Current state of evidence-based practice education for undergraduate nursing students in Taiwan: A questionnaire study

    Current state of evidence-based practice education for undergraduate nursing students in Taiwan: A questionnaire study Hsiao-Ying Hung, Yu-Fung Huang, Jing-Jane Tsai, Ying-Ju Chang PII: DOI: Reference:

S0260-6917(15)00184-7 doi: 10.1016/j.nedt.2015.05.001 YNEDT 2951

To appear in:

Nurse Education Today

Accepted date:

1 May 2015

Please cite this article as: Hung, Hsiao-Ying, Huang, Yu-Fung, Tsai, Jing-Jane, Chang, Ying-Ju, Current state of evidence-based practice education for undergraduate nursing students in Taiwan: A questionnaire study, Nurse Education Today (2015), doi: 10.1016/j.nedt.2015.05.001

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ACCEPTED MANUSCRIPT Current state of evidence-based practice education for undergraduate nursing

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students in Taiwan: A questionnaire study

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Hsiao-Ying Hung1 , Yu-Fung, Huang2 , Jing-Jane,Tsai3, Ying-Ju Chang 4

Institution of Allied Health Sciences & Department of Nursing, College of Medicine, National

Department of Obstetrics & Gynecology, National Cheng Kung University Hospital, College of

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2

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Cheng Kung University, Tainan, Taiwan.

Medicine, National Cheng Kung University, Tainan, Taiwan. Institute of Education, College of Social Sciences & Department of Neurology, National Cheng

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Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan

Department of Nursing & Institution of Allied Health Sciences, College of Medicine, National

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Cheng Kung University, Tainan, Taiwan. Address correspondence to Ying-Ju Chang, Department of Nursing, College of Medicine, National Cheng Kung University, No. 1 University Road, Tainan, Taiwan, 701, R. O. C. Phone: 886-62353535 ext. 5854. Fax: -886-6-2377550, E-mail: [email protected]

Word count: 5689 (revised manuscript) Conflict of Interest Statement No conflict of interest is declared by the authors. Acknowledgments The study was supported by a grant from the National Science Council of Taiwan (NSC100-2511-S-006-009). The authors would like to thank all participants who contributed to this research.

ACCEPTED MANUSCRIPT Current state of evidence-based practice education for undergraduate nursing students in Taiwan: A questionnaire survey

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ABSTRACT

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Background: Evidence-based practice (EBP) has been emphasized as the core competency of

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undergraduate nursing students and must be cultivated before graduation. However, there is limited

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information of EBP education for undergraduate nursing students in Taiwan. Objectives: The purpose of this study was to investigate the current state of EBP education for

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undergraduate nursing students in Taiwan.

Design: A survey using a self-developed questionnaire was applied. The questionnaire, validated by

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experienced educators, was designed to explore curriculum design, teaching resources, qualification of

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teachers, and barriers regarding EBP education.

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Participants: A total of 21 nursing schools and colleges participated. The chair of each recommended a faculty member involved in teaching EBP as the school’s representative to fill out the questionnaire. Results: Among the 21 nursing schools and colleges, 18 (85.7%) had implemented EBP education in the curriculum. Among these schools, 22.2% conducted an independent EBP course, 50% had incorporated concepts of EBP with other courses, and the remainder had combined both strategies. Multiple strategies, including classroom lecture, group discussion, oral presentation, and simulation, were incorporated to teach the EBP steps. Less than 35% of the schools had designed or adopted standardized teaching materials and evaluated students’ learning outcomes. Although 55.6% of the schools reimbursed faculty for participation in EBP training, 39% of their faculty members who taught EBP did not received any EBP training. Shortage of qualified faculty and limited opportunity to involve students in evidence-based applications were reported as major obstacles to teaching EBP. In addition, reading English literature was the major difficulty that students encountered when learning EBP.

ACCEPTED MANUSCRIPT Conclusions: EBP education has already gained the attention of nursing schools in Taiwan. However, lack of comprehensive EBP training among teachers and the difficulty of teaching clinical application of EBP require special consideration. In order to promote EBP education in undergraduate nursing curriculums, we

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suggest that nursing schools reinforce and support faculty to participate in formal EBP training. Also

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needed is a systematic curriculum design with multiple teaching strategies and links with clinical practicum.

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Keywords: Evidence-based practice, nursing student, education, curriculum design, obstacles of

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teaching

ACCEPTED MANUSCRIPT INTRODUCTION Evidence-based practice (EBP), which integrates the best research evidence with expert opinion as well as patient values to solve clinical problems (Sigma Theta Tau International, 2004), has been considered as an

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effective strategy for improving the quality of care (Stichler et al., 2011). Necessary EBP knowledge and

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skills include formulating answerable clinical questions, searching for the best evidence, and appraising and integrating evidence for clinical practices (Quality and Safety Education for Nursing [QSEN], 2007).

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appropriately (Brown et al., 2009; Chang et al., 2013).

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Lacking the knowledge and skills of EBP would limit nurses’ capability to utilize research evidence

In 2011, both the American Association of Colleges of Nursing (AACN) and the Institute of Medicine

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(IOM) emphasized that EBP is not only an important competency of baccalaureate nursing students but also should be cultivated before graduation. Nursing schools in Europe (Finotto et al., 2013; Johnson et al.,

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2010), in the United States (Moch et al., 2010), and in Asia (Oh et al., 2010; Zhang et al., 2012) have valued

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the EBP competency of undergraduate students and developed EBP curriculums or courses for their students. However, reports from these studies differ; e.g., in Europe, Finotto et al., (2013) developed a 3-

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year program where classroom lessons and clinical practicums were involved in teaching EBP; in Korea, Oh et al., (2010) integrated EBP into a 6-day clinical practicum in a RN-to-BSN program, where lectures on the concepts and processes of EBP were provided prior to the practicum, and group conferences were provided afterwards to enhance students’ EBP skills; and in China, one school incorporated EBP into the clinical practicum, and the strategies of self-directed learning and workshops were adapted to teach EBP (Zhang et al., 2012). In Taiwan, EBP education has been strongly emphasized and implemented in clinical practice (Li et al., 2011; Mu et al., 2013; Yeh et al., 2010). However, there is little information regarding the curriculum design of EBP for undergraduate nursing students. In order to develop an EBP curriculum for nursing students, it is first necessary to understand the current implementation of EBP education in Taiwan. Therefore, the purpose of this study was to investigate curriculum design, teaching resources, qualification of teachers, and barriers to EBP education in Taiwan. BACKGROUND An effective EBP education should involve the teaching goals and objectives, teaching content, the

ACCEPTED MANUSCRIPT preparation of faculty members, and facilitator and barriers to teaching EBP. EBP involves knowledge generation and research utilization (Titler et al., 2001). Nevertheless, traditional nursing education focuses on conducting research rather than applying evidence. The content of traditional

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nursing education focuses on research hypothesis, methodology, and proposal writing, yet little emphasis is

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given to the diversity and applications of evidence (Fineout-Overholt et al., 2005; Klassen et al., 2002). Nursing graduates are nonetheless expected to translate existing evidence into clinical practice. The

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capability of understanding the interplay of theories, practice, and research as well as making changes to

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practice based on evaluating the credibility of evidence are demanded (AACN, 2011). Therefore, EBP education for undergraduate nursing students should focus on cultivating both these abilities. In addition,

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cultivating students’ spirit of inquiry and critical thinking should be a foundation of EBP education. These abilities not only enable students to think beyond routines but also inspirit them to search for the best care to

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meet patients’ needs (Ferguson & Day, 2005; Profetto-McGrath, 2005).

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Nursing students should be enlightened on the steps of EBP. These steps include formulating a clinical question, searching and appraising evidence, integrating research evidence with expert opinions and

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patients’ preferences into practice, assessing outcomes and disseminating of EBP results (Jenicek & Hitchcock, 2004; Melnyk et al., 2010). In order for students to effectively acquire EBP knowledge and skill, the concepts of EBP should be systemically integrated into professional nursing courses (Burns & Foley, 2005; Rolloff, 2010). In addition, multiples strategies, well-developed teaching materials, and abundant resources are all important facilitators of EBP education (Killeen & Barnfather, 2005; Melnyk et al., 2008). Evaluating EBP learning outcomes is also important in EBP education, because it is conducive to understanding whether the EBP teaching objectives have been achieved and how to improve the teaching quality (Levin & Feldman, 2006). Nursing teachers play an important role in promoting EBP education. They cultivate EBP champions, achieve desired education outcomes, and even shape the future nursing profession through education and role modeling (Levin & Feldman, 2006). Therefore, teachers’ preparation prior to EBP teaching is of vital importance. Rather than focusing on developing knowledge, the teachers should familiarize themselves with the core value of EBP and the process of research utilization (Stichler et al., 2011). In addition, only when teachers are conversant with the concepts and steps of EBP can they incorporate EBP into teaching and

ACCEPTED MANUSCRIPT support students’ EBP learning (Ciliska, 2005; Ferguson & Day, 2005). Common barriers to EBP education have been revealed as insufficient resources (such as time and money),

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inadequate library resources, and a shortage of EBP teachers (Hussein & Hussein, 2013; Melnyk et al., 2008; Stichler et al., 2011). Other identified barriers include teachers with lower motivation to develop their

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EBP knowledge and skills (Burns & Foley, 2005), incomprehensible relevant statistical analyses, confusion

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over the objectives and approaches of EBP education, as well as a traditional teaching philosophy that focuses on evidence development instead of evidence application (Melnyk et al., 2008; Stichler et al.,

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2011).

In Taiwan, there are two systems of educational nursing programs. After completing 9 years of compulsory

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education and 3 years senior high school, students can enter a 4-year university or polytechnic college for nursing education (minimum 128 graduate credits required to get a bachelor’s degree). The second program

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is a 5-year junior college of nursing (minimum 220 graduate credits required to get an associate’s degree). If

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students want to get higher nursing education, they can enter a 2-year post-junior college program in a

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university or polytechnic college (minimum 72 graduate credits required to get a bachelor’s degree) after finishing the junior college of nursing (Chang and Yu, 2010; Ministry of Education, 2015). Because of the different nursing education systems, curriculum design and course structures in universities and polytechnic colleges also differ. In general, in order to prepare students for the Taiwanese registered professional nurses examination, the nursing schools usually arrange their mandatory courses into two categories, including fundamental medical sciences (Anatomy, Physiology, Microbiology and Immunology, Pharmacology and Pathology) and professional nursing sciences and practicum (Human Development, Physical Examination and Health Assessment, Introduction to Nursing, Fundamentals of Nursing, Adult Health Nursing, Maternity Nursing, Pediatric Nursing, Mental Health Nursing, Community Nursing, Nursing Administration, and Nursing Research). However, EBP courses are not mandatory in either of the nursing programs.

METHOD A self-developed questionnaire was used to investigate the current state of EBP education in undergraduate nursing students of Taiwan. The study was approved by the Institutional Review Board and was conducted

ACCEPTED MANUSCRIPT from August 2012 to July 2013.

Participants All of the 26 nursing colleges and schools in Taiwan (13 general universities and 13 polytechnic colleges),

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were invited to participate. Finally, 21 of them consented to participate. The questionnaire was filled out by

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a faculty member involved in teaching EBP who had been recommended by the chair as representative.

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Instrument

The questionnaire was developed by the researchers based on literature that dealt with the effective

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elements of EBP education (Burns & Foley, 2005; Fineout-Overholt and Johnston, 2007; Melnyk et al.,

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2010; Rolloff, 2010; Smith et al., 2007; Stichler, et al., 2011) and the phenomena of EBP continuing education in Taiwan (Li et al., 2011; Mu et al., 2013). The questionnaire comprised 26 items that were

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intended to explore EBP curriculum design (8 items), teaching resources (5 items), course evaluation (5

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items), qualification of teachers (4 items), and obstacles to EBP education (4 items). The content validity of the questionnaire was evaluated by three experienced EBP education experts.

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Correctness, relevancy, and clearness of the questionnaire were appraised. The correctness referred to the degree to which the items were able to guide the participants to give genuine answers. The relevancy index referred to the degree to which the items were relevant to the research purposes. The clearness index referred to the degree to which the word choices and statements were lucid, unambiguous, and easy to read. Each item was rated by these experts on a 4-point Likert scale, where 1 represented an improper item that required deletion and 4 represented an excellent, suitable item. All three experts rated all the items in the questionnaire as either 3 or 4; therefore, the overall content validity index (CVI) was 1 (Polit & Beck, 2006). Because the level of measurement of this questionnaire was nominal, the items could not be scored to estimate the reliability. However, in order to increase the reliability in this study (Sharma & Petosa, 2014), the recommendations that involved the design of the questionnaire (improving the clarity of items, adding directions to the beginning of each division of questions, and providing clear guidance about whether there were one or more answer choices) were discussed and emphasized within the research team in order to guide the respondents to truly reflect their reality of EBP education in their schools.

ACCEPTED MANUSCRIPT Procedure The questionnaire was mailed in August 2012 to all of the 26 nursing colleges and schools in Taiwan with a request that the chair of the college or school confirm willingness to participate in the study. The chair

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recommended a faculty member involved in EBP education to fill out the questionnaire and sign the

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informed consent on behalf of the school.

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Data Analysis

Data of this study included information about the elements of EBP education, including curriculum

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design, teaching resources, course evaluation, qualification of teachers, and barriers to EBP

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education. All data were collected, revised, and analyzed with SPSS 17.0 software. Frequency and percentage were calculated for descriptive data analyses.

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RESULTS

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Of the 26 questionnaires mailed out, 21 were returned, indicating a response rate of 80.8%. Three

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of the 21 schools that responded offered no EBP courses in their curriculum. Hence, the following results came from 18 schools that had implemented EBP education. Half of the representative respondents were associate professors (n = 9). Most respondents were involved in the school administration and were members of the curriculum design committee (n = 17). Curriculum design

As shown in Table 1, among the 18 schools that had implemented EBP courses, 22.2% (n = 4) had independent EBP courses. The course names were “Evidence-Based Nursing” or “Introduction to Evidence-Based Nursing.” Only one school considered their EBP courses mandatory; whereas the others deemed them electives. All of these independent EBP courses were for two credits and were offered to senior students. 50.0% (n=9) schools incorporated EBP concepts into other nursing professional courses. Most of these schools (n = 7) reported that they incorporated EBP concepts into more than one nursing course. Nursing Research courses were reported as the main course (n = 6) where EBP was taught; the others were Adult Health Nursing, Pediatric Nursing, Maternity

ACCEPTED MANUSCRIPT Nursing, and Mental Health Nursing. (For example, one school reported that they incorporated EBP into Adult Health Nursing and Nursing Research. In Adult Health Nursing, introduction to the

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EBP concept and its application was presented in a 2-hour lecture; in Nursing Research, 8 hours of lecture included introduction to the basic concepts of EBP, exploring and framing the PICO

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question, search strategy, level of evidence, and introduction to the EBP written report.) The

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remaining 27.8% schools offered both independent and incorporated EBP courses.

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Curricular content and pedagogical strategy

The steps of EBP comprised the major teaching content. Over 80% of the schools introduced EBP

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to students as well as taught them how to search for evidence, formulate PICO questions, and appraise evidence; in addition, 72.2% also targeted clinical applications. Although answering

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foreground questions was essential, 44.4 % of the schools emphasized background questions such

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as pathophysiology and pharmacology. Moreover, schools applied multiple strategies to teach

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EBP, including classroom lecture, group discussion, oral presentation, and simulation. Teaching resources and course evaluation Only 33.3% of these schools designed or adopted standardized teaching materials, such as textbooks and PICO samples, for teachers to teach EBP. The top five medical databases provided were CINAHL, PubMed, Cochrane Library, Medline Ovid, and Cochrane Reviews (Chinese version). In addition, 50% of the schools applied e-learning to facilitate students’ learning. Only 27.8% of the schools evaluated students’ learning outcomes, including the ability of adopting appropriate keywords to search literature, formulating PICO questions, and appraising literature. The main methods for evaluating learning outcomes were oral presentation, written report, and peer evaluation. Qualification of teachers Among the 18 schools that had conducted EBP courses, 55.6% of them had teachers with

ACCEPTED MANUSCRIPT certification of EBP training from international or domestic institutions, and 50% had teachers with a minimum of 4 hours of EBP training. The main specialties of these teachers were nursing. Two

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schools reported that their EBP teachers also included a statistics specialty, and one school reported that their EBP teachers included a medical specialty.

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Obstacles to EBP education

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As shown in Table 2, 83.3% of the schools that had implemented EBP course reported that the

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obstacles to teaching EBP included a lack of qualified EBP teachers, limited opportunity for students to participate in evidence applications at bedside, lack of integrated course materials and

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available time for teaching. In addition, teachers also reported the difficulties encountered by students were reading English literature, formulating PICO clinical questions, choosing appropriate

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literature, choosing appropriate appraisal tools, and appraising relevant literature. DISCUSSION

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The study findings reveal that 85.7 % of nursing colleges and schools in Taiwan have conducted EBP education, with the main teaching content being introduction to EBP, searching for evidence, PICO question formulation, evidence appraisal, and application. However, critical issues about teaching EBP were also revealed, including difficulty in teaching the clinical application, lack of standardized teaching materials, inadequate evaluation of learning outcomes, lack of comprehensive EBP training among teachers, and students’ English-reading difficulties.

Findings indicate that EBP education has already gained attention in most nursing schools of Taiwan. This result corresponds to the constant advocacy of the importance of EBP by AACN (2011) and IOM (2011). Contents of the EBP education in this study were in line with those of the suggestions from AACN and other studies (Burns & Foley, 2005; Finotto et al., 2013; Moch et al., 2010) that emphasize the steps of EBP. However, this study found that the clinical applications of EBP were less taught. The possible reason for this finding might relate to the complexity of integrating best evidence, expert opinions, and patient perspectives, as well as the difficulty of transforming research evidence into practice (Melnyk et al., 2010). Our finding that more than half of the schools reported the difficulty of students’ engagement in clinical application of EBP could also reflect the difficulty of teaching the clinical application of EBP. Although

ACCEPTED MANUSCRIPT EBP lectures can enhance students’ knowledge, skill, and attitude of EBP, the learning process would be fruitless and meaningless if EBP education focused merely on confirming clinical questions and searching for and appraising literature instead of applying evidence into practice (Coomarasamy & Khan, 2004;

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Jeniceck & Hitchcock, 2004; Yousefi-Nooraie et al., 2007). Hence, multiple teaching strategies, such as

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clinical conferences and journal club meetings might be incorporated in EBP education to enhance students’ competence of clinical EBP application (Winters & Echeverri, 2012). Another interesting finding of our

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study is that almost half of the schools emphasized students’ background knowledge as a foundation before

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asking a well-built foreground question. Fineout-Overholt and Stillwell (2011) proposed that students should cultivate the competence to distinguish background from foreground questions, and thus they will

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know where they can find the right answers.

In terms of teaching resources, we found that only a few schools designed or adopted the standardized

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material to teach EBP. Ambiguous teaching objectives and methods have been reported as the barriers to

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EBP teaching (Stichler et al., 2011). Therefore, whether such a phenomenon will affect the quality of EBP teaching is worthy of further study. The majority of schools in this study reported having provided

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electronic databases such as PubMed, CINAHL, Medline, and Cochrane library for their students. Securing the best evidence promptly is a crucial EBP step (Cronenwett et al., 2007; Fineout-Overholt et al., 2005; Trangenstein & Weiner, 2006), and abundant library resources could assist students in learning how to search for and obtain the best research evidence (Winters & Echeverri, 2012). However, nursing schools in this study rarely provided electronic databases that encompassed systematic reviews, such as JBI, BMJ Clinical Evidence, DynaMed, MD Consult, and Clin-eguide. The reason might be that DynaMed and MD Consult provide appraised and integrated evidence-based information in relation to diagnosis and treatment (Dicenso et al., 2009; Klem & Weiss, 2005) and teachers might misconceive and consider these databases as medically oriented and inappropriate for nursing students. Another reason might be related to limited budgets of schools to purchase the databases. Although using the free database of PubMed might help students develop search strategies, it is mainly used to search for non-appraised original studies, and students then have to spend additional time to appraise and integrate evidence (Grandage et al., 2002; Klem & Weiss, 2005). The databases that offer pre-appraised and integrated evidence would not only enable students to understand what the best evidence is but would also satisfy their need to promptly respond to

ACCEPTED MANUSCRIPT care demands in clinical practice (Dicenso et al., 2009; Yousefi-Nooraie et al., 2007). This study also found that over half of the schools applied e-learning to assist EBP teaching. The reason for this might be lower education costs, faster information delivery, as well as flexible, effective learning (Hadley et al., 2010; Feng

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et al., 2013). Therefore, e-learning systems might be utilized as supplementary teaching materials for EBP

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education in the future.

This study also showed that only a few schools evaluate students’ learning outcomes and most of them

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target EBP knowledge but not the clinical practice. The possible reason might relate to the complex

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interactions of teaching EBP (Fineout-Overholt & Johnston, 2007). However, evaluating only EBP knowledge falls short of understanding the success of EBP teaching. Diverse strategies of evaluating

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learning outcomes including teaching-learning interactions, feedback process, and quality of patient care are necessary (Davidson et al., 2004).

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Another notable finding is that among the 18 schools that have implemented EBP education, approximately

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40% reported that their EBP teachers had never received any EBP training. Teachers without EBP training

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might have misconceptions about EBP and center on conducting research rather than utilizing research evidence (Ciliska, 2005; Klassen et al., 2002; McInerney & Suleman, 2010). Although some schools in this study had provided funds to support EBP training for teachers, it was not known whether the support had motivated teachers’ EBP learning. Hence, developing strategies that encourage teachers to learn EBP would be worthwhile in the future.

Shortages of human resources, time, and teaching materials were reported in this study as obstacles to teaching EBP, which was consistent with previous studies (Hussein & Hussein, 2013; Melnyk et al., 2008; Stichler et al., 2011). The unique difference between this and previous studies was the students’ difficulty participating in clinical applications of EBP. As stated earlier, the applications of EBP might be related to the complicated situation of transferring research evidence into practice. Therefore, being equipped only with basic EBP knowledge and skills is not enough for students to develop confidence in clinical applications of evidence. In addition, we found that the lack of competency in reading English literature was the main hindrance to students in EBP learning. This finding is consistent with previous studies, which mentioned that English reading abilities are indeed a hindrance for non-native English speakers to utilize

ACCEPTED MANUSCRIPT research evidence (Finotto et al., 2013; Mu et al., 2013). Another study suggested that nurses’ comprehension of statistics, research methodology, and appraisal of research can be enhanced by participating in journal clubs (Deenadayalan et al., 2008). Whether this strategy can apply to undergraduate

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nursing students to help their comprehension of English literature requires further study.

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Formulating PICO questions and choosing appropriate literature, other hindrances to EBP learning in this study, are closely related. Florin et al., (2012) found that formulating questions is more difficult for students

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than searching and appraising literature. The formulation of clinical questions is related to whether students

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have the spirit of inquiry, critical thinking, and curiosity (Melnyk et al., 2009; Winters & Echeverri, 2012). Furthermore, students might have insufficient knowledge of how to reconstruct a clinical question into

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PICO form (Levin & Feldman, 2006). When students have trouble formulating an answerable question (PICO format), they will also encounter trouble in choosing appropriate literature. This is because an

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inappropriate question might either generate a large amount of literature or fail to find any readable

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literature (Heye & Stevens, 2009). In order to assist students in practicing subsequent steps of EBP rather than being stopped in the formulation of questions and selection of literature, teachers could prepare

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pertinent clinical questions, and then search for whether these questions have sufficient relevant literature or other evidence for students to read in advance.

Limitations and suggestions

This is the first study to investigate EBP education of undergraduate nursing students in Taiwan. Several limitations require future consideration. First, we did not explore some critical issues related to curriculum design, such as how to motivate students and strengthen the prerequisite knowledge for EBP learning. Second, we did not explore how these nursing schools systematically integrated EBP into the current curriculum and collaborated with the hospital to cultivate students’ competence with EBP. Third, the content validity index can be criticized as an inflated estimate outcome because we could not adjust the chance agreement among the experts, especially, when only a few were invited to evaluate the content validity (Beckstead, 2009; Polit & Beck, 2006). Finally, e-learning has become a trend for EBP teaching because of its benefits in flexible and effective learning. Future studies might explore the design of templates, teaching objectives, and course content of e-learning systems.

ACCEPTED MANUSCRIPT CONCLUSION This study found that EBP education has already gained attention in the nursing schools of Taiwan

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and that EBP steps are the main teaching content. However, this study found that clinical applications of EBP were less taught and more than half of the schools reported the difficulty of

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students’ engagement in EBP clinical application. Developing multiple teaching strategies and

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collaborating with hospital/clinic to cultivate students’ competence of EBP application are necessary in the future. In addition, this study also detected many factors that may affect the

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quality of EBP teaching, such as teachers with no EBP training, a lack of standard teaching

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materials, and a lack of evaluations of EBP learning outcomes. Therefore, this study suggests that nursing schools reinforce and support teachers to participate in formal EBP training so as to meet

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the demand for EBP education of the future. Furthermore, a systemic curriculum design with

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multiple teaching strategies and links with clinical practicum is also needed in the future.

ACCEPTED MANUSCRIPT REFERENCES American Association of Colleges of Nursing (AACN). (2011). The Essentials of Baccalaureate Education for Professional Nursing Practice. Retrieved

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from http://www.aacn.nche.edu/education-resources/BaccEssentials08.pdf

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Beckstead, J. W. (2009). Content validity is naught. International Journal of Nursing Studies, 46(9), 1274–

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1283. doi: 10.1016/j.ijnurstu.2009.04.014

Brown, C. E., Wickline, M. A., Ecoff, L., & Glaser, D. (2009). Nursing practice, knowledge, attitudes and

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perceived barriers to evidence-based practice at an academic medical center. Journal of Advanced Nursing, 65(2), 371–381. doi: 10.1111/j.1365-2648.2008.04878.x

MA

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(6), 351–

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357. doi: 10.1016/j.profnurs.2005.10.001

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Chang, H. C., Jones, M. K., & Russell, C. (2013). Exploring attitudes and barriers toward the use of

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evidence-based nursing among nurse managers in Taiwanese residential aged care facilities. Journal of Gerontological Nursing, 39(2), 36–42. doi: 10.3928/00989134-20130110-02 Chang, M., & Yu, Y. M. (2010). Nursing workforce and nurse practitioner system: Vision and challenges. Taipei, Taiwan: National Health Research Institutes. Ciliska, D. (2005). Educating for evidence-based practice. Journal of Professional Nursing, 21(6), 345–350. doi: 10.1016/j.profnurs.2005.10.008 Coomarasamy, A., & Khan, K. S. (2004). What is the evidence that postgraduate teaching in evidence based medicine changes anything? A systematic review. British Medical Journal, 329(7473), 1017. doi: 10.1136/bmj.329.7473.1017 Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., . . . Warren, J. (2007). Quality and safety education for nurses. Nursing Outlook, 55, 122–131. doi: 10.1016/j.outlook.2007.02.006 Davidson, R. A., Duerson, M., Romrell, L., Pauly, R., & Watson, R. T. (2004). Evaluating evidence-based

ACCEPTED MANUSCRIPT medicine skills during a performance-based examination. Academic Medicine, 79(3), 272–275. Deenadayalan, Y., Grimmer-Somers, K., Prior, M., & Kumar, S. (2008). How to run an effective journal

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club: A systematic review. Journal of Evaluation in Clinical Practice, 14(5), 898–911. doi: 10.1111/j.13652753.2008.01050.x

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Dicenso, A., Bayley, L., & Haynes, R. B. (2009). Accessing pre-appraised evidence: Fine-tuning the 5S

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model into a 6S model. Evidence-Based Nursing, 12(4), 99–101. doi: 10.1136/ebn.12.4.99-b

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Feng, J. Y., Chang, Y. T., Chang, H. Y., Erdley, W. S., Lin, C. H., & Chang, Y. J. (2013). Systematic review of effectiveness of situated e-learning on medical and nursing education. Worldviews on Evidence-

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Based Nursing, 10(3), 174–183. doi: 10.1111/wvn.12005

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Nursing Education, 44(3), 107–115.

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Ferguson, L., & Day, R. A. (2005). Evidence-based nursing education: Myth or reality? The Journal of

Fineout-Overholt, E., & Johnston, L. (2007). Evaluation: An essential step to the EBP process.

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Worldviews on Evidence-Based Nursing, 4(1), 54–59. doi: 10.1111/j.1741-6787.2007.00081.x Fineout-Overholt, E., Melnyk, B. M., & Schultz, A. (2005). Transforming health care from the inside out: Advancing evidence-based practice in the 21st century. Journal of Professional Nursing, 21(6), 335–344. doi: 10.1016/j.profnurs.2005.10.005

Fineout-Overholt, E., & Stillwell, S. B. (2011). Asking compelling clinical questions. In B. M. Melnyk, & E. Fineout-Overholt (Eds.), Evidence- based practice in nursing and healthcare: A guide to best practice (pp. 25–39). Philadelphia: Lippincott Williams and Wilkins.

Finotto, S., Carpanoni, M., Turroni, E. C., Camellini, R., & Mecugni, D. (2013). Teaching evidence-based practice: Developing a curriculum model to foster evidence-based practice in undergraduate student nurses. Nurse Education in Practice, 13(5), 459–465. doi: 10.1016/j.nepr.2013.03.021 Florin, J., Ehrenberg, A., Wallin, L., & Gustavsson, P. (2012). Educational support for research

ACCEPTED MANUSCRIPT utilization and capability beliefs regarding evidence-based practice skills: A national survey of senior nursing students. Journal of Advanced Nursing, 68(4), 888–897. doi: 10.1111/j.1365-

PT

2648.2011.05792.x Grandage, K. K., Slawson, D. C., & Shaughnessy, A. F. (2002). When less is more: A practical

RI

approach to searching for evidence-based answers. Journal of the Medical Library Association,

SC

90(3), 298–304.

Hadley, J., Kulier, R., Zamora, J., Coppus, S. F., Weinbrenner, S., Meyerrose, B., . . . Khan, K. S. (2010).

NU

Effectiveness of an e-learning course in evidence-based medicine for foundation (internship) training.

MA

Journal of the Royal Society of Medicine, 103(7), 288–294. doi: 10.1258/jrsm.2010.100036 Heye, M. L., & Stevens, K. R. (2009). Using new resources to teach evidence-based practice. Journal of

D

Nursing Education, 48(6), 334–339.

TE

Hussein, A. H. M., & Hussein, R. G. (2013). The attitudes and barriers towards evidence-based practice

AC CE P

among nursing educators. Journal of American Science, 9(12), 609–618. Institute of Medicine (IOM). (2011). The Future of Nursing: Focus on Education. Retrieved from http://www.iom.edu/~/media/Files/Report%20Files/2010/The-Future-of-Nursing /Nursing%20Education%202010%20Brief.pdf Jenicek, M., & Hitchcock, D. L. (2004). Evidence-based practice: Logic and critical thinking in medicine. Chicago: AMA Press. Johnson, N., List-Ivankovic, J., Eboh, W. O., Ireland, J., Adams, D., Mowatt, E., & Martindale, S. (2010). Research and evidence based practice: Using a blended approach to teaching and learning in undergraduate nurse education. Nurse Education in Practice, 10(1), 43–47. doi: 10.1016/j.nepr.2009.03.012 Killeen, M. B., & Barnfather, J. S. (2005). A successful teaching strategy for applying evidence-based practice. Nurse Educator, 30(3), 127–132. Klassen, P. G., Karshmer, J. F., & Lile, J. L. (2002). Research-based practice: Applying the standard in

ACCEPTED MANUSCRIPT nursing education. Journal of Nursing Education, 41(3), 121–124. Klem, M. L., & Weiss, P. M. (2005). Evidence-based resources and the role of librarians in developing

PT

evidence-based practice curricula. Journal of Professional Nursing, 21(6), 380–387. doi: 10.1016/j.profnurs.2005.10.004

RI

Levin, R. F., & Feldman, H. R. (2006). Teaching evidence-based practice in nursing. New York, NY:

SC

Springer.

NU

Li, C. Y., Wang, W. F., & Chang, Y. J. (2011).The effects of evidence-based nursing training program on

MA

nurses’ knowledge, attitude, and behavior. New Taipei Journal of Nursing, 13(1), 19–31. McInerney, P., & Suleman, F. (2010). Exploring knowledge, attitudes, and barriers toward the use of evidence-based practice amongst academic health care practitioners in their teaching in a South African

6787.2009.00180.x

TE

D

university: A pilot study. Worldviews on Evidence-Based Nursing, 7(2), 90–97. doi: 10.1111/j.1741-

AC CE P

Melnyk, B. M., Fineout-Overholt, E., Feinstein, N. F., Sadler, L. S., & Green-Hernandez, C. (2008). Nurse practitioner educators' perceived knowledge, beliefs, and teaching strategies regarding evidence-based practice: Implications for accelerating the integration of evidence-based practice into graduate programs. Journal of Professional Nursing, 24(1), 7–13. doi: 10.1016/j.profnurs.2007.06.023 Melnyk, B. M., Fineout-Overholt, E., Stillwell, S. B., & Williamson, K. M. (2009). Evidence-based practice: Igniting a spirit of inquiry: An essential foundation for evidence-based practice. American Journal of Nursing, 109(11), 49–52. Melnyk, B. M., Fineout-Overholt, E., Stillwell, S. B., & Williamson, K. M. (2010). Evidence-based practice: Step by step: The seven steps of evidence-based practice. American Journal of Nursing, 110(1), 51–53. doi: 10.1097/01.NAJ.0000366056.06605.d2 Ministry of Education of Taiwan (2015). Educational system. Retrieved from http://english.moe.gov.tw/ct.asp?xItem=15742&CtNode=11434&mp=1

ACCEPTED MANUSCRIPT Moch, S. D., Cronje, R. J., & Branson, J. (2010). Part 1. Undergraduate nursing evidence-based practice education: Envisioning the role of students. Journal of Professional Nursing, 26(1), 5–13. doi:

PT

10.1016/j.profnurs.2009.01.015 Mu, P. F., Tsay, S. F., & Chang, L. Y. (2013). Factors associated with evidence-based nursing promotion in

RI

Taiwan. VGH Nursing, 30(2), 130–143.

SC

Oh, E. G., Kim, S., Kim, S. S., Kim, S., Cho, E. Y., Yoo, J. S., . . . Lee, H. (2010). Integrating evidence-

NU

based practice into RN-to-BSN clinical nursing education. Journal of Nursing Education, 49(7), 387–392. doi: 10.3928/01484834-20100331-02

MA

Polit, D. F., & Beck, C. T. (2006). The content validity index: Are you sure you know what’s being reported? Critique and recommendations. Research in Nursing and Health, 29, 489–497.

TE

D

Profetto-McGrath, J. (2005). Critical thinking and evidence-based practice. Journal of Professional Nursing, 21(6), 364–371. doi: 10.1016/j.profnurs.2005.10.002

AC CE P

Quality and Safety Education for Nursing (QSEN). (2007). Quality and safety competencies. Retrieved from http://www.qsen.org/competencies.php. Rolloff, M. (2010). A constructivist model for teaching evidence-based practice. Nursing Education Perspectives,31(5), 290–293.

Sharma, M., & Petosa, R. L. (2014). Measurement and evaluation for health educators. Burlington, MA: Jones & Bartlett Learning. Sigma Theta Tau International. (2004). Evidence-based nursing: Rationale and resources. Worldview on Evidence-based Nursing, 1(1), 69–75. doi: 10.1111/j.1741-6787.2004.04015.x Smith, E. L., Cronenwett, L., & Sherwood, G. (2007). Current assessments of quality and safety education in nursing. Nursing Outlook, 55(3), 132–137. doi: 10.1016/j.outlook.2007.02.005 Stichler, J. F., Fields, W., Kim, S. C., & Brown, C. E. (2011). Faculty knowledge, attitudes, and perceived barriers to teaching evidence-based nursing. Journal of Professional Nursing, 27(2), 92–100. doi:

ACCEPTED MANUSCRIPT 10.1016/j.profnurs.2010.09.012 Titler, M. G., Kleiber, C., Steelman, V. J., Rakel, B. A., Budreau, G., Everett, L. Q., . . . Goode, C. J.

PT

(2001). The Iowa model of evidence-based practice to promote quality care. Critical Care Nursing Clinics of North America, 13(4), 497–509.

RI

Trangenstein, P., & Weiner, E. (2006). Meeting the informatics needs of today's nursing students. Studies in

SC

Health Technology and Informatics, 122, 205–210.

MA

Care Nurse, 32(3), 49–54. doi: 10.4037/ccn2012159

NU

Winters, C. A., & Echeverri, R. (2012). Teaching strategies to support evidence-based practice. Critical

Yeh, C. C., Huang, C. Y., Liao, Y. C., Chang, S. C., & Huang, S. T. (2010). Effectiveness of attending an evidence-based nursing workshop for nurses in a medical center. New Taipei Journal of Nursing, 12(2), 7–

TE

D

15.

Yousefi-Nooraie, R., Rashidian, A., Keating, J. L., & Schonstein, E. (2007). Teaching evidence-based

AC CE P

practice: The teachers consider the content. Journal of Evaluation in Clinical Practice, 13(4), 569–575. doi: 10.1111/j.1365-2753.2007.00885.x

Zhang, Q., Zeng, T., Chen, Y., & Li, X. (2012). Assisting undergraduate nursing students to learn evidencebased practice through self-directed learning and workshop strategies during clinical practicum. Nurse Education Today, 32(5), 570–575. doi: 10.1016/j.nedt.2011.05.018

ACCEPTED MANUSCRIPT Table 1 Curriculum design of EBP in the nursing schools and colleges (N = 18). Number of schools

Incorporated concepts of EBP into other courses

9

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4

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Curriculum design Independent EBP courses

Both

Percentage

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Item

22.2 50.0

5

27.8

18

100

16

88.9

16

88.9

15

83.3

13

72.2

8

44.4

16

88.9

Group discussions

14

77.8

Oral presentations

12

66.7

Simulation

12

66.7

Paper assignments

8

44.4

Case study

3

16.7

6

33.3

Textbooks

5

27.8

Examples of PICO questions

5

27.8

Examples of literature appraisal

5

27.8

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Curricular content

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Searching for evidence Introduction of EBP Formulating PICO questions

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Background questions

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Clinical application

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Appraising evidence

Pedagogical strategy Lectures

Teaching resources Standardized teaching materials

Examples of clinical questions

1

5.6

Examples of clinical application

1

5.6

CINAHL

16

88.9

PubMed

15

Cochrane Library

13

72.2

Medline Ovid

SC

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13

72.2

9

50.0

7

38.9

5

27.8

1

5.6

1

5.6

1

5.6

9

50.0

Adopting appropriate keywords to search literature

5

27.8

Formulating complete structured PICO question

4

22.2

Appraisal of literature

4

22.2

Integration of literature to make clinical decisions

3

16.7

Classification of clinical questions

3

16.7

Selection of appropriate appraisal tools

2

11.1

Finding relevant literature accurately and promptly

2

11.1

Integration of experts’ and patients’ opinions to make clinical decisions

2

11.1

Oral presentations

5

27.8

Written reports

4

22.2

RI

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Cochrane Reviews (Chinese version) JBI

MA

BMJ Clinical Evidence DynaMed

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MD Consult

TE

Clin-eguide

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E-learning

PT

Databases

83.3

Evaluation items

Methods of evaluation

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16.7

Paper-based tests

1

5.6

Self-evaluations

1

5.6

PT

Peer evaluations

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MA

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SC

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EBP, evidence-based practice.

ACCEPTED MANUSCRIPT Table 2 Obstacles to EBP education in the nursing schools and colleges (N = 18). Number of schools

PT

Items

Difficulties in learning EBP

9

RI

Reading English literature

50.0

5

27.8

5

27.8

4

22.2

4

22.2

3

16.7

3

16.7

Classification of clinical questions

2

11.1

Keywords and strategies for searching evidence

2

11.1

15

83.3

Lack of qualified teachers

10

55.6

Limited opportunity for students to participate in evidence-based applications

10

55.6

Lack of integrated teaching materials

9

50.0

Lack of available time for teaching

8

44.4

Choosing appropriate literature

Clinical application

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Unfamiliarity with databases

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Reviewing and appraising literature

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Choosing tools for appraisal of literature

Obstacles to teaching EBP

EBP, evidence-based practice.

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Formulating PICO questions

Percentage

ACCEPTED MANUSCRIPT Highlights

1. Findings of this study indicated that EBP education has already gained attention in the most nursing schools

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of Taiwan.

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2. Shortage of EBP qualified faculty and limited opportunity to involve students in evidence-based practice

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were major obstacles of teaching EBP.

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3. Reading English literatures was the major difficulty of learning EBP in nursing students. 4. A systemic curriculum design with multiple teaching strategies and links with clinical practicum are in a great

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need in the future.