GJ: A systematic review of skills transfer after surgical simulation training.

    Ann Surg 2008, 248(2):166-179. PubMed Abstract | Publisher Full Text OpenURL

  35. Steadman RH, Coates WC, Huang YM, Matevosian R, Larmon BR, McCullough L, Ariel D: Simulation-based training is superior to problem-based learning for the acquisition of critical assessment and management skills.

    Crit Care Med 2006, 34(1):151-157. PubMed Abstract | Publisher Full Text OpenURL

  36. Lamb D: Could simulated emergency procedures practised in a static environment improve the clinical performance of a Critical Care Air Support Team (CCAST)? A literature review.

    Intensive Crit Care Nurs 2007, 23(1):33-42. PubMed Abstract | Publisher Full Text OpenURL

  37. Bruppacher HR, Alam SK, LeBlanc VR, Latter D, Naik VN, Savoldelli GL, Mazer CD, Kurrek MM, Joo HS: Simulation-based training improves physicians’ performance in patient care in high-stakes clinical setting of cardiac surgery.

    Anesthesiology 2010, 112(4):985-992. PubMed Abstract | Publisher Full Text OpenURL

  38. Daniels K, Arafeh J, Clark A, Waller S, Druzin M, Chueh J: Prospective randomized trial of simulation versus didactic teaching for obstetrical emergencies.

    Simul Healthc 2010, 5(1):40-45. PubMed Abstract | Publisher Full Text OpenURL

  39. Ellis D, Crofts JF, Hunt LP, Read M, Fox R, James M: Hospital, simulation center, and teamwork training for eclampsia management: a randomized controlled trial.

    Obstet Gynecol 2008, 111(3):723-731. PubMed Abstract | Publisher Full Text OpenURL

  40. Hamilton R: Nurse’s knowledge and skill retention following cardiopulmonary resuscitation training: a review of the literature.

    J Adv Nurs 2005, 51(3):288-297. PubMed Abstract | Publisher Full Text OpenURL

  41. Merien AE, Van de Ven J, Mol BW, Houterman S, Oei SG: Multidisciplinary team training in a simulation setting for acute obstetric emergencies: a systematic review.

    Obstet Gynecol 2010, 115(5):1,021-1,031. OpenURL

  42. Crofts JF, Ellis D, Draycott TJ, Winter C, Hunt LP, Akande VA: Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomised controlled trial of local hospital, simulation centre and teamwork training.

    BJOG 2007, 114(12):1,534-1,541. OpenURL

  43. Kerfoot BP, Fu Y, Baker H, Connelly D, Ritchey ML, Genega EM: Online spaced education generates transfer and improves long-term retention of diagnostic skills: a randomized controlled trial.

    J Am Coll Surg 2010, 211(3):331-337. PubMed Abstract | Publisher Full Text OpenURL

  44. Kerfoot BP, Kearney MC, Connelly D, Ritchey ML: Interactive spaced education to assess and improve knowledge of clinical practice guidelines: a randomized controlled trial.

    Ann Surg 2009, 249(5):744-749. PubMed Abstract | Publisher Full Text OpenURL

  45. Kerfoot BP, Baker HE, Koch MO, Connelly D, Joseph DB, Ritchey ML: Randomized, controlled trial of spaced education to urology residents in the United States and Canada.

    J Urol 2007, 177(4):1,481-1,487. OpenURL

  46. Coomarasamy A, Khan KS: What is the evidence that postgraduate teaching in evidence based medicine changes anything? A systematic review.

    BMJ 2004, 329(7473):1,017. OpenURL

  47. Harrington SS, Walker BL: The effects of computer-based training on immediate and residual learning of nursing facility staff.

    J Contin Educ Nurs 2004, 35(4):154-163.

    quiz 186–7

    PubMed Abstract OpenURL

  48. Curran VR, Fleet L: A review of evaluation outcomes of web-based continuing medical education.

    Med Educ 2005, 39(6):561-567. PubMed Abstract | Publisher Full Text OpenURL

  49. Choa M, Park I, Chung HS, Yoo SK, Shim H, Kim S: The effectiveness of cardiopulmonary resuscitation instruction: animation versus dispatcher through a cellular phone.

    Resuscitation 2008, 77(1):87-94. PubMed Abstract | Publisher Full Text OpenURL

  50. Farmer AP, Legare F, Turcot L, Grimshaw J, Harvey E, McGowan JL, Wolf F: Printed educational materials: effects on professional practice and health care outcomes.

    Cochrane Database Syst Rev 2008, 3:CD004398. PubMed Abstract | Publisher Full Text OpenURL

  51. Liaw ST, Sulaiman ND, Barton CA, Chondros P, Harris CA, Sawyer S, Dharmage SC: An interactive workshop plus locally adapted guidelines can improve general practitioners asthma management and knowledge: a cluster randomised trial in the Australian setting.

    BMC Fam Pract 2008, 9:22. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text OpenURL

  52. Gysels M, Richardson A, Higginson IJ: Communication training for health professionals who care for patients with cancer: a systematic review of training methods.

    Support Care Canc 2005, 13(6):356-366. Publisher Full Text OpenURL

  53. Berkhof M, Van Rijssen HJ, Schellart AJ, Anema JR, Van der Beek AJ: Effective training strategies for teaching communication skills to physicians: an overview of systematic reviews.

    Patient Educ Couns 2011, 84(2):152-162. PubMed Abstract | Publisher Full Text OpenURL

  54. Rabol LI, Ostergaard D, Mogensen T: Outcomes of classroom-based team training interventions for multiprofessional hospital staff: A systematic review.

    Qual Saf Health Care 2010, 19(6):e27. PubMed Abstract | Publisher Full Text OpenURL

  55. Woolfolk AE: Educational Psychology. 11th edition. Upper Saddle River, NJ: Pearson/Merrill/Prentice Hall; 2009. OpenURL

  56. Mayer RE: Applying the science of learning to medical education.

    Med Educ 2010, 44(6):543-549. PubMed Abstract | Publisher Full Text OpenURL

  57. Gott S, Lesgold A: Competence in the workplace: how cognitive performance models and situated instruction can accelerate skill acquisition. In Advances in Instructional Psychology, Volume 4. Edited by Glaser R. Hillsdale, NJ: Erlbaum; 2000. OpenURL