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Part 1. Undergraduate Nursing Evidence-Based Practice Education: Envisioning the Role of Students
PART 1. UNDERGRADUATE NURSING EVIDENCE-BASED PRACTICE EDUCATION: ENVISIONING THE ROLE OF STUDENTS SUSAN D. MOCH, PHD,* RUTH J. CRONJE, PHD,y AND JESSICA BRANSONz Nursing educators have embraced the integration of evidence-based practice (EBP) into the nursing education curriculum in numerous ways. As this review of the nursing pedagogy literature demonstrates, most of these approaches built upon long-standing commitments to helping students understand the scientific research process, think critically, and develop the information literacy skills that will enable them to find the evidence that can inform their practice. Many reports in the nursing pedagogy literature recounted various strategies used to teach EBP to nursing students. Another category of nursing pedagogy articles discussed ways that EBP education can be suffused throughout the nursing school curriculum. Few educators, however, have envisioned students as having a role beyond that of the mere recipients of EBP education. Nonetheless, a small but growing number of nurse educators have begun to envision students as enablers of practice change in clinical settings. These innovators advocate a pedagogical paradigm that places students into socially meaningful partnerships with practicing nurses as a means to promote the uptake of EBP in clinical settings. (Index words: Evidencebased practice; Nursing education; Undergraduate; Research utilization; Research–Practice gap) J Prof Nurs 26:5–13, 2010. © 2010 Elsevier Inc. All rights reserved.
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NE SIGN THAT evidence-based practice (EBP) has achieved widespread acceptance among nursing professionals is the extent to which it has been integrated into the curriculum of nursing schools. The nursing pedagogy literature is now replete with descriptions of strategies for teaching EBP to both graduate and undergraduate nursing students and descriptions of how EBP education can suffuse the curriculum (Estabrooks, Floyd, Scott-Findlay, O'Leary,
*Professor, College of Nursing and Health Science, University of Wisconsin-Eau Claire, Eau Claire, WI 54702-4004. †Associate Professor, Scientific and Technical Writing Program, University of Wisconsin-Eau Claire, Eau Claire, WI 54702-4004. ‡Undergraduate student, University of Wisconsin-Eau Claire, Eau Claire, WI 54702-4004. This work was funded by a Student-Faculty collaborative research grant from the University of Wisconsin-Eau Claire. This is the first part of a three-part series. Address correspondence to Dr. Moch: College of Nursing and Health Science, University of Wisconsin-Eau Claire, 105 Garfield Avenue, Eau Claire, WI. E-mails: [email protected], [email protected], [email protected] 8755-7223/09/$ - see front matter
& Gushta, 2003; Melnyk & Fineout-Overholt, 2005). Less often, one finds reports of evidence of success in instilling in nursing students an understanding of the principles and procedures of EBP (Ferguson & Day, 2005). It seems clear that, if nursing educators have anything to say about it, EBP is here to stay. The Institute of Medicine has recommended a number of initiatives designed to close the health care quality chasm by the Year 2010; included among them is the recommendation that all health care practices be evidence based (Institute of Medicine, 2003). One year before the recommended deadline seems an apt time to take stock of the state of evidence-based nursing pedagogy and to consider whether the recommendations for instilling EBP knowledge, skills, and attitudes in nursing education made by Cronenwett et al. (2007) are being met. In this article, we review the literature on pedagogy in nursing schools targeted toward teaching EBP to undergraduate nursing students. Specifically, we consider how the role of faculty and that of students has been envisioned as a means to promote the integration of EBP in the nursing profession.
Journal of Professional Nursing, Vol 26, No 1 (January-February), 2010: pp 5–13 © 2010 Elsevier Inc. All rights reserved.
5 doi:10.1016/j.profnurs.2009.01.015
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Article Selection
8. Stevens and Cassidy (1999), Evidence-Based
Teaching: Current Research in Nursing Education.
Using the Cumulative Index to Nursing and Allied Health Literature (CINAHL) database, the following search strategy was used: exp education, nursing + nursing practice, evidence-base, and limited to 1997–2007. All articles that included undergraduate nursing education and EBP were included. Articles that focused on continuing education in the clinical setting only were generally excluded. The reference lists of all articles used were also reviewed for any other references that included nursing education, students, and EBP. In addition, a manual search of the table of contents was made of the following journals for at least 5 years or since onset of the journal: Journal of Nursing Education, Nurse Educator, Journal of Professional Nursing, Perspectives in Nursing Education, and World Views on EvidenceBased Nursing. Articles in these journals, as well as articles in reference lists, were selected if learning–teaching in formal education programs, rather than only continuing education programs, was included. Articles that discussed undergraduate education, graduate education, academic– practice partnerships, and community–student endeavors were also reviewed for the inclusion of undergraduate students and EBP. Articles that only discussed continuing education or education within health care agencies were omitted unless a teaching strategy or the research was applicable to this review. No independent evaluations were completed about whether an article was eligible, and no blinding procedures for journals, authors, or institutions were included as all articles found that addressed EBP and undergraduate education were included. Article selection was not limited to research articles as few research articles on this topic were found. Editorials, commentaries, essays, and descriptions of teaching strategies related to the topic were included as these articles often described possibilities and future trends for students and EBP. Nursing-related textbooks or books on EBP and teaching were also reviewed:
The EBP nursing pedagogy literature reveals an effort to link the innovation of EBP to long-standing traditions in nursing education, suggesting that EBP represents less a rupture in nursing pedagogy than a refinement of commitments already in place. The legacy of teaching the research process, for example, is both explicit and implicit in the EBP pedagogy literature. Ciliska (2006) cautioned about the need to be careful in substituting education in EBP for education in research content, suggesting that educators sometimes shift content from research courses to EBP courses. She urged research on specific teaching strategies that measure outcomes and recommended faculty development in EBP. The legacy of instruction in critical thinking is also apparent throughout the EBP pedagogy literature. Profetto-McGrath (2005) asserted that “among the knowledge, skill, and processes need to support EBP, CT (critical thinking) is paramount” (p. 364). Seymour, Kinn, and Sutherland (2003) suggested that learning critical thinking in a collaborative manner with colleagues and educators could decrease the research–practice gap as “merely teaching and learning about research is not enough to ensure that such learning translates into the culture of practice” (p. 292). Information literacy is also emphasized in the undergraduate EBP education literature. The need for students to know how to access information has been articulated as a major step in the EBP process (Cronenwett et al., 2007; Fineout-Overholt, Cox, Robbins, & Gray, 2005; Flesner, Miller, McDaniel, & Rantz, 2006; Skiba, 2005; Trangenstein & Weiner, 2006) and as a skill that needs to be integrated into the curriculum (Staggers, Gassert, & Curran, 2001; Verhey, 1999). Fineout-Overholt, Cox, et al. (2005) identified a myriad of pedagogical resources related to informatics and gaining information.
1. Brown (2009), Evidence-Based Nursing: The
The Scope and Content of EBP Pedagogy
Research–Practice Connection. 2. DiCenso, Guyatt, and Caliska (2005), Evidence-
Based Nursing: A Guide to Clinical Practice. 3. Gibbs (2003), Evidence-Based Practice for the
4.
5.
6.
7.
Helping Professions: A Practical Guide with Integrated Multimedia. Levin and Feldman (2006), Teaching EvidenceBased Practice in Nursing: A Guide for Academic and Clinical Settings. Malloch and Porter-O'Grady (2006), Introduction to Evidence-Based Practice in Nursing and Health Care. Melnyk and Fineout-Overholt (2005), EvidenceBased Practice in Nursing and Healthcare: A Guide to Best Practice. Schmidt and Brown (2009), Evidence-Based Practice for Nurses.
Findings The Evolution of EBP Nursing Pedagogy
Numerous articles in the EBP pedagogy literature have addressed the question of what general knowledge and specific skills future nurses will require. There seems to be general consensus that the content of EBP pedagogy should parallel the EBP process as it is currently conceptualized. Melnyk and Fineout-Overholt (2005), for example, described the process of systematically teaching students to ask compelling questions, critically appraise the evidence, and apply it. Similar to the textbook of Melnyk and Fineout-Overholt, FineoutOverholt, Cox, et al. (2005) outlined the same plan for teaching the steps of EBP. Two other textbooks on EBP (DiCenso et al., 2005; Levin & Feldman, 2006b) also advocated teaching these steps of the EBP process. Many reports in the nursing pedagogy literature described specific strategies educators have used to instill understanding of EBP principles and processes in
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Table 1. EBP Learning/Teaching Strategies References
Content
August-Brady (2005)
August-Brady included a collaborative clinical project in the research course content to facilitate active involvement in research by RN–BSN students. Students collected data on a safety issue in the clinical setting. Brancato (2006) Brancato advocated for a senior-level RN–BSN student practicum involving projects on EBP in a clinical setting. Students were assisted by hospital preceptors in doing an EBP project on real patientcare problems. Brosnan et al. (2005) The authors described the application of a community partnership model to a nursing assignment. The model links education, research, and practice through EBP, service learning, and scholarly teaching in a school-based project with high-risk student populations. Students were actively involved in research activities with community partners to meet the public health needs identified. Burman et al. (2007) The authors discussed the use of oral examinations in a graduate program for evaluating student comprehension on EBP articles and their applicability to the student's practice. They suggested that graduate students orally present the review of a research article. Cader et al. (2006) The authors used a health needs analysis assignment to learn about EBP. Through this qualitative study, the authors found that students needed more assistance with making judgments about the information found. Cheek et al. (2005) Cheek, Gillham, and Ballantyne described the Web Resource Appraisal Process, a teaching strategy which engages postgraduate student nurses to evaluate and integrate evidence into practice. Courey et al. (2006) Courey et al. reported a comparison study between two groups of associate degree nursing students on information literacy. The literacy program had a positive effect on students' information literacy skills and a negative effect on students' attitude toward staying current in the literature. Feldman and Levin (2006) Feldman and Levin advocated for cooperative learning groups for teaching EBP. Students were encouraged to work in cooperative learning groups to learn from each other in EBP learning. The mission was helping students learn and not about “teaching.” Fineout-Overholt, Hofstetter, The authors suggested that, in teaching EBP, search questions and search skills are necessary. The use et al. (2005) of the PICOT question, the databases, and search strategy are important content areas. In addition, collaboration among educators, librarians, and learners is essential in the searching process. Fineout-Overholt and Johnston Fineout-Overholt and Johnston proposed changing as is education practice based on tradition and (2005) evidence generation to teaching students to quickly find evidence, incorporate patient values, and use valid evidence. They stated that, “Nursing literature is relatively silent on the issue of how best to teach and evaluate skills required for EBP” (p. 38). Fonteyn (2002) Fonteyn advocated for education in locating and utilizing synopses journals (i.e., Evidence-Based Nursing) to quickly supplement and improve class and clinical content and thus improve practice. Foster (2004) Foster pointed out that nursing research courses lack clinical scholarship and suggested reasons for the lapse (i.e., research textbooks and information illiteracy). She proposed EBP reviews and presentations to procedure committees. Goodfellow (2004) Goodfellow described a process of implementing journal clubs for a postclinical conference in the clinical area. Through an evaluation by students and staff, she shared how this strategy spurred the students' excitement in locating, sharing, and using EBP. Hatala and Guyatt (2002) Hatala and Guyatt discussed the significance of EBP competencies which includes identifying the problem and the question, searching for literature, critically appraising evidence, and integrating evidence. However, they noted a lack of evidence for how to teach these skills. Ironside and Speziale (2006) Ironside and Speziale reported on a National League of Nursing survey that shows that preparation for EBP exists in the curriculum. The authors issued challenges for further research on the topic and asked about best practices for teaching EBP. Johnston and Fineout-Overholt Johnston and Fineout-Overholt discussed that translating “uncertainty” to an answerable question is a (2005) difficult but an important step in EBP. Teachers need to assist students in this process of identifying the PICOT question. Johnston and Fineout-Overholt Johnston and Fineout-Overholt noted that teaching critical appraisal skills is a difficult process but (2006) very important at the undergraduate level. They discussed several approaches to teaching critical appraisal in classes and suggested “librarian-facilitated access to distilled information sources” in the clinical area. Kelly et al. (2005) The assessing clinical evidence course for the accelerated BS–MS involved students working with clinicians in a research project. Partnerships with practice were established, and according to the authors, “this partnership did not only change clinical policy, it changed the academic practices” (p. 231). Kent and Fineout-Overholt Utilizing clinical practice guidelines is an EBP teaching–learning tool for practicing nurses. (2007) Kent et al. (2007) The authors described how to use practice guidelines in teaching and in practice. Ways for assessing the validity of the guidelines and the resources to assist in guideline distribution were included. (continued on next page)
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Table 1. (Continued) References Killeen and Barnfather (2005)
Content
Killeen and Barnfather used the conduct and utilization of research model to engage senior baccalaureate students in completing EBP projects in clinical agencies. The authors linked a research and a capstone course, and they promoted several semesters of involvement by students to create a richer EBP experience for students and a more meaningful project for staff. Klassen et al. (2002) Research-based skills manuals created by graduate students provided undergraduate students with the up-to-date research on the rationale for nursing skills. Lander (2005) Lander called for new strategies to increase undergraduate appraisal skills. One strategy is to use an Internet tool for accessing and appraising evidence (www.searchca.net). Leake (2004) Leake stated that students learned about tradition rather than research-based practices and policies through a sacred-cow contest. The contest continued to evolve and generated enthusiasm for research for students and nurses in practice. Levin and Feldman (2006b) The edited book of Levin and Feldman includes suggestions for teaching, which include asking questions, using a library, appraising evidence, and teaching meta-synthesis. Plans for teaching graduate students and nurses in practice were also included. Other authors discussed journal clubs, hospitalbased settings, and teaching nurse practitioners and second-degree students. Marchiondo (2006) Marchiondo engaged RN–BSN students in a research course in completing research utilization projects to help students understand the value of EBP. The students presented the protocol projects to involved agencies. McDaniel et al. (2002) The authors advocated the use of undergraduate student learners in EBP. Students disseminated information and worked with practitioners in EBP learning. Milner et al. (2006) This systematic review on clinical nurse educators revealed that clinical nurse educators are an important resource in research utilization. There is a need for increasing clinical appraisal skills and research knowledge among nurse educators. The Promoting Action on Research Implementation in Health Services framework was used in the study. Moch and Cronje (2007) Moch and Cronje suggested involving nursing students in new knowledge discussion groups to decrease the barriers often cited in diffusing EBP in practice settings. The role of students in fostering awareness of, appreciation for, and ability in EBP among practicing nurses was emphasized. Mulhall et al. (2000) Mulhall et al. described content and examined outcomes from a series of ten 4-day workshops on research-based practice. Content for the workshops was accessing literature, recognizing research designs, and assessing the potential for studies in the workplace. Outcomes included reducing fear and lack of understanding of research and increasing skills in critical appraisal. Newhouse (2007) Newhouse discussed how master's-level students do projects for clinical agencies through academic partnerships. Penz and Bassendowski (2006) Penz and Bassendowski shared strategies for clinical nurse educators to teach about EBP. Educators need to know about EBP; assure that policies, procedures, and guidelines are evidence based; and correct through consulting libraries, systematic reviews, and other resources. Radjenovic and Chally (1998) Radjenovic and Chally discussed implementation of a research utilization project based on the Stetler model in a senior nursing course. Students critiqued research and made posters for possible future implementation. Ravert et al. (2004) The authors discussed having all students work as research assistants in faculty–student research projects at least once during the undergraduate experience. An experience with clinical simulation was highlighted. Reeves (2006) Reeves discussed the application of the ACE Star Model to help bring research into practice in a course assignment. Students selected topics and then interviewed a nurse about the evidence and observed nurses in practice related to the topic. Schmidt and Brown (2007) Schmidt and Brown discussed the application of the innovation–decision process teaching strategy to aid students in overcoming impediments in comprehension and utilization of EBP. Students worked on issues identified by community representatives. Schoenfelder (2007) Schoenfelder described a teaching technique where students read and summarized a published EBPbased guideline and then developed a “tip sheet” which is then given to health professionals. Seymour et al. (2003) The authors advocated a transfer of critical-thinking skills from the classroom to the clinical setting and incorporated connections between practice and education such as journal clubs, critical incident analysis, and reflection. Learning research in the clinical environment with partnerships in education was advocated. Sheriff and Chaney (2006) Sheriff and Chaney discussed an evidence-based research paper, a presentation, and participation in a faculty-sponsored research project as a way to increase enthusiasm for and knowledge about research. Skiba (2005) Skiba discussed a lack of information literacy among practicing nurses; therefore, educators must ensure that nursing students are information literate for EBP. She encouraged an evaluation of literacy competency in educational settings.
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Table 1. (Continued) References Stevens (2001) Stevens and Long (1998)
Stone and Rowles (2007)
Trangenstein and Weiner (2006) Welk (2007) Williams et al. (2002)
Content Stevens promoted systematic reviews as essential for EBP. These reviews or evidence summaries are designed to answer clinical questions and are important for advanced practice nurses. Stevens and Long proposed a strategy for using systematic reviews in nursing education. The authors described the strategy and the procedures used to evaluate the strategy in undergraduate and graduate teaching. The study used undergraduate nursing students in a senior research utilization course to help staff nurses stay current with current research related to their unit. The research supported the use of students in saving time and increasing staff awareness. Trangenstein and Weiner proposed informatics competencies for various levels of nursing students. Competencies ranged from using the Internet to synthesizing data for decision making. Welk reviewed the meaning of seven statistical terms commonly used in EBP articles. Using an example, the author demonstrated use of EBP literature in teaching. The authors described teams of students and staff who developed evaluation projects. Thirty participants from four community agencies developed projects, and the benefits to students, staff, and faculty are summarized.
undergraduates (Table 1). The learning–teaching strategies described in these articles have potential to help undergraduates learn to value research and to understand the procedures of EBP. Most of these reports described a pilot teaching project deployed with a small group of students but did not discuss how these strategies can be applied to the entire undergraduate population.
Evidence-Based Practice Pedagogy Across the Curriculum Another class of EBP pedagogy articles (Table 2) discussed how the skills required for EBP can be threaded throughout the undergraduate nursing curriculum, as Ciliska (2005) has called for. As DiCenso, Cullum, and Ciliska (1998) have noted, We have learned that it is not sufficient to give nursing students a few lectures on the process of doing research and then expect them to use that knowledge throughout their careers in an ongoing process of gathering and interpreting research evidence and implementing findings (p. 38). Most articles focusing on curriculum development addressed the question of how to foster critical-thinking skills generally and how to instill knowledge of EBP procedures specifically. A few articles have addressed the question of bridging the nursing school–practice gap. Early in the EBP pedagogy discussion, Estabrooks (1998) suggested that nursing curricula should focus on “acquiring the skill sets and critical-thinking capacities necessary to not only locate and understand information, but also to be able to judge the appropriate match between evidential sources and the contextual demands of clinical encounters [italics added]” (p. 30). In 2003, Estabrooks et al. reviewed the literature identifying the need for more interdisciplinary, theoretically coherent research to investigate ways to better integrate EBP in practice settings. They concluded that there is still much work to be done to optimize the
integration of EBP in clinical settings. Frequently, creative pedagogical strategies that integrate clinical practice involve RN–bachelor of science in nursing (BSN; AugustBrady, 2005; Brancato, 2006), accelerated, postgraduate (Cheek, Gillham, & Ballantyne, 2005), or graduate students (Kelly et al., 2005; Newhouse, 2007). Seymour et al. (2003) recommended partnerships between universities and clinical institutions that provide students with active and participatory experiences that will teach them to think in the clinical setting. However, only a few articles in the nursing pedagogy literature (Callister, Matsumura, Lookinland, Mangum, & Loucks, 2005; Chaboyer, Willman, Johnson, & Stockhausen, 2004; Stevens 2005) directly discussed plans designed for implementing measures throughout the curriculum to give students realworld practice in applying EBP in clinical settings (Table 2).
The Role of Nursing Education in Promoting EBP in Clinical Settings A general consensus expressed in the nursing pedagogy literature is the belief that the key to ensuring EBP in clinical settings lies in instilling a commitment to EBP in future nurses while they are still in nursing school. Estabrooks et al. (2003) reported evidence that supports a link between beliefs and attitudes and research utilization among practicing nurses and clearly saw the classroom as a place to promulgate the beliefs and attitudes that will lead to EBP. Ciliska (2005) envisioned baccalaureate nursing school graduates as “good consumers of research —evidence users” who will help ensure a clinical culture that promotes reflection on practice and a desire to investigate alternatives. Ciliska (2005) and Sebastian et al. (2000) both advocated providing graduate nursing students not only with instruction in the principles and procedures of EBP but also with instruction in leadership, in which they would be exposed to change theories and taught skills that would enable them to help implement innovations in the practice environment. However, a small number of nurse educators have also begun to envision empowering nursing students with
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Table 2. Curriculum Development Literature References
Content
Aronson et al. (2007)
The authors described research on a reconfiguration of three courses to include evidence-based nursing interventions in courses. The reconfiguration of providing EBP in early course work demonstrated both greater student clinical preparation and more student satisfaction. Burns and Foley (2005) Burns and Foley pointed out the importance of introducing EBP early in the nursing curriculum. They described how EBP was integrated into the freshmen year course as a foundation for further EBP in the undergraduate curriculum. Callister et al. (2005) The authors offered student reactions to the implementation of inquiry throughout the nursing curriculum. A description of the process of sensitizing students to research-related issues, stimulating collaborative learning about research, creating mentored opportunities, and other processes was described. Chaboyer et al. (2004) The article provided aims, content, and teaching methods to educate undergraduate nursing students on EBP throughout the curriculum. The authors described a benchmarking project in which two academics, one with a clinical focus and one with a research focus, partnered with another education agency to compare process and outcomes in EBP teaching–learning. Ciliska (2005) Ciliska shared ideas on how to incorporate EBP curriculum throughout the undergraduates' education. In addition, Ciliska shared appropriate expectations and possible assignments for undergraduate students in EBP. Cronenwett et al. (2007) The article outlined what nursing students should be taught at multiple points in the curriculum in regard to the EBP knowledge, skills, and attitudes for nursing practice. Dufault (2001) Dufault described an integrated curriculum in which students are placed in active, ongoing partnerships with practicing nurses and faculty researchers to integrate evidence into practice regarding research on pain. Jacobs et al. (2003) The authors described how EBP was integrated into all core courses in a master's program. Information literacy was an important thread in the integration and was assessed at yearly intervals. Levin and Feldman (2006a) Curriculum change is important for moving to EBP. The authors advocated starting with the faculty as learners and having EBP become the everyday language of nursing curricula. McConnell et al. (2007) The authors discussed development or the process and the outcomes of nursing students' participation in the implementation of an evidence-based intervention to manage oral hygiene in long-term care facilities. Orchard et al. (2006) The authors advocated for incorporating nursing-sensitive outcomes into undergraduate curriculum to help students make connections between patient assessments, nursing interventions, and patient outcomes. In addition, students learned to evaluate patient care. Pierce (2005) Pierce used EBP and pedagogy literature to describe steps and a model for integrating EBP into nursing curricula throughout undergraduate nursing education. Profetto-McGrath (2005) Profetto-McGrath supported the incorporation of critical thinking in curricula. “Critical thinking and EBP much be explicitly and implicitly integrated for nurses starting in their basic nursing education program” (p. 369). Suggested strategies to improve critical thinking include problem-based learning, reflective journals, role modeling, and journal clubs. Smith et al. (2007) The authors described a survey in which nursing leaders were satisfied with faculty expertise and student competency related to the domain of EBP in relation to quality and patient safety. The leaders thought that quality and safety information was embedded in the curriculum. Staggers et al. (2001) The authors described several levels of informatics competencies necessary for curricula. The competency areas include computer skills, knowledge, and attitudes based on four levels of nurses from beginning to informatics innovators. Stevens (2005) Stevens described a consensus process through which important curriculum items related to EBP were developed. The following competencies were articulated for undergraduate curricula: primary research, evidence summary, translation, integration, and evaluation.
roles that more directly promote EBP in practice settings. Some projects have united undergraduate students with nursing researchers (Dufault, 2001; McDaniel et al., 2002; Moch & McDaniel, 2002) to conduct studies and with practitioners to find answers to EBP questions (Dufault, 2001; Gibbs, 2003; Moch & Cronje, 2007). Marchiondo (2006) engaged RN–BSN students in presenting protocol projects to health care clinical agencies, whereas Stone and Rowles (2007) involved undergraduate students in finding evidence for nurses in practice. Moch and Cronje (2007) partnered nursing students with practitioners in new knowledge discussion groups to find, appraise, and integrate evidence into
practice. Dufault (2001) described an innovative process whereby students conduct a search of the literature (under the supervision of faculty) and then “take the lead in evaluating the study's methodology as they are developing these skills in their nursing research course on campus” (p. 3). Then, practitioner participants in the research roundtables determine the feasibility and applicability of the studies. It is clear, then, that the glimmer of a new paradigm may currently be forming among nursing educators: a resolution to forge a stronger link between nursing education and the practice setting as the means to promote evidence-based nursing practice. This paradigm
UNDERGRADUATE NURSING EBP EDUCATION
envisions students not merely as the recipients of education in EBP but also as active enablers who promote EBP within clinical settings by forming partnerships with practicing nurses.
Discussion Nursing education has traditionally included learning within the practice setting through clinical experiences. It is ironic, then, that with the increasing urgency to promote EBP, pedagogical innovators have not made and/or capitalized on more opportunities to immerse students in learning and applying EBP in real-world clinical settings. It is only in such practical settings that students can experience the challenges intrinsic to applying scientific evidence to the care of real patients. In these clinical settings, students can experience both the frustrations and the triumphs inevitable to integrating scientific knowledge into patient care. Extending EBP education into the most active, handson aspects of nursing students' educational experiences is entirely consistent with evidence from pedagogical studies that supports the importance of active, handson learning opportunities. If the interventions related to belief are important to nursing students, such interventions may be important for nurses in practice as well. Mulhall, Le May, and Alexander (2000) have noted the need to educate practitioners on the critical appraisal of research and the implementation of research in practice. Interventions to alter practicing nurses' beliefs about EBP are important to address the perceptual obstacles to EBP adoption. In their study of nurses in practice, Melnyk et al. (2004) found that “knowledge and beliefs about EBP are related to the extent that nurses engage in EBP” (p. 190). As Melnyk et al. (2004) noted, “Future interventions targeted toward strengthening nurses' beliefs about the benefits of EBP in improving clinical care and patient outcomes will mostly likely trigger a higher level of motivation or intention to learn about and engage in evidence-based care” (p. 190). Just as involving students in the research process is an effective way to help students understand and value the scientific process (AugustBrady, 2005), involving students in opportunities to implement EBP in clinical settings may consolidate belief in the merits of this technology among the practicing nurses with whom these students come into contact. The literature reviewed in this article that describes more active roles for students in clinical settings, albeit scant, suggests that allowing students to interact in ongoing and meaningful ways with practicing nurses may remove or mitigate barriers to the adoption of EBP among practicing nurses. In Part II of this article series, we communicate a new model that threads opportunities for students to interact meaningfully with practicing nurses throughout the curriculum. In Part III, we discuss the potential for students to serve as opinion leaders to diffuse EBP among practicing nurses in light of Everett Rogers's theories of the social nature of diffusion networks.
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References Aronson, B. S., Rebeschi, L. M., & Killion, S. W. (2007). Enhancing evidence bases for interventions in a baccalaureate program. Nursing Education Perspectives, 28, 257–262. August-Brady, M. M. (2005). Teaching undergraduate research from a process perspective. Journal of Nursing Education, 44, 519–521. Brancato, V. C. (2006). An innovative clinical practicum to teach evidence-based practice. Nurse Educator, 31, 195–199. Brosnan, C. A., Upchurch, S. L., Meininger, J. C., Hester, L. E., Johnson, G., & Eissa, M. A. (2005). Student nurses participate in public health research and practice through a school-based screening program. Public Health Nursing, 22, 260–266. Brown, S. J. (2009). Evidence-based nursing: The research– practice connection. Boston: Jones & Bartlett. Burman, M. E., Hart, A. M., Brown, J., & Sherard, P. (2007). Use of oral examinations to teach concepts of evidence-based practice to nurse practitioner students. Journal of Nursing Education, 46, 238–242. Burns, H. K., & Foley, S. M. (2005). Building a foundation for an evidence-based approach to practice: Teaching basic concepts to undergraduate freshman students. Journal of Professional Nursing, 21, 351–357. Cader, R., Derbyshire, J., Smith, A. G., Gannon-Leary, P., & Walton, G. (2006). In search of evidence: A small scale study exploring how student nurses accessed information for a health needs assignment. Nurse Education Today, 26, 403–408. Callister, L. C., Matsumura, G., Lookinland, S., Mangum, S., & Loucks, C. (2005). Inquiry in baccalaureate nursing education: Fostering evidence-based practice. Journal of Nursing Education, 44, 59–64. Chaboyer, W., Willman, A., Johnson, P., & Stockhausen, L. (2004). Embedding evidence-based practice in a nursing curriculum: A benchmarking project. Nurse Education in Practice, 4, 216–223. Cheek, J., Gillham, D., & Ballantyne, A. (2005). Using education to promote research dissemination in nursing. International Journal of Nursing Education Scholarship, 2, 1–10. Ciliska, D. (2005). Educating for evidence-based practice. Journal of Professional Nursing, 21, 345–350. Ciliska, D. (2006). EBN notebook. Evidence-based nursing: How far have we come? What's next? Evidence-Based Nursing, 9, 38–40. Courey, T., Benson-Soros, J., Deemer, K., & Zeller, R. A. (2006). The missing link: Information literacy and evidencebased practice as a new challenge for nurse educators. Nursing Education Perspectives, 27, 320–323. Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., et al. (2007). Quality and safety education for nurses. Nursing Outlook, 55, 122–131. DiCenso, A., Cullum, N., & Ciliska, D. (1998). Implementing evidence-based nursing: Some misconceptions. Evidence-Based Nursing, 1, 38–40. DiCenso, A., Guyatt, G., & Ciliska, D. (2005). Evidence-based nursing: A guide to clinical practice. St. Louis: Elsevier Mosby. Dufault, M. A. (2001). A program of research evaluating the effects of a collaborative research utilization model. Online Journal of Knowledge Synthesis for Nursing, 8. Estabrooks, C. A. (1998). Will evidence-based nursing practice make practice perfect? Canadian Journal of Nursing Research, 30, 37–39. Estabrooks, C. A., Floyd, J. A., Scott-Findlay, S., O'Leary, K. A., & Gushta, M. (2003). Individual determinants of research
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utilization: A systematic review. Journal of Advanced Nursing, 43, 506–520. Feldman, H. R., & Levin, R. F. (2006). Our approach to teaching/learning EBP: The talking head verses the dancing feet. In R. F. Levin & H. R. Feldman (Eds.). Teaching evidencebased practice in nursing. (pp. 15–22). New York: Springer Publishing Company. Ferguson, L., & Day, R. A. (2005). Evidence-based nursing education: Myth or reality? Journal of Nursing Education, 44, 107–116. Fineout-Overholt, E., Cox, J., III, Robbins, B., & Gray, Y. L. (2005). Teaching evidence-based practice. In B. M. Melnyk & E. Fineout-Overholt (Eds.). Evidence-based practice in nursing and health care: A guide to best practice. (pp. 407–441). Philadelphia: Lippincott Williams & Wilkins. Fineout-Overholt, E., Hofstetter, S., Shell, L., & Johnston, L. (2005). Teaching EBP: Getting to the gold: How to search for the best evidence. Worldviews on Evidence-Based Nursing, 2, 207–211. Fineout-Overholt, E., & Johnston, L. (2005). Teaching EBP: A challenge for educators in the 21st century. Worldviews on Evidence-Based Nursing, 2, 37–39. Flesner, M. K., Miller, L., McDaniel, R., & Rantz, M. (2006). In K. Malloch & T. Porter-O'Grady (Eds.). From nursing process to nursing synthesis. Introduction to evidence-based practice in nursing and health care. (pp. 65–85). Boston: Jones and Bartlett Publishing Company. Fonteyn, M. (2002). Print and online version of evidencebased nursing: Innovative teaching tools for nurse educators. Evidence-Based Nursing, 5, 6–7. Foster, R. L. (2004). Editorial: Challenges in teaching evidence-based practice. Journal for Specialists in Pediatric Nursing, 9, 75–76. Gibbs, L. E. (2003). Evidence-based practice for the helping professions: A practical guide with integrated multimedia. Toronto, ON: Brooks/Cole. Goodfellow, L. M. (2004). Can a journal club bridge the gap between research and practice? Nurse Educator, 29, 107–110. Hatala, R., & Guyatt, G. (2002). Evaluating the teaching of evidence-based medicine. Journal of American Medical Association, 288, 1110–1112. Institute of Medicine. (2003). Health professions education: A bridge to quality. Washington, DC: National Academies Press. Ironside, P. M., & Speziale, H. S. (2006). Using evidence in education and practice: More findings from the national survey on excellence in nursing education. Nursing Education Perspectives, 27, 219–221. Jacobs, S. K., Rosenfeld, P., & Haber, J. (2003). Information literacy as the foundation for evidence-based practice in graduate nursing education: A curriculum-integrated approach. Journal of Professional Nursing, 19, 320–328. Johnston, L., & Fineout-Overholt, E. (2005). Teaching EBP: “Getting from zero to one.” Moving from recognizing and admitting uncertainties to asking searchable, answerable questions. Worldviews on Evidence-Based Nursing, 2, 98–102. Johnston, L., & Fineout-Overholt, E. (2006). Teaching EBP: The critical step of critically appraising the literature. Worldviews on Evidence-Based Practice, 3, 44–46. Kelly, E. K., Hunley, A. L., Wegner, J. L., Grogan, A., Walker, A., Malone, K. J., et al. (2005). Evidence-based nursing: Making changes in the clinical practice through the collaboration of nursing students and practicing nurses. Applied Nursing Research, 18, 229–231. Kent, B., & Fineout-Overholt, E. (2007). Teaching EBP: Part 1. Worldviews on Evidence-Based Nursing, 4, 106–111.
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Kent, B., Fineout-Overholt, E., & Wimpenny, P. (2007). Teaching EBP: Part 2—making sense of clinical practice guidelines. Worldviews on Evidence-Based Nursing, 4, 164–169. Killeen, M. B., & Barnfather, J. S. (2005). A successful teaching strategy for applying evidence-based practice. Nurse Educator, 30, 127–132. Klassen, P. G., Karshmer, J. F., & Lile, J. L. (2002). Researchbased practice: Applying the standard in nursing education. Journal of Nursing Education, 41, 121–124. Lander, J. A. (2005). Editorial: Finding, evaluating, and using research for best practice. Clinical Nursing Research, 14, 299–302. Leake, P. Y. (2004). Teaming with students and a sacred cow contest to make changes in nursing practice. Journal of Continuing Education in Nursing, 35, 271–277. Levin, R. F., & Feldman, H. R. (2006). Teaching evidencebased practice: Starting with the learner. Research and Theory for Nursing Practice: An International Journal, 20, 269–272. Levin, R. F. & Feldman, H. R. (Eds.) (2006). Teaching evidence-based practice in nursing: A guide for academic and clinical settings. New York: Springer Publishing Company. Malloch, K. & Porter-O'Grady, T. (Eds.) (2006). Introduction to evidence-based practice in nursing and health care. Boston: Jones and Bartlett Publishing Company. Marchiondo, K. (2006). Planning and implementing an evidence-based project. Nurse Educator, 31, 4–6. McConnell, E. S., Lekan, D., Hebert, C., & Leatherwood, L. (2007). Academic–Practice partnership to promote evidencebased practice in long-term care: Oral hygiene care practices as an exemplar. Nursing Outlook, 55, 95–105. McDaniel, J., Drew, T., Gueldenzopf, S., Yang, M. Z., Davids, K., & Moch, S. D. (2002). Trying to promote EBP in your school of nursing? Don't overlook non-nursing students! Reflections on Nursing Leadership, 28, 8–9. Melnyk, B. M., Fineout-Overholt, E., Feinstein, N. F., Li, H., Small, L., Wilcox, L., & Kraus, R. (2004). Nurses' perceived knowledge, beliefs, skills, and needs regarding evidence-based practice: Implications for accelerating the paradigm shift. Worldviews on Evidence-Based Nursing, 1, 185–193. Melnyk, B. M., & Fineout-Overholt, E. (2005). Evidencebased practice in nursing and healthcare: A guide to best practice. Philadelphia: Lippincott Williams and Wilkins. Milner, M., Estabrooks, C. A., & Myrick, F. (2006). Research utilization and clinical nurse educators: A systematic review. Journal of Evaluation in Clinical Practice, 12, 639–655. Moch, S. D., & Cronje, R. J. (2007). New knowledge discussion groups: Counteracting the common barriers to evidence-based practice. Worldviews on Evidence-Based Nursing, 4, 112–115. Moch, S. D., & McDaniel, J. J. (2002). Undergraduate students as research assistants: Why and how. Poster presentation at the Midwest Nursing Research Society, Chicago, IL. Mulhall, A., Le May, A., & Alexander, C. (2000). Research based nursing practice—an evaluation of an educational programme. Nurse Education Today, 20, 435–442. Newhouse, R. P. (2007). Collaborative synergy: Practice and academic partnerships in evidence-based practice. Journal of Nursing Administration, 37, 105–108. Orchard, C., Reid-Haughian, C., & Vanderlee, R. (2006). Health outcomes for better information and care (HOBIC): Integrating patient outcome information into nursing undergraduate curricula. Canadian Journal of Nursing Leadership, 19, 28–33.
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Penz, K. L., & Bassendowski, S. L. (2006). Evidence-based nursing in clinical practice: Implication for nurse educators. Journal of Continuing Education in Nursing, 37, 250–256. Pierce, S. T. (2005). Integrating evidence-based practice into nursing curricula. Annual Review of Nursing Education, 3, 233–248. Profetto-McGrath, J. (2005). Critical thinking and evidencebased practice. Journal of Professional Nursing, 21, 364–371. Radjenovic, D., & Chally, P. S. (1998). Research utilization by undergraduate students. Nurse Educator, 23, 26–29. Ravert, P., Boyer, B., Harmon, K., & Scoffield, H. (2004). Learning nursing research through faculty-mentored projects. Nurse Educator, 29, 170–174. Reeves, K. (2006). Editorial: The importance of utilizing evidence-based practice. MEDSURG Nursing, 15, 329–330. Schmidt, N. A., & Brown, J. M. (2007). Use of the innovationdecision process teaching strategy to promote evidence-based practice. Journal of Professional Nursing, 23, 150–156. Schmidt, N. A., & Brown, J. M. (2009). Evidence-based practice for nurses: Appraisal and application of research. Boston: Jones and Bartlett. Schoenfelder, D. P. (2007). Simply the best: Teaching gerontological nursing students to teach evidence-based practice. Journal of Gerontological Nursing, 33, 6–11. Sebastian, J. G., Christman, N. J., Howard, P. B., Lock, S. E., Free, T. A., Chelbowy, D. O., et al. (2000). Evidence-based practice and the advanced practice nurse: A curriculum for the future. Seminars in Perioperative Nursing, 9, 143–148. Seymour, B., Kinn, S., & Sutherland, N. (2003). Valuing both critical and creative thinking in clinical practice: Narrowing the research–practice gap? Journal of Advanced Nursing, 42, 288–296. Sheriff, S., & Chaney, S. (2006). Active participation in a research study: A teaching strategy. Nurse Educator, 31, 53–56.
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Skiba, D. J. (2005). Preparing for evidence-based practice: Revisiting information literacy. Nursing Education Perspectives, 26, 310–311. Smith, E. L., Cronenwett, L., & Sherwood, G. (2007). Current assessments of quality and safety education in nursing. Nursing Outlook, 55, 132–137. Staggers, N., Gassert, C. A., & Curran, C. (2001). Informatics competencies for nurses at four levels of practice. Journal of Nursing Education, 40, 303–316. Stevens, K. R. (2001). Systematic reviews: The heart of evidence-based practice. AACN Clinical Issues: Advance Practice in Acute and Critical Care, 12, 529–538. Stevens, K. R. (2005). Essential competencies for evidencebased practice in nursing. San Antonio, TX: Academic Center for Evidence-Based Practice, UTHSCSA. Stevens, K. R., & Cassidy, V. R. (1999). Evidence-based teaching: Current research in nursing education. Sudbury, MA: Jones and Bartlett Publishers. Stevens, K. R., & Long, J. D. (1998). Incorporating systematic reviews into nursing education. Online Journal of Knowledge Synthesis for Nursing, 5, 1–7. Stone, C., & Rowles, C. J. (2007). Nursing students can help support evidence-based practice on clinical nursing units. Journal of Nursing Management, 15, 367–370. Trangenstein, P., & Weiner, E. (2006). Meeting the informatics needs of today's nursing students. Studies in Health Technology and Informatics, 122, 205–210. Verhey, M. P. (1999). Information literacy in an undergraduate nursing curriculum: Development, implementation, and evaluation. Journal of Nursing Education, 38, 252–259. Welk, D. S. (2007). How to read, interpret, and understand evidence-based literature statistics. Nurse Educator, 32, 16–20. Williams, K., Cobb, A. K., Nowak, J., Domian, E. W., Hicks, V., & Starling, C. (2002). Faculty–agency partnering for improved client outcomes. Journal of Nursing Education, 41, 531–534.
O
NE SIGN THAT evidence-based practice (EBP) has achieved widespread acceptance among nursing professionals is the extent to which it has been integrated into the curriculum of nursing schools. The nursing pedagogy literature is now replete with descriptions of strategies for teaching EBP to both graduate and undergraduate nursing students and descriptions of how EBP education can suffuse the curriculum (Estabrooks, Floyd, Scott-Findlay, O'Leary,
*Professor, College of Nursing and Health Science, University of Wisconsin-Eau Claire, Eau Claire, WI 54702-4004. †Associate Professor, Scientific and Technical Writing Program, University of Wisconsin-Eau Claire, Eau Claire, WI 54702-4004. ‡Undergraduate student, University of Wisconsin-Eau Claire, Eau Claire, WI 54702-4004. This work was funded by a Student-Faculty collaborative research grant from the University of Wisconsin-Eau Claire. This is the first part of a three-part series. Address correspondence to Dr. Moch: College of Nursing and Health Science, University of Wisconsin-Eau Claire, 105 Garfield Avenue, Eau Claire, WI. E-mails: [email protected], [email protected], [email protected] 8755-7223/09/$ - see front matter
& Gushta, 2003; Melnyk & Fineout-Overholt, 2005). Less often, one finds reports of evidence of success in instilling in nursing students an understanding of the principles and procedures of EBP (Ferguson & Day, 2005). It seems clear that, if nursing educators have anything to say about it, EBP is here to stay. The Institute of Medicine has recommended a number of initiatives designed to close the health care quality chasm by the Year 2010; included among them is the recommendation that all health care practices be evidence based (Institute of Medicine, 2003). One year before the recommended deadline seems an apt time to take stock of the state of evidence-based nursing pedagogy and to consider whether the recommendations for instilling EBP knowledge, skills, and attitudes in nursing education made by Cronenwett et al. (2007) are being met. In this article, we review the literature on pedagogy in nursing schools targeted toward teaching EBP to undergraduate nursing students. Specifically, we consider how the role of faculty and that of students has been envisioned as a means to promote the integration of EBP in the nursing profession.
Journal of Professional Nursing, Vol 26, No 1 (January-February), 2010: pp 5–13 © 2010 Elsevier Inc. All rights reserved.
5 doi:10.1016/j.profnurs.2009.01.015
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Article Selection
8. Stevens and Cassidy (1999), Evidence-Based
Teaching: Current Research in Nursing Education.
Using the Cumulative Index to Nursing and Allied Health Literature (CINAHL) database, the following search strategy was used: exp education, nursing + nursing practice, evidence-base, and limited to 1997–2007. All articles that included undergraduate nursing education and EBP were included. Articles that focused on continuing education in the clinical setting only were generally excluded. The reference lists of all articles used were also reviewed for any other references that included nursing education, students, and EBP. In addition, a manual search of the table of contents was made of the following journals for at least 5 years or since onset of the journal: Journal of Nursing Education, Nurse Educator, Journal of Professional Nursing, Perspectives in Nursing Education, and World Views on EvidenceBased Nursing. Articles in these journals, as well as articles in reference lists, were selected if learning–teaching in formal education programs, rather than only continuing education programs, was included. Articles that discussed undergraduate education, graduate education, academic– practice partnerships, and community–student endeavors were also reviewed for the inclusion of undergraduate students and EBP. Articles that only discussed continuing education or education within health care agencies were omitted unless a teaching strategy or the research was applicable to this review. No independent evaluations were completed about whether an article was eligible, and no blinding procedures for journals, authors, or institutions were included as all articles found that addressed EBP and undergraduate education were included. Article selection was not limited to research articles as few research articles on this topic were found. Editorials, commentaries, essays, and descriptions of teaching strategies related to the topic were included as these articles often described possibilities and future trends for students and EBP. Nursing-related textbooks or books on EBP and teaching were also reviewed:
The EBP nursing pedagogy literature reveals an effort to link the innovation of EBP to long-standing traditions in nursing education, suggesting that EBP represents less a rupture in nursing pedagogy than a refinement of commitments already in place. The legacy of teaching the research process, for example, is both explicit and implicit in the EBP pedagogy literature. Ciliska (2006) cautioned about the need to be careful in substituting education in EBP for education in research content, suggesting that educators sometimes shift content from research courses to EBP courses. She urged research on specific teaching strategies that measure outcomes and recommended faculty development in EBP. The legacy of instruction in critical thinking is also apparent throughout the EBP pedagogy literature. Profetto-McGrath (2005) asserted that “among the knowledge, skill, and processes need to support EBP, CT (critical thinking) is paramount” (p. 364). Seymour, Kinn, and Sutherland (2003) suggested that learning critical thinking in a collaborative manner with colleagues and educators could decrease the research–practice gap as “merely teaching and learning about research is not enough to ensure that such learning translates into the culture of practice” (p. 292). Information literacy is also emphasized in the undergraduate EBP education literature. The need for students to know how to access information has been articulated as a major step in the EBP process (Cronenwett et al., 2007; Fineout-Overholt, Cox, Robbins, & Gray, 2005; Flesner, Miller, McDaniel, & Rantz, 2006; Skiba, 2005; Trangenstein & Weiner, 2006) and as a skill that needs to be integrated into the curriculum (Staggers, Gassert, & Curran, 2001; Verhey, 1999). Fineout-Overholt, Cox, et al. (2005) identified a myriad of pedagogical resources related to informatics and gaining information.
1. Brown (2009), Evidence-Based Nursing: The
The Scope and Content of EBP Pedagogy
Research–Practice Connection. 2. DiCenso, Guyatt, and Caliska (2005), Evidence-
Based Nursing: A Guide to Clinical Practice. 3. Gibbs (2003), Evidence-Based Practice for the
4.
5.
6.
7.
Helping Professions: A Practical Guide with Integrated Multimedia. Levin and Feldman (2006), Teaching EvidenceBased Practice in Nursing: A Guide for Academic and Clinical Settings. Malloch and Porter-O'Grady (2006), Introduction to Evidence-Based Practice in Nursing and Health Care. Melnyk and Fineout-Overholt (2005), EvidenceBased Practice in Nursing and Healthcare: A Guide to Best Practice. Schmidt and Brown (2009), Evidence-Based Practice for Nurses.
Findings The Evolution of EBP Nursing Pedagogy
Numerous articles in the EBP pedagogy literature have addressed the question of what general knowledge and specific skills future nurses will require. There seems to be general consensus that the content of EBP pedagogy should parallel the EBP process as it is currently conceptualized. Melnyk and Fineout-Overholt (2005), for example, described the process of systematically teaching students to ask compelling questions, critically appraise the evidence, and apply it. Similar to the textbook of Melnyk and Fineout-Overholt, FineoutOverholt, Cox, et al. (2005) outlined the same plan for teaching the steps of EBP. Two other textbooks on EBP (DiCenso et al., 2005; Levin & Feldman, 2006b) also advocated teaching these steps of the EBP process. Many reports in the nursing pedagogy literature described specific strategies educators have used to instill understanding of EBP principles and processes in
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Table 1. EBP Learning/Teaching Strategies References
Content
August-Brady (2005)
August-Brady included a collaborative clinical project in the research course content to facilitate active involvement in research by RN–BSN students. Students collected data on a safety issue in the clinical setting. Brancato (2006) Brancato advocated for a senior-level RN–BSN student practicum involving projects on EBP in a clinical setting. Students were assisted by hospital preceptors in doing an EBP project on real patientcare problems. Brosnan et al. (2005) The authors described the application of a community partnership model to a nursing assignment. The model links education, research, and practice through EBP, service learning, and scholarly teaching in a school-based project with high-risk student populations. Students were actively involved in research activities with community partners to meet the public health needs identified. Burman et al. (2007) The authors discussed the use of oral examinations in a graduate program for evaluating student comprehension on EBP articles and their applicability to the student's practice. They suggested that graduate students orally present the review of a research article. Cader et al. (2006) The authors used a health needs analysis assignment to learn about EBP. Through this qualitative study, the authors found that students needed more assistance with making judgments about the information found. Cheek et al. (2005) Cheek, Gillham, and Ballantyne described the Web Resource Appraisal Process, a teaching strategy which engages postgraduate student nurses to evaluate and integrate evidence into practice. Courey et al. (2006) Courey et al. reported a comparison study between two groups of associate degree nursing students on information literacy. The literacy program had a positive effect on students' information literacy skills and a negative effect on students' attitude toward staying current in the literature. Feldman and Levin (2006) Feldman and Levin advocated for cooperative learning groups for teaching EBP. Students were encouraged to work in cooperative learning groups to learn from each other in EBP learning. The mission was helping students learn and not about “teaching.” Fineout-Overholt, Hofstetter, The authors suggested that, in teaching EBP, search questions and search skills are necessary. The use et al. (2005) of the PICOT question, the databases, and search strategy are important content areas. In addition, collaboration among educators, librarians, and learners is essential in the searching process. Fineout-Overholt and Johnston Fineout-Overholt and Johnston proposed changing as is education practice based on tradition and (2005) evidence generation to teaching students to quickly find evidence, incorporate patient values, and use valid evidence. They stated that, “Nursing literature is relatively silent on the issue of how best to teach and evaluate skills required for EBP” (p. 38). Fonteyn (2002) Fonteyn advocated for education in locating and utilizing synopses journals (i.e., Evidence-Based Nursing) to quickly supplement and improve class and clinical content and thus improve practice. Foster (2004) Foster pointed out that nursing research courses lack clinical scholarship and suggested reasons for the lapse (i.e., research textbooks and information illiteracy). She proposed EBP reviews and presentations to procedure committees. Goodfellow (2004) Goodfellow described a process of implementing journal clubs for a postclinical conference in the clinical area. Through an evaluation by students and staff, she shared how this strategy spurred the students' excitement in locating, sharing, and using EBP. Hatala and Guyatt (2002) Hatala and Guyatt discussed the significance of EBP competencies which includes identifying the problem and the question, searching for literature, critically appraising evidence, and integrating evidence. However, they noted a lack of evidence for how to teach these skills. Ironside and Speziale (2006) Ironside and Speziale reported on a National League of Nursing survey that shows that preparation for EBP exists in the curriculum. The authors issued challenges for further research on the topic and asked about best practices for teaching EBP. Johnston and Fineout-Overholt Johnston and Fineout-Overholt discussed that translating “uncertainty” to an answerable question is a (2005) difficult but an important step in EBP. Teachers need to assist students in this process of identifying the PICOT question. Johnston and Fineout-Overholt Johnston and Fineout-Overholt noted that teaching critical appraisal skills is a difficult process but (2006) very important at the undergraduate level. They discussed several approaches to teaching critical appraisal in classes and suggested “librarian-facilitated access to distilled information sources” in the clinical area. Kelly et al. (2005) The assessing clinical evidence course for the accelerated BS–MS involved students working with clinicians in a research project. Partnerships with practice were established, and according to the authors, “this partnership did not only change clinical policy, it changed the academic practices” (p. 231). Kent and Fineout-Overholt Utilizing clinical practice guidelines is an EBP teaching–learning tool for practicing nurses. (2007) Kent et al. (2007) The authors described how to use practice guidelines in teaching and in practice. Ways for assessing the validity of the guidelines and the resources to assist in guideline distribution were included. (continued on next page)
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Table 1. (Continued) References Killeen and Barnfather (2005)
Content
Killeen and Barnfather used the conduct and utilization of research model to engage senior baccalaureate students in completing EBP projects in clinical agencies. The authors linked a research and a capstone course, and they promoted several semesters of involvement by students to create a richer EBP experience for students and a more meaningful project for staff. Klassen et al. (2002) Research-based skills manuals created by graduate students provided undergraduate students with the up-to-date research on the rationale for nursing skills. Lander (2005) Lander called for new strategies to increase undergraduate appraisal skills. One strategy is to use an Internet tool for accessing and appraising evidence (www.searchca.net). Leake (2004) Leake stated that students learned about tradition rather than research-based practices and policies through a sacred-cow contest. The contest continued to evolve and generated enthusiasm for research for students and nurses in practice. Levin and Feldman (2006b) The edited book of Levin and Feldman includes suggestions for teaching, which include asking questions, using a library, appraising evidence, and teaching meta-synthesis. Plans for teaching graduate students and nurses in practice were also included. Other authors discussed journal clubs, hospitalbased settings, and teaching nurse practitioners and second-degree students. Marchiondo (2006) Marchiondo engaged RN–BSN students in a research course in completing research utilization projects to help students understand the value of EBP. The students presented the protocol projects to involved agencies. McDaniel et al. (2002) The authors advocated the use of undergraduate student learners in EBP. Students disseminated information and worked with practitioners in EBP learning. Milner et al. (2006) This systematic review on clinical nurse educators revealed that clinical nurse educators are an important resource in research utilization. There is a need for increasing clinical appraisal skills and research knowledge among nurse educators. The Promoting Action on Research Implementation in Health Services framework was used in the study. Moch and Cronje (2007) Moch and Cronje suggested involving nursing students in new knowledge discussion groups to decrease the barriers often cited in diffusing EBP in practice settings. The role of students in fostering awareness of, appreciation for, and ability in EBP among practicing nurses was emphasized. Mulhall et al. (2000) Mulhall et al. described content and examined outcomes from a series of ten 4-day workshops on research-based practice. Content for the workshops was accessing literature, recognizing research designs, and assessing the potential for studies in the workplace. Outcomes included reducing fear and lack of understanding of research and increasing skills in critical appraisal. Newhouse (2007) Newhouse discussed how master's-level students do projects for clinical agencies through academic partnerships. Penz and Bassendowski (2006) Penz and Bassendowski shared strategies for clinical nurse educators to teach about EBP. Educators need to know about EBP; assure that policies, procedures, and guidelines are evidence based; and correct through consulting libraries, systematic reviews, and other resources. Radjenovic and Chally (1998) Radjenovic and Chally discussed implementation of a research utilization project based on the Stetler model in a senior nursing course. Students critiqued research and made posters for possible future implementation. Ravert et al. (2004) The authors discussed having all students work as research assistants in faculty–student research projects at least once during the undergraduate experience. An experience with clinical simulation was highlighted. Reeves (2006) Reeves discussed the application of the ACE Star Model to help bring research into practice in a course assignment. Students selected topics and then interviewed a nurse about the evidence and observed nurses in practice related to the topic. Schmidt and Brown (2007) Schmidt and Brown discussed the application of the innovation–decision process teaching strategy to aid students in overcoming impediments in comprehension and utilization of EBP. Students worked on issues identified by community representatives. Schoenfelder (2007) Schoenfelder described a teaching technique where students read and summarized a published EBPbased guideline and then developed a “tip sheet” which is then given to health professionals. Seymour et al. (2003) The authors advocated a transfer of critical-thinking skills from the classroom to the clinical setting and incorporated connections between practice and education such as journal clubs, critical incident analysis, and reflection. Learning research in the clinical environment with partnerships in education was advocated. Sheriff and Chaney (2006) Sheriff and Chaney discussed an evidence-based research paper, a presentation, and participation in a faculty-sponsored research project as a way to increase enthusiasm for and knowledge about research. Skiba (2005) Skiba discussed a lack of information literacy among practicing nurses; therefore, educators must ensure that nursing students are information literate for EBP. She encouraged an evaluation of literacy competency in educational settings.
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Table 1. (Continued) References Stevens (2001) Stevens and Long (1998)
Stone and Rowles (2007)
Trangenstein and Weiner (2006) Welk (2007) Williams et al. (2002)
Content Stevens promoted systematic reviews as essential for EBP. These reviews or evidence summaries are designed to answer clinical questions and are important for advanced practice nurses. Stevens and Long proposed a strategy for using systematic reviews in nursing education. The authors described the strategy and the procedures used to evaluate the strategy in undergraduate and graduate teaching. The study used undergraduate nursing students in a senior research utilization course to help staff nurses stay current with current research related to their unit. The research supported the use of students in saving time and increasing staff awareness. Trangenstein and Weiner proposed informatics competencies for various levels of nursing students. Competencies ranged from using the Internet to synthesizing data for decision making. Welk reviewed the meaning of seven statistical terms commonly used in EBP articles. Using an example, the author demonstrated use of EBP literature in teaching. The authors described teams of students and staff who developed evaluation projects. Thirty participants from four community agencies developed projects, and the benefits to students, staff, and faculty are summarized.
undergraduates (Table 1). The learning–teaching strategies described in these articles have potential to help undergraduates learn to value research and to understand the procedures of EBP. Most of these reports described a pilot teaching project deployed with a small group of students but did not discuss how these strategies can be applied to the entire undergraduate population.
Evidence-Based Practice Pedagogy Across the Curriculum Another class of EBP pedagogy articles (Table 2) discussed how the skills required for EBP can be threaded throughout the undergraduate nursing curriculum, as Ciliska (2005) has called for. As DiCenso, Cullum, and Ciliska (1998) have noted, We have learned that it is not sufficient to give nursing students a few lectures on the process of doing research and then expect them to use that knowledge throughout their careers in an ongoing process of gathering and interpreting research evidence and implementing findings (p. 38). Most articles focusing on curriculum development addressed the question of how to foster critical-thinking skills generally and how to instill knowledge of EBP procedures specifically. A few articles have addressed the question of bridging the nursing school–practice gap. Early in the EBP pedagogy discussion, Estabrooks (1998) suggested that nursing curricula should focus on “acquiring the skill sets and critical-thinking capacities necessary to not only locate and understand information, but also to be able to judge the appropriate match between evidential sources and the contextual demands of clinical encounters [italics added]” (p. 30). In 2003, Estabrooks et al. reviewed the literature identifying the need for more interdisciplinary, theoretically coherent research to investigate ways to better integrate EBP in practice settings. They concluded that there is still much work to be done to optimize the
integration of EBP in clinical settings. Frequently, creative pedagogical strategies that integrate clinical practice involve RN–bachelor of science in nursing (BSN; AugustBrady, 2005; Brancato, 2006), accelerated, postgraduate (Cheek, Gillham, & Ballantyne, 2005), or graduate students (Kelly et al., 2005; Newhouse, 2007). Seymour et al. (2003) recommended partnerships between universities and clinical institutions that provide students with active and participatory experiences that will teach them to think in the clinical setting. However, only a few articles in the nursing pedagogy literature (Callister, Matsumura, Lookinland, Mangum, & Loucks, 2005; Chaboyer, Willman, Johnson, & Stockhausen, 2004; Stevens 2005) directly discussed plans designed for implementing measures throughout the curriculum to give students realworld practice in applying EBP in clinical settings (Table 2).
The Role of Nursing Education in Promoting EBP in Clinical Settings A general consensus expressed in the nursing pedagogy literature is the belief that the key to ensuring EBP in clinical settings lies in instilling a commitment to EBP in future nurses while they are still in nursing school. Estabrooks et al. (2003) reported evidence that supports a link between beliefs and attitudes and research utilization among practicing nurses and clearly saw the classroom as a place to promulgate the beliefs and attitudes that will lead to EBP. Ciliska (2005) envisioned baccalaureate nursing school graduates as “good consumers of research —evidence users” who will help ensure a clinical culture that promotes reflection on practice and a desire to investigate alternatives. Ciliska (2005) and Sebastian et al. (2000) both advocated providing graduate nursing students not only with instruction in the principles and procedures of EBP but also with instruction in leadership, in which they would be exposed to change theories and taught skills that would enable them to help implement innovations in the practice environment. However, a small number of nurse educators have also begun to envision empowering nursing students with
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Table 2. Curriculum Development Literature References
Content
Aronson et al. (2007)
The authors described research on a reconfiguration of three courses to include evidence-based nursing interventions in courses. The reconfiguration of providing EBP in early course work demonstrated both greater student clinical preparation and more student satisfaction. Burns and Foley (2005) Burns and Foley pointed out the importance of introducing EBP early in the nursing curriculum. They described how EBP was integrated into the freshmen year course as a foundation for further EBP in the undergraduate curriculum. Callister et al. (2005) The authors offered student reactions to the implementation of inquiry throughout the nursing curriculum. A description of the process of sensitizing students to research-related issues, stimulating collaborative learning about research, creating mentored opportunities, and other processes was described. Chaboyer et al. (2004) The article provided aims, content, and teaching methods to educate undergraduate nursing students on EBP throughout the curriculum. The authors described a benchmarking project in which two academics, one with a clinical focus and one with a research focus, partnered with another education agency to compare process and outcomes in EBP teaching–learning. Ciliska (2005) Ciliska shared ideas on how to incorporate EBP curriculum throughout the undergraduates' education. In addition, Ciliska shared appropriate expectations and possible assignments for undergraduate students in EBP. Cronenwett et al. (2007) The article outlined what nursing students should be taught at multiple points in the curriculum in regard to the EBP knowledge, skills, and attitudes for nursing practice. Dufault (2001) Dufault described an integrated curriculum in which students are placed in active, ongoing partnerships with practicing nurses and faculty researchers to integrate evidence into practice regarding research on pain. Jacobs et al. (2003) The authors described how EBP was integrated into all core courses in a master's program. Information literacy was an important thread in the integration and was assessed at yearly intervals. Levin and Feldman (2006a) Curriculum change is important for moving to EBP. The authors advocated starting with the faculty as learners and having EBP become the everyday language of nursing curricula. McConnell et al. (2007) The authors discussed development or the process and the outcomes of nursing students' participation in the implementation of an evidence-based intervention to manage oral hygiene in long-term care facilities. Orchard et al. (2006) The authors advocated for incorporating nursing-sensitive outcomes into undergraduate curriculum to help students make connections between patient assessments, nursing interventions, and patient outcomes. In addition, students learned to evaluate patient care. Pierce (2005) Pierce used EBP and pedagogy literature to describe steps and a model for integrating EBP into nursing curricula throughout undergraduate nursing education. Profetto-McGrath (2005) Profetto-McGrath supported the incorporation of critical thinking in curricula. “Critical thinking and EBP much be explicitly and implicitly integrated for nurses starting in their basic nursing education program” (p. 369). Suggested strategies to improve critical thinking include problem-based learning, reflective journals, role modeling, and journal clubs. Smith et al. (2007) The authors described a survey in which nursing leaders were satisfied with faculty expertise and student competency related to the domain of EBP in relation to quality and patient safety. The leaders thought that quality and safety information was embedded in the curriculum. Staggers et al. (2001) The authors described several levels of informatics competencies necessary for curricula. The competency areas include computer skills, knowledge, and attitudes based on four levels of nurses from beginning to informatics innovators. Stevens (2005) Stevens described a consensus process through which important curriculum items related to EBP were developed. The following competencies were articulated for undergraduate curricula: primary research, evidence summary, translation, integration, and evaluation.
roles that more directly promote EBP in practice settings. Some projects have united undergraduate students with nursing researchers (Dufault, 2001; McDaniel et al., 2002; Moch & McDaniel, 2002) to conduct studies and with practitioners to find answers to EBP questions (Dufault, 2001; Gibbs, 2003; Moch & Cronje, 2007). Marchiondo (2006) engaged RN–BSN students in presenting protocol projects to health care clinical agencies, whereas Stone and Rowles (2007) involved undergraduate students in finding evidence for nurses in practice. Moch and Cronje (2007) partnered nursing students with practitioners in new knowledge discussion groups to find, appraise, and integrate evidence into
practice. Dufault (2001) described an innovative process whereby students conduct a search of the literature (under the supervision of faculty) and then “take the lead in evaluating the study's methodology as they are developing these skills in their nursing research course on campus” (p. 3). Then, practitioner participants in the research roundtables determine the feasibility and applicability of the studies. It is clear, then, that the glimmer of a new paradigm may currently be forming among nursing educators: a resolution to forge a stronger link between nursing education and the practice setting as the means to promote evidence-based nursing practice. This paradigm
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envisions students not merely as the recipients of education in EBP but also as active enablers who promote EBP within clinical settings by forming partnerships with practicing nurses.
Discussion Nursing education has traditionally included learning within the practice setting through clinical experiences. It is ironic, then, that with the increasing urgency to promote EBP, pedagogical innovators have not made and/or capitalized on more opportunities to immerse students in learning and applying EBP in real-world clinical settings. It is only in such practical settings that students can experience the challenges intrinsic to applying scientific evidence to the care of real patients. In these clinical settings, students can experience both the frustrations and the triumphs inevitable to integrating scientific knowledge into patient care. Extending EBP education into the most active, handson aspects of nursing students' educational experiences is entirely consistent with evidence from pedagogical studies that supports the importance of active, handson learning opportunities. If the interventions related to belief are important to nursing students, such interventions may be important for nurses in practice as well. Mulhall, Le May, and Alexander (2000) have noted the need to educate practitioners on the critical appraisal of research and the implementation of research in practice. Interventions to alter practicing nurses' beliefs about EBP are important to address the perceptual obstacles to EBP adoption. In their study of nurses in practice, Melnyk et al. (2004) found that “knowledge and beliefs about EBP are related to the extent that nurses engage in EBP” (p. 190). As Melnyk et al. (2004) noted, “Future interventions targeted toward strengthening nurses' beliefs about the benefits of EBP in improving clinical care and patient outcomes will mostly likely trigger a higher level of motivation or intention to learn about and engage in evidence-based care” (p. 190). Just as involving students in the research process is an effective way to help students understand and value the scientific process (AugustBrady, 2005), involving students in opportunities to implement EBP in clinical settings may consolidate belief in the merits of this technology among the practicing nurses with whom these students come into contact. The literature reviewed in this article that describes more active roles for students in clinical settings, albeit scant, suggests that allowing students to interact in ongoing and meaningful ways with practicing nurses may remove or mitigate barriers to the adoption of EBP among practicing nurses. In Part II of this article series, we communicate a new model that threads opportunities for students to interact meaningfully with practicing nurses throughout the curriculum. In Part III, we discuss the potential for students to serve as opinion leaders to diffuse EBP among practicing nurses in light of Everett Rogers's theories of the social nature of diffusion networks.
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