Strategies For Teaching Evidence-based Practice In Nursing .
Horntvedt et al. BMC Medical Education (2018) EARCH ARTICLEOpen AccessStrategies for teaching evidence-basedpractice in nursing education: a thematicliterature reviewMay-Elin T. Horntvedt1*, Anita Nordsteien2, Torbjørg Fermann1 and Elisabeth Severinsson3AbstractBackground: Evidence-based practice (EBP) is imperative for ensuring patient safety. Although teaching strategiesto enhance EBP knowledge and skills are recommended, recent research indicates that nurses may not be wellprepared to apply EBP. A three-level hierarchy for teaching and learning evidence-based medicine is suggested,including the requirement for interactive clinical activities in EBP teaching strategies. This literature review identifiesthe teaching strategies for EBP knowledge and skills currently used in undergraduate nursing education. We alsodescribe students’ and educators’ experiences with learning outcomes and barriers.Methods: We conducted literature searches using Medline, Embase, CINAHL, ERIC and Academic Search Premier.Six qualitative studies and one mixed-method study met the inclusion criteria and were critically evaluated basedon the Critical Appraisal Skills Programme. Using Braun and Clarke’s six phases, the seven studies were deductivelyand thematically analysed to discover themes.Results: Four teaching strategy themes were identified, including subthemes within each theme: i.e., interactiveteaching strategies; interactive and clinical integrated teaching strategies; learning outcomes; and barriers. Althoughfour studies included a vague focus on teaching EBP principles, they all included research utilisation and interactiveteaching strategies. Reported learning outcomes included enhanced analytical and critical skills and using researchto ensure patient safety. Barriers included challenging collaborations, limited awareness of EBP principles and poorinformation literacy skills.Conclusion: Four of the seven analysed studies included a vague focus on the use of EBP teaching strategies.Interactive teaching strategies are used, but primary strategies focus on searching for and critically appraisingresearch for practice-based application. Although this review included a relatively small sample of literature, thefindings indicate a need for more qualitative research investigating interactive and clinically integrated teachingstrategies towards further enhancing EBP undergraduate nursing students’ knowledge and skills.Keywords: Teaching strategies, Evidence-based practice, Nursing education, Curriculum, Learning outcomeBackgroundEvidence-based practice (EBP) in health care has becomeimperative for patient safety. EBP involves a conscious useand application of various knowledge sources, includingthe use of published research in conjunction with clinicalexpertise and patient values and preferences [1]. Theprocess of EBP includes that health-care personnel* Correspondence: may-elin.t.horntvedt@usn.no1Faculty of Health and Social Sciences, the Department of Nursing andHealth Sciences, University of South-Eastern Norway, P.O. Box 235, N-3603Kongsberg, NorwayFull list of author information is available at the end of the articleformulate structured queries, and then conduct searchesof databases from which they acquire trustworthy and reliable evidence. Further, they must then critically appraisethe research for its reliability, validity and applicability to aclinical context [2, 3].Interactive methods including interactive lectures, smallgroup work, journal clubs, reading quizzes, clinical nursepresentations, workshops and problem-based learning areneeded in teaching EBP [2, 3]. An interactive approach involves an interaction amongst the participants [3]. Effective learning reflects the quality of teaching. Learning The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication o/1.0/) applies to the data made available in this article, unless otherwise stated.
Horntvedt et al. BMC Medical Education (2018) 18:172though a constructivist approach refers to the creation ofan environment in which the learner is an active participant who gains experience and engages in reflection,leading to problem-based, transformative learning [4].Toengage the next generation of nurses and enhance theirEBP knowledge and skills, a variety of teaching strategieshave been recommended [5–7].Khan and Coomarasamy [3] have described a three-levelhierarchy of evidence-based medicine (EBM) teaching andlearning methods. The first level is interactive clinical activities. The second level is classroom didactics using clinical and interactive activities. Finally, although lesspreferred for teaching EBP, the third level is classroom didactic or stand-alone teaching [3]. According to FineoutOverholt et al. [2], it is important to keep teaching strategies simple and integration of EBP must be a natural partof the academic culture.Research supports the first level in this hierarchy whenteaching EBP; i.e., an interactive style is often preferredbecause this method facilitates student learning [8–10].Johnson et al. [11] found that new learning methods andblended approaches to teaching EBP impact students’ attitudes towards research. In addition, Crookes et al. [12]identified different meaningful and engaging teachingstrategies that have been adopted by nurse educators,such as online teaching, gaming and simulation techniques. However, these authors also concluded thatnursing education needs to include more active lecturestyles to strengthen the link between course content andclinical practice [12]. Ryan [10] introduced teachingstrategies as extrinsic factors and found that teachingEBP and research methods may be more relevant iftaught in a clinical context rather than using traditionaldidactic methods.A mixed-methods meta-synthesis examining awarenessand adoption of EBP stated that EBP skills for registerednurses and Bachelor of Science in Nursing (RN-to-BSN)students are influenced by exposure to partnerships andcontextual teaching and learning, as well as clinical practice experience [13]. Teaching and learning strategies haveincluded clinical practicum projects, lectures, small groupwork, post-clinical conferences, online modules and simulations [13]. EBP teachers who collaborate with their students, and nurses in clinical practice also influencestudents’ integration of EBP [2].To ensure nursing students’ enhanced EBP knowledge,it is also essential to build partnerships with librarianswho teach information literacy, which involves searchingfor relevant research in databases and evaluating andusing that information in relation to course requirementsand assignments [2, 14]. Reported barriers to the adoptionof EBP include difficulties with searching databases andevaluating research, feeling isolated from knowledgeablecolleagues and the perception that there are minimalPage 2 of 11benefits from EBP. Countering these barriers, Phillips andCullen [13] found that a variety of teaching and learningstrategies may empower students’ implementation of EBPin clinical practice.Emerson and Records’ [15] overview of scholarshipand its role in nursing education includes a descriptionof catalysts that enhance EBP in nursing and the knowledge necessary for EBP teaching. They state that scholarly teaching is an academic expectation; however, itdoes not appear to advance either the education or thediscipline beyond the individual level. Indeed, nursesface challenges to EBP from their inability to locate andcritically evaluate information [16–19].The European Higher Education Area (EHEA) framework specifies expected learning outcomes for candidates with a Bachelor’s degree, including skills infinding, evaluating, referring and applying scientific information [20]. Likewise, the Code of Ethics of the International Council of Nurses stresses that nurses must beaware of and implement research results into their clinical practice [21]. Despite these guidelines, it appearsthat teaching EBP in nursing education varies amongnurse educators and universities, and that clinical preceptors may have insufficient knowledge needed to support students [2, 10, 19]. Recent research indicates thatnurses may not be well prepared to use EBP in theirclinical practice [22, 23].There is a dearth of literature regarding the effect ofteaching and learning strategies on implementing EBP innursing education [10, 13, 23, 24] and it is currently unclear whether implementation of EBP training leads toimproved nursing practice [13].AimIn this literature review, we aimed to identify strategies forteaching EBP in undergraduate nursing education. The review questions were: “What teaching strategies are used toenhance knowledge and skills in EBP in undergraduatenursing education and what are the learning outcomesand barriers?”MethodsIdentification of studiesWe conducted literature searches using Medline, Embase,CINAHL, Academic Search Premier and ERIC. The PICoframework for qualitative research was used to develop thereview questions, plan the search and define the inclusioncriteria. The population or participants assessed were nursing students, nursing education and nursing programmes.The phenomenon of interest was teaching and the specificcontext was EBP education. These concepts were transformed into the actual subject headings and text used inthe search strategy in Medline (Table 1), which representshow the concepts were truncated and combined using
Horntvedt et al. BMC Medical Education (2018) 18:172Table 1 Example of the search strategy in Medline1. exp. Education, Nursing/Page 3 of 11nursing education. The final seven articles were included in the review.2. (nurs* adj3 education).ab, ti.3. (nurs* adj3 program*).ab, ti.4. (nurs* adj3 student*).ab, ti.5. 1 or 2 or 3 or 46. teaching.ab, ti.7. exp. Teaching/8. 6 or 79. exp. Evidence-Based Practice/10. evidence-based.ab, ti.11. 9 or 1012. 5 and 8 and 1113. limit 12 to (english language and yr. “2006–2017”)14. limit 13 to “qualitative (best balance of sensitivity and specificity)”Boolean and proximity operators in all database searches.The search criteria included qualitative studies published inEnglish from 2006 through 2017. This range was chosenbased on an initial search in PubMed PubReMiner indicating that most research on EBP training in nursing education was published since 2006, when EBP gained a footholdin nursing education. We examined the references cited inthe retrieved studies, as well as studies in Google Scholarthat cited the retrieved studies.The inclusion criteria were: 1) original, qualitative research focused on EBP teaching strategies in undergraduatenursing education, i.e., we focused on qualitative researchto gain a deeper insight into teacher and student experiences with these strategies; 2) peer-reviewed, original research; 3) studies on educators, student participation, orboth; and 4) studies evaluated as moderate or high qualityaccording to the Critical Appraisal Skills Programme(CASP) [25]. The exclusion criteria were: reviews, quantitative studies, theoretical studies and contributions that werenot original research articles. Articles related to teachingstrategies directed at health-care personnel, master programmes or postgraduate nursing education were alsoexcluded.We used the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) [26] flowchart in the retrieval and selection process (Fig. 1) toidentify 972 records from an initial database search andan additional 35 by manually searching those studies’bibliographies. After duplicates were eliminated, wescreened the abstracts of 724 articles. Of these, 708 articles did not meet our inclusion criteria, thus we obtained 16 full-text articles for further analysis. Each ofthe four authors examined all 16 articles, of which ninewere excluded because of their low quality, focus onclinical intervention, or lack of focus on undergraduateCritical appraisalAll four authors independently appraised the seven finalarticles for their methodological quality using CASP(Table 2), with moderate and high methodological qualitydefined as meeting 6–8 and 9–10 of the CASP checklistcriteria, respectively. We discussed disagreements untilconsensus was reached.AnalysisA thematic analysis was conducted to identify themesbased on the six phases described by Braun and Clarke[27], whose deductive approach refers to themes identifiedtop down; in other words, we coded themes based on ourspecific review question. Although Braun and Clarke [27]recommend using narrative text, the included qualitativestudies and mixed-methods study provided text-baseddata. In the first phase, all four authors familiarised themselves with the research by reading and rereading the datafrom each study. In the second phase, the first author carried out a systematic, manual coding of features that ledto initial codes, before searching for themes in the thirdphase. Phase four involved reviewing the themes for correlation with the codes and identification of subthemes.After defining the themes in phase five, the findings wereevaluated for relevance to the research question. The authors met several times to discuss the analysis process andto reach consensus on the labelling.ResultsA summary of the studies and their findings are presentedin Table 3. The seven studies were conducted in Norway,the United Kingdom (UK), Sweden, Australia and Finland[28–33]. Qualitative data were also gathered from onemixed-methods study [34] conducted in the UK which, although using mixed methods, reported qualitative findingsfrom students’ graffiti board comments and a focus groupinterview regarding lectures.The four themes (and subthemes within each theme)were: 1) Interactive teaching strategies (Research utilisation, Information literacy and Assignments as learning activities); 2) Interactive and clinically integrated teachingstrategies (Teaching EBP principles and Clinical integration and collaborations); 3) Learning outcomes (Enhancing analytical skills and Changing attitudes towardutilising research); and 4) Barriers (Information literacyskills and knowledge and Challenging collaboration).Interactive teaching strategiesAn improved understanding of the differences betweenquantitative and qualitative methods was highlighted asan important aspect of preparation for nursing practice
Horntvedt et al. BMC Medical Education (2018) 18:172Page 4 of 11Fig. 1 PRISMA flowchart of the screening and the assessment processof students’ research findings in a clinical setting werehighlighted as an important part of the teaching andlearning strategy [28, 32, 34].[29–32, 34]. Interactive strategies to teach the researchprocess, critical appraisal and development of informationliteracy skills were also emphasised. Interactive learningactivities such as problem-based learning, sharing information, flipped classroom and virtual simulation, workshops, group work and seminars with discussions wereidentified [30, 33, 34]. In some studies, oral presentationsResearch utilisationTraditional teaching methods preparing students to useresearch were aimed at improving critical thinking skills,Table 2 Quality assessment based on the CASP Qualitative Research ChecklistAuthors12345678910Assessment1André et al. [28]YYYYUNYUYYModerate2Cader et al. [29]YYYNYYYYYUModerate3Friberg and Lyckhage [30]YYYYYNNUYUModerate4Irvine et al. [34] Mixed methodsYYYUYNYUYYModerate5Malik et al. [31]YYYYYUYYYYHigh6Mattila and Eriksson [32]YYYYYYYYYYHigh7Nayda and Rankin [33]YYYYYNYYYYHighCASP criteria for qualitative studies: 1. Was there a clear statement of the aims of the research?; 2. Was a qualitative methodology appropriate?; 3. Was theresearch design appropriate to address the aims of the research?; 4. Was the recruitment strategy appropriate to the aims of the research?; 5. Was the datacollected in a way that addressed the research issue?; 6. Has the relationship between researcher and participants been adequately considered?; 7 Have ethicalissues been considered?; 8. Was the data analysis sufficiently rigorous?; 9. Is there a clear statement of the findings?; 10. How valuable is the research? (Y Yes, NNo, U Unclear)
Horntvedt et al. BMC Medical Education (2018) 18:172Page 5 of 11Table 3 Studies included in this reviewAuthors,country,journalAimMethodologySummary of findingsAndré et al. How undergraduate students can increase skills[28]and knowledge towards EBP throughNorwayparticipation in clinical research projects.NurseEducation inPracticePilot: QualitativeSample: Five third-year nursing studentsData collection: qualitative data fromopen-ended questions in a questionnaire. Kvale’s analysis method.Four-stage intervention: 1. Informationabout voluntary participation in clinicalresearch projects; 2. Educationprogramme related to EBP; 3.Participation in clinical research projects;4. Instructions and education onanalysing and discussing findings.Allocating nursing students to smallresearch projects and allowing them toparticipate in research projects is useful.Students experienced lack of EBPknowledge when joining the study.Positive collaboration with nurses. Whilestudents were motivated individually,external motivational factor was essential.The experience led to a positiveapproach and EBP knowledge.Cader et al.[29]UKNurseEducationTodayPre-registration nursing programme: exploringstudent experiences with accessing and utilisinginformation for an assignment aimed atenhancing EBP skills.QualitativeSample: 16 nursing studentsData collection: two focus groups.Grounded theory used in the analysisprocess.Teaching strategy: conducting healthneeds analyses through collaborationwith practice-based assignment. Threemain themes were identified: 1. Challenges in evidence gathering: i.e., students need more skills in accessing,utilising and appraising information; 2.Nature of support needed: guidancefrom academic and library staff workingin collaboration is required to enhanceEBP skills; 3. Understanding the importance of evidence for practice: Bridgingthe gap between theory and practice.Development of computer and information literacy (IL) skills is important.Friberg evelopment of literature-based models forBachelor’s degree essays and evaluation of students’ experiences.Qualitative ActionSample: 34 lecturers and nearly 80students divided into seven studentgroups who participated over the courseof 4 years.Data collection: Informal interviews andfield notes. Reflective journals of 86students. Content analysis.Teaching strategy: writing Bachelor’sdegree, essays and establishing teachingmodules related to the research process(concept analysis, identifying evidencebased quantitative and qualitative research, critical assessment, identifying discourses in documents and practicalimplications of research). Crossprofessional collaboration between faculty and library to improve lecturers’competence. Literature-based modelsprovided guidance to students and improved their skills in literature retrievaland academic writing. Development ofcomputer literacy and IL skills.Irvine et al.[34]UKNurseEducation inPracticeImplementation of changes to improve theteaching and learning of research methods in asecond-year pre-registration nursing programmeat one university.Evaluation of students’ and lecturers’experiences.Mixed methods1. A questionnaire answered by 49 outof 53 nursing students.2. An informal qualitative ‘graffiti board’evaluation of the cohort.3. Group interview
Strategies for teaching evidence-based practice in nursing education: a thematic literature review May-Elin T. Horntvedt1*, Anita Nordsteien2, Torbjørg Fermann1 and Elisabeth Severinsson3 Abstract Background: Evidence-based practice (EBP) is imperative for ensuring patient safety. Although teaching strategies
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