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Examining Evidence-Based Practice Beliefs in Undergraduate Nursing Students: A Pilot Study
Teaching and Learning in Nursing 14 (2019) 246–250
Contents lists available at ScienceDirect
Teaching and Learning in Nursing journal homepage: www.jtln.org
Examining evidence-based practice beliefs in undergraduate nursing students: A pilot study Rita Ann Laske, EdD, RN, CNE ⁎, Jane Kurz, PhD, RN School of Nursing and Health Sciences, La Salle University, Philadelphia, PA, 19141, USA
a r t i c l e
i n f o
Article history: Accepted 30 April 2019 Keywords: Evidence-based practice Beliefs Undergraduate nursing students
a b s t r a c t This study examined how a new course affected evidence-based practice (EBP) beliefs in junior nursing students (N = 18) compared with senior nursing students (N = 18). These students completed the EBP Belief Scale. An independent t test revealed no significant difference in scores. There were statistically significant differences on 2 items (p b .05): “measuring outcomes of clinical care” and “the ability to implement EBP”. Through early introduction of skills, students have more opportunities to use EBP in clinical practicums. © 2019 Published by Elsevier Inc. on behalf of Organization for Associate Degree Nursing.
Introduction Evidence-based practice (EBP) is a problem-solving approach to clinical decision-making. Consistent with adopting EBP strategies in health care, health professionals locate, appraise, and use the best available evidence, consider their own clinical expertise, and center efforts on patients' values and preferences. The aim is to achieve the best outcomes for individual patients, families, and communities (Melnyk & Fineout-Overholt, 2015). For decades, the nursing community has recognized EBP strategies as essential for the delivery of high-quality nursing care at the lowest costs. Numerous organizations formally support EBP. For example, the Institute of Medicine (2003) has mandated that all health professionals be educated to deliver patient-centered care emphasizing EBP. In addition, the American Association of Colleges of Nursing (AACN, 2008), in its “Essentials for Baccalaureate Education for Professional Nursing Practice,” directed educators to cover the research process and teach students how to retrieve, appraise, and synthesize evidence. Furthermore, prelicensure student curriculums are expected to focus on providing students with opportunities to integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences when planning, implementing, and evaluating the outcomes of care (AACN, 2008). The faculty of the Quality and Safety Education for Nurses (2018) project has set targets regarding the knowledge, skills, and attitudes
The author declares no conflict of interest. No financial support was provided for this study. ⁎ Corresponding author. Tel.: 1 610 888 7512 (cell). E-mail addresses: [email protected], (R.A. Laske), [email protected]. (J. Kurz).
to be identified and carried out in curriculums of nursing prelicensure programs. Competency in six major areas of nursing is a goal for student development; EBP is specified. To address these competencies, some nursing educators clearly indicate that undergraduate nursing students require a strong foundation in nursing research (Burns & Foley, 2005; Llasus, Angosta, & Clark, 2014). However, throughout the United States, registered nurses generally report low competency in EBP despite being supportive of its use (Melnyk et al., 2018). New graduate nurses report difficulty in applying EBP theory in their actual clinical practice (Ryan, 2016), with the most common problems related to asking Problem, Intervention, Comparison, Outcome, Time (PICOT) questions, finding evidence relevant for the populations' problems, and critically evaluating and collecting the best-known evidence. To address these challenges, researchers have recommended that nursing educators develop courses that help nursing undergraduates obtain greater EBP competency before graduation (Aglen, 2016; Llasus et al., 2014; Wonder, Spurlock, & Ironside, 2016). Background and Significance Aglen (2016), in a systematic review, reported that, to promote students' application of EBP, they must understand its relevance as much as they require information literacy and an understanding of the research topics. In addition, Aglen recommended that students begin using EBP in clinical areas under the direction of nursing faculty. A later scoping review by Fiset, Graham, and Davies (2017) highlighted the most prominent barriers to nursing students' use of EBP, which included negative attitudes toward the use of research findings and a lack of time to implement those findings in practice.
https://doi.org/10.1016/j.teln.2019.04.009 1557-3087/© 2019 Published by Elsevier Inc. on behalf of Organization for Associate Degree Nursing.
R.A. Laske, J. Kurz / Teaching and Learning in Nursing 14 (2019) 246–250
Similarly, Ryan (2016) cited attitudes as a major factor shaping undergraduates' EBP competencies and recommended that student nurses collaborate further with full-fledged clinical nurses to increase their use of EBP. Unfortunately, nursing students often rate gaining psychomotor skills, like administering injections or inserting an indwelling urinary catheter, as more necessary to their bedside practice than learning how to implement EBP (Aglen, 2016). Among undergraduate nursing students, a positive relationship connects EBP knowledge, readiness, and implementation. For instance, Llasus et al. (2014), in a study of 174 students from four states, found a significant, positive correlation between EBP readiness and EBP knowledge, as well as a positive correlation between EBP readiness and EBP implementation. Blackman and Giles (2017) found that graduating nursing students' abilities to analyze, critique, and synthesize existing research as well as their ability to apply the mechanics of research could significantly predict their ability to use EBP. In addition, Pashaeypoor, Ashktorab, Rassouli, and Alavi-Majd (2016) used path analysis to show that EBP knowledge, as well as the complexity, observability, and trialability of EBP, predicted the implementation of EBP in a sample of 170 nursing students. Boström, Sommerfeld, Stenhols, and Kiessling (2018) surveyed students from four health professional programs (occupational therapy, physical therapy, medicine, and nursing) and found that all four groups of students tended to have a high degree of confidence in their EBP skills, with senior students having stronger beliefs in their EBP skills than novice students. They also found a correlation between EBP beliefs and EBP implementation. Several researchers noted that, although knowledge of EBP is obtained within classroom EBP research courses, its implementation tends to be actualized through concurrent and subsequent clinical courses (Coyne, Kennedy, Self, & Bullock, 2018; Ryan, 2016; Scurlock-Evans, Upton, Rouse, & Upton, 2017). In other words, students gain EBP knowledge in the classroom setting but learn how to implement that knowledge in the clinical setting over several semesters. A similar learning pattern is believed to apply to graduate students (Zeleníková, Beach, Ren, Wolff, & Sherwood, 2014). However, reports are in conflict on whether EBP is effectively taught in practice. For instance, students reported receiving less support for EBP during clinical courses (Fiset et al., 2017), whereas faculty members indicated they generally assist students in implementing EBP during such courses. Overall, educators continue to search for the optimal strategy of teaching students how to implement EBP. Nursing educators are also seeking evidence to determine the optimal method of planning the EBP research course. Scurlock-Evans et al. (2017) compared two groups of students about how the experience of a given curriculum affected student knowledge, use, and attitude toward EBP. One group of students followed an older curriculum involving a modular research course, whereas the other group followed a newer, embedded curriculum wherein students were exposed to EBP across several courses of increasing complexity. In both groups, EBP skills consistently improved from the first to the third year of the curriculum. However, the embedded-curriculum group showed greater improvements in skills related to retrieving and reviewing evidence as well as applying and sharing EBP (all of which were cited as barriers to EBP competency in past studies). Scurlock-Evans et al.'s study, unfortunately, does not make it clear which year of undergraduate nursing education would be the most appropriate to introduce an EBP course, given that clinical courses are planned for every semester. Other studies focused on students completing the research course in their final year (Pashaeypoor et al., 2016), save for the studies. No studies were located that specified which year an EBP course should be placed in the nursing curriculum. Arranging the EBP course early in the curriculum might allow students more time to develop a deeper understanding of EBP and give them more opportunities to apply it in clinical areas (Aglen, 2016).
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Purpose and Question In this study, we examine the effect of a curriculum revision, in which the nursing research course was moved from the senior year to the junior year and the content revised, on nursing students' beliefs about principles of EBP. The junior year course that emphasized EBP principles was implemented in one nursing baccalaureate program. At the same time, the research course for seniors was delivered consistent with the outgoing curriculum. This study was guided by the following research question: In a cohort of junior nursing students, how much would a new EBP research course affect their beliefs in EBP when compared with senior nursing students? We hypothesized that the junior class would show stronger beliefs in the value of EBP and in their own ability to implement EBP compared with the senior students at the end of the semester. For the purpose of this study the dependent variable, EBP beliefs, is conceptualized as integrating the best available research evidence to make decisions about patient care. Framework The transtheoretical model framed the study. The model is often called the stages of change that assesses the individual's readiness to act on a new behavior and provides strategies of change to guide the individual. The exposure to both courses on research and EBP content and skills fostered students' development in this aspect of professional nursing practice. Course outcomes are evaluated through assignments and tests. The instrument used in this study added a measure that might demonstrate change in beliefs in EBP principles. Method Design A comparative descriptive study design was used. The independent variable was type of evidence-based research course and varied by outgoing research course offered in the senior year versus the new curriculum, EBP course completed in the junior year. The dependent variable, EBP beliefs, was measured by the EBP Beliefs Scale (Melnyk & Fineout-Overholt, 2015). The instrument was administered via Qualtrix. Participants At the end of the fall semester and completion of the thee-credit research courses, 36 junior and 34 senior nursing students were invited to participate in a study examining their EBP beliefs and their ability to implement EBP. We obtained no demographic data from participants to maintain anonymity because of the small, homogenous sample. The age ranges of the junior and senior classes were 19–20 and 21–23 years, respectively. Instrument Students completed the EBP Beliefs Scale (Melnyk & FineoutOverholt, 2015), which was developed using the transtheoretical model as a framework. The original authors of the scale gave us their permission to use this scale. The EBP Beliefs Scale contains 16 items assessing a person's beliefs about the value of EBP and their ability to implement it. Responses are made on a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree). Two negatively phrased items are reverse scored, and then all the item scores are summed to arrive at a total score ranging from 16 to 80. Scores of less than 64 indicate weaker beliefs in their knowledge of and ability
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to implement EBP. Specifically, scores of 48–63 indicate currently weak commitment to EBP (with the potential for stronger commitment in the future), whereas scores of less than 48 indicate no current commitment to EBP. Furthermore, any single item with a score of below 3–3.5 is considered a possible target for intervention to boost EBP beliefs. Melnyk, Fineout-Overholt, and Mays (2008) reported that the scale had a Cronbach's alpha coefficient (internal consistency) of .90 and a Spearman–Brown coefficient (i.e., split-half reliability) of .87. They further found that the scale had acceptable face and content validity, construct validity, and criterion validity (based on the knowngroups method). Other studies using the EBP Beliefs Scale have also confirmed the reliability and validity of the tool (Verloo, Desmedt, & Morin, 2017). Procedures for Data Collection Our university's Institutional Review Board (IRB) committee approved this study. Completing the survey was taken as giving consent to participate. The survey data were stored on the researcher's computer in a password-protected file. The computer was secured in a locked office in the researcher's home. All invited students received three reminders to complete the survey over a period of 3 months. By the end of the 3-month period, 18 juniors and 18 seniors responded by accessing an online Qualtrics link and completing the anonymous survey. Data Analysis and Results Thirty-six surveys were completed. The responses were downloaded from Qualtrics into SPSS Statistics 24 (IBM Corp., Armonk, NY). The Cronbach's alpha coefficient for the EBP Beliefs Scale was .86 in this sample. The mean scores of each item in the EBP Belief Scale were also calculated for each group (Table 1). The highest rated items focused on beliefs about the positive effect of EBP, whereas the lowest rated items focused on the required time to implement EBP. Another independent t test was used to examine the group differences in item scores. A statistically significant difference was found between the two groups for two items, with both differences being in favor of seniors: “I am sure how to measure the outcomes of clinical care,” t(34) = 2.83, p = .008, and “I am sure that I can implement EBP,” t(34) = 1.14, df = 34, p = .05. As for the mean total score on the EBP Beliefs Scale, seniors' mean was 62.38 and juniors' mean was 57.88 (Table 2). The mean did not significantly differ between the groups (based on an independent t test [two-tailed]). The findings suggest that neither group was fully committed to EBP, although they might develop such a commitment in the future. Discussion We found no significant difference in the general beliefs regarding EBP between the two groups of students. Many researchers have reported on the ambiguity concerning which year of nursing education is most appropriate to introduce EBP content (Burns & Foley, 2005). Melnyk (2005) recommended that students are more likely to adopt and use EBP skills when they are introduced earlier and applied consistently in the education of health care professionals. Callister, Matsumura, Lookinland, Mangum, and Loucks (2005) showed that students taught EBP skills earlier in their curriculum tended to have increased interest in EBP and research and had a greater understanding of real-world clinical research. Likewise, Aglen (2016) argued that introducing EBP skills earlier in the curriculum allows students more time to prepare and practice EBP in clinical settings. In contrast to all
Table 1 Mean score by group for each item on the EBP Belief Scale Item
Group n
I believe that EBP results in the best clinical care for patients. I am clear about the steps of EBP.
Senior Junior Senior Junior I am sure that I can implement EBP. Senior Junior I believe that critically appraising evidence Senior is an important step in the EBP process. Junior I am sure that evidence-based guidelines Senior can improve clinical care. Junior Senior I believe that I can search for the best evidence to answer clinical questions in a Junior time-efficient way. I believe that I can overcome barriers in Senior implementing EBP. Junior I am sure that I can implement EBP in a Senior time-efficient way. Junior I am sure that implementing EBP will Senior improve the care I deliver to my patients. Junior I am sure how to measure the outcomes of Senior clinical care. Junior I believe that EBP takes too much time. Senior Junior I am sure that I can access the best Senior resources to implement EBP. Junior I believe that EBP is difficult. Senior Junior I know how to implement EBP sufficiently Senior to make practice changes. Junior I am confident about my ability to Senior implement EBP where I work. Junior I believe the care that I deliver is evidence Senior based. Junior
M
SD
SE
18 18 18 18 18 18 18 18 18 18 18 18
4.39 4.33 4.00 3.78 4.17 3.61 4.28 4.22 4.44 4.44 3.61 3.50
0.979 1.029 1.085 0.647 0.707 0.979 0.669 0.808 0.616 0.705 0.778 0.924
0.231 0.243 0.256 0.152 0.167 0.231 0.158 0.191 0.145 0.166 0.183 0.218
18 18 18 18 18 18 18 18 18 18 18 18 18 18 18 18 18 18 18 18
3.67⁎ 3.39 3.78 3.50 4.67 4.28 4.00 3.17 3.22 3.06 3.61 3.50 2.78 2.39 3.56 3.44 3.83⁎ 3.22 4.39 4.06
0.594 0.850 0.647 0.924 0.485 0.826 0.767 0.985 1.003 1.392 0.778 0.786 0.943 1.195 0.784 0.856 0.707 1.060 0.608 0.539
0.140 0.200 0.152 0.218 0.114 0.195 0.181 0.232 0.236 0.328 0.183 0.185 0.222 0.282 0.185 0.202 0.167 0.250 0.143 0.127
Note. EBP = evidence-based practice. ⁎ p b .05.
three of these studies, we found that implementing the research course in the junior year, as compared with the senior year, did not lead to any differences in students' beliefs about EBP. Nevertheless, both groups had similar scores on the EBP Beliefs Scale, and the scores suggested that, although they did not have full commitment to EBP currently, they might develop greater commitment in the future. Despite the lack of group differences, earlier introduction of EBP (i.e., in the junior year) provides students more opportunities to implement EBP in patient care, so that they may achieve competency in EBP to ensure safe and quality patient care. Both student groups rated several items related to the positive effect of EBP quite highly. Specifically, both student groups perceived that EBP guidelines can improve clinical care and that implementing EBP might lead to the best clinical care for patients. These items were also highly rated in a study of Czech and Slovakian nurses (Zeleníkóva et al., 2016). Both groups of students in this study also concurred that the care they delivered was evidence based. For all these items, seniors had consistently higher mean scores than did the juniors. Seniors might have had higher scores because they have more clinical experience and opportunities to deliver safe and quality care to patients. Although most students believed that the implementation of EBP improves patient care, some believed that it might take too much time. Indeed, one of the lowest rated items focused on the time Table 2 Total mean survey scores by group for the EBP Belief Scale Group
n
M
SD
SE
Senior Junior
18 18
62.388 57.888
5.065 9.517
1.194 2.243
R.A. Laske, J. Kurz / Teaching and Learning in Nursing 14 (2019) 246–250
required to use EBP (“I believe that EBP takes too much time”). Fifteen out of the 36 students agreed or strongly agreed that EBP skills are time-consuming, and the mean scores on these items were similar between the groups. Students find the process of searching for articles and differentiating among the types of articles (e.g., a quality improvement project vs. a research study) time-consuming and frustrating. Similarly, Brooke, Hvalic-Touzery, and Skela-Savic (2015) reported that student nurses in England and Slovenia found the research process overwhelming and difficult to understand. While researching the impact of undergraduate research education, Leach, Hofmeyer, and Bobridge (2016) found that Australian nursing students identified a lack of time and inadequate skills in interpreting EBP as barriers to implementing EBP. Leach et al. concluded that the introduction of EBP skills earlier in the curriculum might improve nursing students' skills and use of EBP. Although our study showed no difference in EBP beliefs between the two student groups, we believe that the earlier introduction of EBP in our curriculum might enhance students' EBP skills. In summary, both juniors and seniors reported having generally positive beliefs about implementing EBP to improve patient care— that is, they tended to believe that they could deliver EBP care in the clinical setting. However, both groups found EBP difficult and time-consuming to implement. Because the introduction of the EBP research course earlier in the curriculum (junior year instead of senior year) did not have a negative impact on students' EBP beliefs, we suggest that EBP be introduced at such an earlier stage to allow nursing students more time to develop and practice the skills needed to apply EBP in patient care. Limitations This study has some limitations. First, the sample size for both junior and senior students was small. At the time of this study, the nursing program at our university had only 32 junior students and 64 senior students. Despite this small sample size, the overall reliability of the EBP Belief Scale was high. Second, although all students were invited to participate anonymously, some students might not have felt comfortable in participating because of the small class sizes. Third, we did not clarify the groups' demographic characteristics, including age, clinical and work experiences, or their clinical faculty's use of EBP. Examining the correlations between those variables and students' EBP Beliefs Scale scores could have added depth to our findings. Finally, we examined EBP beliefs at only one period: after the research course. Thus, it is unclear whether the new curriculum (where the research course is delivered in the junior year instead of the senior year) will strengthen students' EBP beliefs in the future or if the use of EBP in their clinical practice for an additional academic year would improve their EBP Beliefs Scale scores by the time of graduation. Implications for Educators and Future Research To fully evaluate the impact of the new curriculum, we recommend that a longitudinal study be conducted in the future, focusing on whether students' EBP Beliefs Scale scores improve over time. Such a study might involve assessing students' EBP beliefs in subsequent semesters, after they have been given more opportunities to practice their EBP skills in the clinical and classroom settings. Further research exploring how nursing undergraduates' understanding of EBP is affected by additional practice opportunities in the clinical setting is required to fully understand the effectiveness of the curricular change in promoting EBP skills. Future studies should also employ incentives (e.g., drawing for a gift card) to increase the number of participants.
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Nursing faculty should design clinical activities that encourage students to use their EBP skills for patient care throughout the curriculum. Other studies have demonstrated that students will use EBP skills if they are introduced to EBP at an earlier stage and are given opportunities to apply it consistently throughout their education (Aglen, 2016; Callister et al., 2005). Both classroom and clinical faculty should collaborate to investigate innovative teaching strategies and design assignments that enhance and reinforce students' EBP skills. In addition, integration of EBP into other clinical and classroom courses is crucial for fostering the clinical practice of nursing students. Educators must prepare nursing students to adopt and implement EBP to provide effective and efficient care for their patients in all settings as future professional nurses. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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Contents lists available at ScienceDirect
Teaching and Learning in Nursing journal homepage: www.jtln.org
Examining evidence-based practice beliefs in undergraduate nursing students: A pilot study Rita Ann Laske, EdD, RN, CNE ⁎, Jane Kurz, PhD, RN School of Nursing and Health Sciences, La Salle University, Philadelphia, PA, 19141, USA
a r t i c l e
i n f o
Article history: Accepted 30 April 2019 Keywords: Evidence-based practice Beliefs Undergraduate nursing students
a b s t r a c t This study examined how a new course affected evidence-based practice (EBP) beliefs in junior nursing students (N = 18) compared with senior nursing students (N = 18). These students completed the EBP Belief Scale. An independent t test revealed no significant difference in scores. There were statistically significant differences on 2 items (p b .05): “measuring outcomes of clinical care” and “the ability to implement EBP”. Through early introduction of skills, students have more opportunities to use EBP in clinical practicums. © 2019 Published by Elsevier Inc. on behalf of Organization for Associate Degree Nursing.
Introduction Evidence-based practice (EBP) is a problem-solving approach to clinical decision-making. Consistent with adopting EBP strategies in health care, health professionals locate, appraise, and use the best available evidence, consider their own clinical expertise, and center efforts on patients' values and preferences. The aim is to achieve the best outcomes for individual patients, families, and communities (Melnyk & Fineout-Overholt, 2015). For decades, the nursing community has recognized EBP strategies as essential for the delivery of high-quality nursing care at the lowest costs. Numerous organizations formally support EBP. For example, the Institute of Medicine (2003) has mandated that all health professionals be educated to deliver patient-centered care emphasizing EBP. In addition, the American Association of Colleges of Nursing (AACN, 2008), in its “Essentials for Baccalaureate Education for Professional Nursing Practice,” directed educators to cover the research process and teach students how to retrieve, appraise, and synthesize evidence. Furthermore, prelicensure student curriculums are expected to focus on providing students with opportunities to integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences when planning, implementing, and evaluating the outcomes of care (AACN, 2008). The faculty of the Quality and Safety Education for Nurses (2018) project has set targets regarding the knowledge, skills, and attitudes
The author declares no conflict of interest. No financial support was provided for this study. ⁎ Corresponding author. Tel.: 1 610 888 7512 (cell). E-mail addresses: [email protected], (R.A. Laske), [email protected]. (J. Kurz).
to be identified and carried out in curriculums of nursing prelicensure programs. Competency in six major areas of nursing is a goal for student development; EBP is specified. To address these competencies, some nursing educators clearly indicate that undergraduate nursing students require a strong foundation in nursing research (Burns & Foley, 2005; Llasus, Angosta, & Clark, 2014). However, throughout the United States, registered nurses generally report low competency in EBP despite being supportive of its use (Melnyk et al., 2018). New graduate nurses report difficulty in applying EBP theory in their actual clinical practice (Ryan, 2016), with the most common problems related to asking Problem, Intervention, Comparison, Outcome, Time (PICOT) questions, finding evidence relevant for the populations' problems, and critically evaluating and collecting the best-known evidence. To address these challenges, researchers have recommended that nursing educators develop courses that help nursing undergraduates obtain greater EBP competency before graduation (Aglen, 2016; Llasus et al., 2014; Wonder, Spurlock, & Ironside, 2016). Background and Significance Aglen (2016), in a systematic review, reported that, to promote students' application of EBP, they must understand its relevance as much as they require information literacy and an understanding of the research topics. In addition, Aglen recommended that students begin using EBP in clinical areas under the direction of nursing faculty. A later scoping review by Fiset, Graham, and Davies (2017) highlighted the most prominent barriers to nursing students' use of EBP, which included negative attitudes toward the use of research findings and a lack of time to implement those findings in practice.
https://doi.org/10.1016/j.teln.2019.04.009 1557-3087/© 2019 Published by Elsevier Inc. on behalf of Organization for Associate Degree Nursing.
R.A. Laske, J. Kurz / Teaching and Learning in Nursing 14 (2019) 246–250
Similarly, Ryan (2016) cited attitudes as a major factor shaping undergraduates' EBP competencies and recommended that student nurses collaborate further with full-fledged clinical nurses to increase their use of EBP. Unfortunately, nursing students often rate gaining psychomotor skills, like administering injections or inserting an indwelling urinary catheter, as more necessary to their bedside practice than learning how to implement EBP (Aglen, 2016). Among undergraduate nursing students, a positive relationship connects EBP knowledge, readiness, and implementation. For instance, Llasus et al. (2014), in a study of 174 students from four states, found a significant, positive correlation between EBP readiness and EBP knowledge, as well as a positive correlation between EBP readiness and EBP implementation. Blackman and Giles (2017) found that graduating nursing students' abilities to analyze, critique, and synthesize existing research as well as their ability to apply the mechanics of research could significantly predict their ability to use EBP. In addition, Pashaeypoor, Ashktorab, Rassouli, and Alavi-Majd (2016) used path analysis to show that EBP knowledge, as well as the complexity, observability, and trialability of EBP, predicted the implementation of EBP in a sample of 170 nursing students. Boström, Sommerfeld, Stenhols, and Kiessling (2018) surveyed students from four health professional programs (occupational therapy, physical therapy, medicine, and nursing) and found that all four groups of students tended to have a high degree of confidence in their EBP skills, with senior students having stronger beliefs in their EBP skills than novice students. They also found a correlation between EBP beliefs and EBP implementation. Several researchers noted that, although knowledge of EBP is obtained within classroom EBP research courses, its implementation tends to be actualized through concurrent and subsequent clinical courses (Coyne, Kennedy, Self, & Bullock, 2018; Ryan, 2016; Scurlock-Evans, Upton, Rouse, & Upton, 2017). In other words, students gain EBP knowledge in the classroom setting but learn how to implement that knowledge in the clinical setting over several semesters. A similar learning pattern is believed to apply to graduate students (Zeleníková, Beach, Ren, Wolff, & Sherwood, 2014). However, reports are in conflict on whether EBP is effectively taught in practice. For instance, students reported receiving less support for EBP during clinical courses (Fiset et al., 2017), whereas faculty members indicated they generally assist students in implementing EBP during such courses. Overall, educators continue to search for the optimal strategy of teaching students how to implement EBP. Nursing educators are also seeking evidence to determine the optimal method of planning the EBP research course. Scurlock-Evans et al. (2017) compared two groups of students about how the experience of a given curriculum affected student knowledge, use, and attitude toward EBP. One group of students followed an older curriculum involving a modular research course, whereas the other group followed a newer, embedded curriculum wherein students were exposed to EBP across several courses of increasing complexity. In both groups, EBP skills consistently improved from the first to the third year of the curriculum. However, the embedded-curriculum group showed greater improvements in skills related to retrieving and reviewing evidence as well as applying and sharing EBP (all of which were cited as barriers to EBP competency in past studies). Scurlock-Evans et al.'s study, unfortunately, does not make it clear which year of undergraduate nursing education would be the most appropriate to introduce an EBP course, given that clinical courses are planned for every semester. Other studies focused on students completing the research course in their final year (Pashaeypoor et al., 2016), save for the studies. No studies were located that specified which year an EBP course should be placed in the nursing curriculum. Arranging the EBP course early in the curriculum might allow students more time to develop a deeper understanding of EBP and give them more opportunities to apply it in clinical areas (Aglen, 2016).
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Purpose and Question In this study, we examine the effect of a curriculum revision, in which the nursing research course was moved from the senior year to the junior year and the content revised, on nursing students' beliefs about principles of EBP. The junior year course that emphasized EBP principles was implemented in one nursing baccalaureate program. At the same time, the research course for seniors was delivered consistent with the outgoing curriculum. This study was guided by the following research question: In a cohort of junior nursing students, how much would a new EBP research course affect their beliefs in EBP when compared with senior nursing students? We hypothesized that the junior class would show stronger beliefs in the value of EBP and in their own ability to implement EBP compared with the senior students at the end of the semester. For the purpose of this study the dependent variable, EBP beliefs, is conceptualized as integrating the best available research evidence to make decisions about patient care. Framework The transtheoretical model framed the study. The model is often called the stages of change that assesses the individual's readiness to act on a new behavior and provides strategies of change to guide the individual. The exposure to both courses on research and EBP content and skills fostered students' development in this aspect of professional nursing practice. Course outcomes are evaluated through assignments and tests. The instrument used in this study added a measure that might demonstrate change in beliefs in EBP principles. Method Design A comparative descriptive study design was used. The independent variable was type of evidence-based research course and varied by outgoing research course offered in the senior year versus the new curriculum, EBP course completed in the junior year. The dependent variable, EBP beliefs, was measured by the EBP Beliefs Scale (Melnyk & Fineout-Overholt, 2015). The instrument was administered via Qualtrix. Participants At the end of the fall semester and completion of the thee-credit research courses, 36 junior and 34 senior nursing students were invited to participate in a study examining their EBP beliefs and their ability to implement EBP. We obtained no demographic data from participants to maintain anonymity because of the small, homogenous sample. The age ranges of the junior and senior classes were 19–20 and 21–23 years, respectively. Instrument Students completed the EBP Beliefs Scale (Melnyk & FineoutOverholt, 2015), which was developed using the transtheoretical model as a framework. The original authors of the scale gave us their permission to use this scale. The EBP Beliefs Scale contains 16 items assessing a person's beliefs about the value of EBP and their ability to implement it. Responses are made on a 5-point scale ranging from 1 (strongly disagree) to 5 (strongly agree). Two negatively phrased items are reverse scored, and then all the item scores are summed to arrive at a total score ranging from 16 to 80. Scores of less than 64 indicate weaker beliefs in their knowledge of and ability
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to implement EBP. Specifically, scores of 48–63 indicate currently weak commitment to EBP (with the potential for stronger commitment in the future), whereas scores of less than 48 indicate no current commitment to EBP. Furthermore, any single item with a score of below 3–3.5 is considered a possible target for intervention to boost EBP beliefs. Melnyk, Fineout-Overholt, and Mays (2008) reported that the scale had a Cronbach's alpha coefficient (internal consistency) of .90 and a Spearman–Brown coefficient (i.e., split-half reliability) of .87. They further found that the scale had acceptable face and content validity, construct validity, and criterion validity (based on the knowngroups method). Other studies using the EBP Beliefs Scale have also confirmed the reliability and validity of the tool (Verloo, Desmedt, & Morin, 2017). Procedures for Data Collection Our university's Institutional Review Board (IRB) committee approved this study. Completing the survey was taken as giving consent to participate. The survey data were stored on the researcher's computer in a password-protected file. The computer was secured in a locked office in the researcher's home. All invited students received three reminders to complete the survey over a period of 3 months. By the end of the 3-month period, 18 juniors and 18 seniors responded by accessing an online Qualtrics link and completing the anonymous survey. Data Analysis and Results Thirty-six surveys were completed. The responses were downloaded from Qualtrics into SPSS Statistics 24 (IBM Corp., Armonk, NY). The Cronbach's alpha coefficient for the EBP Beliefs Scale was .86 in this sample. The mean scores of each item in the EBP Belief Scale were also calculated for each group (Table 1). The highest rated items focused on beliefs about the positive effect of EBP, whereas the lowest rated items focused on the required time to implement EBP. Another independent t test was used to examine the group differences in item scores. A statistically significant difference was found between the two groups for two items, with both differences being in favor of seniors: “I am sure how to measure the outcomes of clinical care,” t(34) = 2.83, p = .008, and “I am sure that I can implement EBP,” t(34) = 1.14, df = 34, p = .05. As for the mean total score on the EBP Beliefs Scale, seniors' mean was 62.38 and juniors' mean was 57.88 (Table 2). The mean did not significantly differ between the groups (based on an independent t test [two-tailed]). The findings suggest that neither group was fully committed to EBP, although they might develop such a commitment in the future. Discussion We found no significant difference in the general beliefs regarding EBP between the two groups of students. Many researchers have reported on the ambiguity concerning which year of nursing education is most appropriate to introduce EBP content (Burns & Foley, 2005). Melnyk (2005) recommended that students are more likely to adopt and use EBP skills when they are introduced earlier and applied consistently in the education of health care professionals. Callister, Matsumura, Lookinland, Mangum, and Loucks (2005) showed that students taught EBP skills earlier in their curriculum tended to have increased interest in EBP and research and had a greater understanding of real-world clinical research. Likewise, Aglen (2016) argued that introducing EBP skills earlier in the curriculum allows students more time to prepare and practice EBP in clinical settings. In contrast to all
Table 1 Mean score by group for each item on the EBP Belief Scale Item
Group n
I believe that EBP results in the best clinical care for patients. I am clear about the steps of EBP.
Senior Junior Senior Junior I am sure that I can implement EBP. Senior Junior I believe that critically appraising evidence Senior is an important step in the EBP process. Junior I am sure that evidence-based guidelines Senior can improve clinical care. Junior Senior I believe that I can search for the best evidence to answer clinical questions in a Junior time-efficient way. I believe that I can overcome barriers in Senior implementing EBP. Junior I am sure that I can implement EBP in a Senior time-efficient way. Junior I am sure that implementing EBP will Senior improve the care I deliver to my patients. Junior I am sure how to measure the outcomes of Senior clinical care. Junior I believe that EBP takes too much time. Senior Junior I am sure that I can access the best Senior resources to implement EBP. Junior I believe that EBP is difficult. Senior Junior I know how to implement EBP sufficiently Senior to make practice changes. Junior I am confident about my ability to Senior implement EBP where I work. Junior I believe the care that I deliver is evidence Senior based. Junior
M
SD
SE
18 18 18 18 18 18 18 18 18 18 18 18
4.39 4.33 4.00 3.78 4.17 3.61 4.28 4.22 4.44 4.44 3.61 3.50
0.979 1.029 1.085 0.647 0.707 0.979 0.669 0.808 0.616 0.705 0.778 0.924
0.231 0.243 0.256 0.152 0.167 0.231 0.158 0.191 0.145 0.166 0.183 0.218
18 18 18 18 18 18 18 18 18 18 18 18 18 18 18 18 18 18 18 18
3.67⁎ 3.39 3.78 3.50 4.67 4.28 4.00 3.17 3.22 3.06 3.61 3.50 2.78 2.39 3.56 3.44 3.83⁎ 3.22 4.39 4.06
0.594 0.850 0.647 0.924 0.485 0.826 0.767 0.985 1.003 1.392 0.778 0.786 0.943 1.195 0.784 0.856 0.707 1.060 0.608 0.539
0.140 0.200 0.152 0.218 0.114 0.195 0.181 0.232 0.236 0.328 0.183 0.185 0.222 0.282 0.185 0.202 0.167 0.250 0.143 0.127
Note. EBP = evidence-based practice. ⁎ p b .05.
three of these studies, we found that implementing the research course in the junior year, as compared with the senior year, did not lead to any differences in students' beliefs about EBP. Nevertheless, both groups had similar scores on the EBP Beliefs Scale, and the scores suggested that, although they did not have full commitment to EBP currently, they might develop greater commitment in the future. Despite the lack of group differences, earlier introduction of EBP (i.e., in the junior year) provides students more opportunities to implement EBP in patient care, so that they may achieve competency in EBP to ensure safe and quality patient care. Both student groups rated several items related to the positive effect of EBP quite highly. Specifically, both student groups perceived that EBP guidelines can improve clinical care and that implementing EBP might lead to the best clinical care for patients. These items were also highly rated in a study of Czech and Slovakian nurses (Zeleníkóva et al., 2016). Both groups of students in this study also concurred that the care they delivered was evidence based. For all these items, seniors had consistently higher mean scores than did the juniors. Seniors might have had higher scores because they have more clinical experience and opportunities to deliver safe and quality care to patients. Although most students believed that the implementation of EBP improves patient care, some believed that it might take too much time. Indeed, one of the lowest rated items focused on the time Table 2 Total mean survey scores by group for the EBP Belief Scale Group
n
M
SD
SE
Senior Junior
18 18
62.388 57.888
5.065 9.517
1.194 2.243
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required to use EBP (“I believe that EBP takes too much time”). Fifteen out of the 36 students agreed or strongly agreed that EBP skills are time-consuming, and the mean scores on these items were similar between the groups. Students find the process of searching for articles and differentiating among the types of articles (e.g., a quality improvement project vs. a research study) time-consuming and frustrating. Similarly, Brooke, Hvalic-Touzery, and Skela-Savic (2015) reported that student nurses in England and Slovenia found the research process overwhelming and difficult to understand. While researching the impact of undergraduate research education, Leach, Hofmeyer, and Bobridge (2016) found that Australian nursing students identified a lack of time and inadequate skills in interpreting EBP as barriers to implementing EBP. Leach et al. concluded that the introduction of EBP skills earlier in the curriculum might improve nursing students' skills and use of EBP. Although our study showed no difference in EBP beliefs between the two student groups, we believe that the earlier introduction of EBP in our curriculum might enhance students' EBP skills. In summary, both juniors and seniors reported having generally positive beliefs about implementing EBP to improve patient care— that is, they tended to believe that they could deliver EBP care in the clinical setting. However, both groups found EBP difficult and time-consuming to implement. Because the introduction of the EBP research course earlier in the curriculum (junior year instead of senior year) did not have a negative impact on students' EBP beliefs, we suggest that EBP be introduced at such an earlier stage to allow nursing students more time to develop and practice the skills needed to apply EBP in patient care. Limitations This study has some limitations. First, the sample size for both junior and senior students was small. At the time of this study, the nursing program at our university had only 32 junior students and 64 senior students. Despite this small sample size, the overall reliability of the EBP Belief Scale was high. Second, although all students were invited to participate anonymously, some students might not have felt comfortable in participating because of the small class sizes. Third, we did not clarify the groups' demographic characteristics, including age, clinical and work experiences, or their clinical faculty's use of EBP. Examining the correlations between those variables and students' EBP Beliefs Scale scores could have added depth to our findings. Finally, we examined EBP beliefs at only one period: after the research course. Thus, it is unclear whether the new curriculum (where the research course is delivered in the junior year instead of the senior year) will strengthen students' EBP beliefs in the future or if the use of EBP in their clinical practice for an additional academic year would improve their EBP Beliefs Scale scores by the time of graduation. Implications for Educators and Future Research To fully evaluate the impact of the new curriculum, we recommend that a longitudinal study be conducted in the future, focusing on whether students' EBP Beliefs Scale scores improve over time. Such a study might involve assessing students' EBP beliefs in subsequent semesters, after they have been given more opportunities to practice their EBP skills in the clinical and classroom settings. Further research exploring how nursing undergraduates' understanding of EBP is affected by additional practice opportunities in the clinical setting is required to fully understand the effectiveness of the curricular change in promoting EBP skills. Future studies should also employ incentives (e.g., drawing for a gift card) to increase the number of participants.
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Nursing faculty should design clinical activities that encourage students to use their EBP skills for patient care throughout the curriculum. Other studies have demonstrated that students will use EBP skills if they are introduced to EBP at an earlier stage and are given opportunities to apply it consistently throughout their education (Aglen, 2016; Callister et al., 2005). Both classroom and clinical faculty should collaborate to investigate innovative teaching strategies and design assignments that enhance and reinforce students' EBP skills. In addition, integration of EBP into other clinical and classroom courses is crucial for fostering the clinical practice of nursing students. Educators must prepare nursing students to adopt and implement EBP to provide effective and efficient care for their patients in all settings as future professional nurses. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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