Teaching evidence based practice to undergraduate nursing students

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Mo-Kyung Sin a,⁎, Rebecca Bliquez b a Seattle University College ... dence-based practice (EBP) in healthcare settings, nursing curriculums have been actively ...
Journal of Professional Nursing 33 (2017) 447–451

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Journal of Professional Nursing

Teaching evidence based practice to undergraduate nursing students☆ Mo-Kyung Sin a,⁎, Rebecca Bliquez b a b

Seattle University College of Nursing, 901 12th Ave, P.O. Box 222000, Seattle, WA 98122-1090, United States Lead Librarian for Online Research & Instruction, Seattle University, United States

a r t i c l e

i n f o

Article history: Received 5 August 2016 Revised 28 April 2017 Accepted 2 June 2017 Keywords: Evidence based practice Information literacy Library instruction Nursing research Teaching strategy Undergraduate

a b s t r a c t Considering the heightened importance of evidence-based practice in healthcare settings, incorporating evidence-based practice into the nursing curriculum, especially in baccalaureate programs is essential because this is a first step to prepare students for their professional role as an RN, and the undergraduate nursing students are the ones who will spend the most time with patients at their bedside providing direct care. Teaching evidence-based practice at the undergraduate level, however, can be challenging. Creative and enjoyable teaching strategies are instrumental in order to promote students' engagement and learning about evidence-based practice. This paper describes useful strategies for teaching evidence-based practice in an undergraduate nursing research course. © 2017 Elsevier Inc. All rights reserved.

The National Academy of Medicine's Roundtable on Evidence-based Medicine has set a goal that by 2020, 90% of clinical decisions will be supported by up-to-date clinical evidence (National Academy of Sciences, 2009). In response to the heightened importance of evidence-based practice (EBP) in healthcare settings, nursing curriculums have been actively incorporating EBP in both undergraduate and graduate nursing education. However, studies reported low levels of knowledge related to EBP among undergraduate nursing students (André, Aune, & Brænd, 2016; Llasus, Angosta, & Clark, 2014). For example, in an online survey of nursing students' understanding of EBP, 174 students surveyed scored low on their EBP knowledge and engagement in EBP implementation behaviors (Llasus et al., 2014). Students' understanding of EBP is essential for them to utilize it in their clinical practice. Teaching EBP with undergraduate students is especially important because this is the first step to prepare them for their professional role as an RN, and they are the ones who will spend the most time with patients at their bedside providing direct care. A study reported that undergraduate nursing students experienced a lack of support and opportunity to practice EBP as well as a lack of confidence to utilize EBP independently (Ryan, 2016). Teaching EBP at the undergraduate level, however, can be challenging. Creative and enjoyable teaching strategies are instrumental in order to promote students' learning about EBP (Liou, Cheng, Tsai, & Chang, 2013; McCurry & Martins, 2010). The purpose of this paper is to describe such strategies used to ☆ The authors declare no conflict of interest. ⁎ Corresponding author. E-mail address: [email protected] (M.-K. Sin).

http://dx.doi.org/10.1016/j.profnurs.2017.06.003 8755-7223/© 2017 Elsevier Inc. All rights reserved.

teach EBP in an undergraduate nursing research course. This EBP project is a group project designed in a Nursing Research Methods course taught in the first quarter of senior year of a baccalaureate program. This paper describes details of the EBP project from group formation to EBP implementation strategies. This EBP project was designed based on the first four steps of 5 A's of the EBP process (ask, acquire, appraise, apply, assess) (Melnyk & Fineout-Overhold, 2005). The four steps were chosen because the project was based on a hypothetical clinical scenario and students were not asked to implement the best intervention. The EBP project consists of two parts: writing a paper (graded) and presenting the paper (award ceremony: not graded) taught by the key faculty and a librarian. Group formation and naming: Students' groups can be formed by faculty or students. The author tries to arrange the groups (4–5 students/group) by the students' clinical sites to help accommodate their meetings for this task among their busy schedule. Students usually take a clinical practicum course along with the research course. Once groups are assigned, each group is asked to come up with its own group name and share with the whole class. A paper assignment 1. Asking a question. Forming a question is a first step of EBP process. In this first step, faculty has framed questions in a scenario format instead of having students form questions in order to enhance the clinical relevance of EBP in their daily practice. In a senior synthesis (last quarter of the nursing school), students are asked to develop a question using a Patient or Population,


M.-K. Sin, R. Bliquez / Journal of Professional Nursing 33 (2017) 447–451

Intervention, Comparison, Outcome (PICO) format for a higher level EBP project. Example scenarios are included below. The scenarios are designed to reflect real clinical situations the students may face in their practice and also give them guidance for how to be an independent change agent based on critical thinking. In a first class, one volunteer from each group is asked to randomly select one scenario from a jar at the beginning of the class (a teaching moment to discuss research terminologies, “random selection”, “random assignment”). In this first step of EBP, students are asked to write short problem statements based on the scenario instead of developing a question. Writing good problem statements is covered in one of the research class sessions using the examples (Box 4.1 Draft Problem Statement on Humor and Stress and Box 4.2 Some Possible Improvements to Problem Statement on Humor and Stress) from the Polit and Beck (2012). The Polit and Beck's guideline on problem statements include six components such as problem identification, background, scope of the problem, consequences of the problem, knowledge gaps and proposed solutions. An example of students' writing based on the scenario below is included in Appendix A. Example scenarios “You are a nurse at xxx Medical Center ICU. You are taking care of Mr. Vent on mechanical ventilation. The hospital protocol says to do saline instillation suction in mechanically ventilated patients to prevent ventilation-associated pneumonia. Since you are a critical thinker educated at Seattle University, you start to think whether saline suctioning has any benefit for preventing ventilation-associated pneumonia. You do literature searches and plan to present the best evidence to the nurses in your unit.” “You are a nurse at xxx medical center tele floor. Your client, Mr. Heart is schedule to get a coronary artery bypass graft surgery early next morning. You instruct him to take a bath with skin antiseptics (chlorhexidine solution) before he goes to bed tonight. Since you are a critical thinker educated at Seattle University, you question yourself whether skin antiseptics are really better than any normal soap bathing/showering in preventing surgical site infections from developing. You now have a full of curiosity and do literature searches. You will present the best evidence to the nurses in your unit.” 2. Acquiring evidence. Selecting appropriate evidence-based resources through literature searches is a next important step in EBP. Collaboration with a librarian is a good strategy to help students learn best practices for EBP research and effective use of library databases. A session with a librarian is assigned as one of the class activities.

Outcomes for the session were developed collaboratively between the faculty and librarian to ensure that content is appropriate to the goals and requirements of the EBP project. These outcomes are designed to teach students how to generate a broad list of search terms (vocabulary) from assigned EBP scenarios, effectively search appropriate nursing and healthcare databases and organize sources in a collaborative group space. In the library session the librarian models how to identify primary search terms using a sample EBP scenario and then shows students how to generate additional vocabulary (synonyms and broader, narrower and related terms) using a thesaurus, internet search or brainstorming within their groups. Next the librarian demonstrates how to use these terms and strategies to search a biomedical database (PubMed) for scholarly literature. Groups are given time to run literature searches on their EBP topics, first in PubMed and then in other nursing/healthcare databases available via the library's Nursing Research Guide (http://libguides.seattleu.edu/nursing/articles and http://

libguides.seattleu.edu/nursing/nursingebp). Finally, students are asked to reflect on the evidence that they have found during their research answering specific questions such as: How do your articles relate to your group's EBP scenario? What specific information will each of them contribute to your systematic review? Groups use a collaborative work space created using the spreadsheet feature in Google docs to record information about the articles they have found during the literature searches. In one section of the spreadsheet, groups collectively break their EBP scenarios down into search terms and then brainstorm additional vocabulary for searching in databases. Next, during the Article Searching Activity, each group works within a designated space/tab in the spreadsheet to record information about articles found on their assigned EBP scenario. The goal of these exercises is to encourage active participation from all group members and to provide a collaborative space where everyone can continue to share their findings outside of the library session. Also, the faculty member and librarian can follow students' progress throughout the research process and provide help as necessary. The prompts and sample searches used in the spreadsheet can be found in Appendices B and C. Students then evaluate and synthesize the articles found during the Article Searching Activity using the Systematic Review Table (Appendix D). Groups are encouraged to schedule small group consultations with the librarian in the weeks between the library session and the EBP project deadline to address additional questions. Several students have scheduled appointments and verbal feedback has indicated that these follow up meetings are helpful for review of topics that the librarian is not able to cover in-depth during the library session. The librarian is also able to communicate with the faculty member about repeat questions or issues that come up during the consultations. 3. Appraising evidence. In this section, students are asked to choose a best intervention from the synthesized literature in the “Acquiring evidence” section and state the rationale for use of this intervention. Students are taught the research based on the standard components of a research report (e.g., introduction, purpose of the study, conceptual framework, literature review, methods (sample, setting, instruments, data collection methods, data analysis), results, discussion). An article appraisal assignment (critiquing a research article per the standard of a research report) is included at the end of the course as a summary of the research course. Each group is asked to appraise the article of choice (between two articles in each quantitative and qualitative methodology) following the appraisal guideline. Some examples of the appraisal guideline include questions on appropriateness of study design and sample size, whether instruments have good reliability/validity, study limitations, and reliability of the study findings. In addition, things to consider when appraising evidence such as financial cost for applying the evidence and relevance of evidence to the clinical setting are covered in the class. Students are asked to state the rationale for their intervention choice incorporating the appraisal learned in the class. 4. Applying evidence. This section is an implementation phase. However, since this EBP project is based on hypothetical clinical scenarios, students are not asked to implement the intervention. Instead, they are asked to identify at least three EBP implementation strategies (strategies to promote behavioral changes of nurses by adopting the intervention) based on their literature review using at least two references. Another way is to have students identify how EBPs are implemented in their clinical practicum site by interviewing a nurse manager, a research nurse or EBP Committee of their Adult Health (medical-surgical) clinical site. The latter method can make interviewees being over-utilized by the students. Alternating both approaches can be considered. Implementation strategies in this paper refers to a first step of EBP implementation, having all applicable health care providers in a facility use the evidence before nurses implementing the evidence to health care clients.

M.-K. Sin, R. Bliquez / Journal of Professional Nursing 33 (2017) 447–451

Presentation of the paper Exchanging what they have researched with other colleagues is a great learning opportunity for students. They are asked to do a short presentation (8 min presentation, 2 min Q & A) of what they have searched for the EBP paper assignment. The style of presentation can be liberal and creative (e.g., PowerPoint presentation, skit, YouTube). This is an example of a YouTube site students made for this presentation: https:// www.youtube.com/watch?v=4nqclAdLM0g. This presentation is set up to have two groups with the same scenario compete with each other. The faculty used an interactive technology to engage students in a large classroom setting. The group with the most votes in the


interactive technology was given an award (small goodies faculty prepared). The faculty named this presentation activity an “award ceremony”. Students have enjoyed this award ceremony. Conclusion In response to the current necessity of EBP implementation in health care settings to promote quality health care and health outcomes, nursing faculty are responsible for preparing students to be ready for EBP implementation. Creative and enjoyable teaching strategies are some ways to enhance students' knowledge and competency of EBP implementation in practice.

Appendix A. Problem statements The efficacy of normal saline instillation in preventing ventilator-associated pneumonia In the United States, pneumonia is the second most common hospital-acquired infection and the leading cause of death among nosocomial infections (Augustyn, 2007). It affects 27% of all critically ill patients and 86% of cases occur in mechanically ventilated patients (Koenig & Truwit, 2006). The mortality rate from ventilator-associated pneumonia (VAP) is 27%, but has risen as high as 43% when the infecting organism was antibiotic resistant (Augustyn, 2007). It is estimated that there are about 250,000 to 300,000 cases of VAP in the U.S. each year, and each case costs between $5000– 20,000 (Koenig & Truwit, 2006). The detrimental effects of VAP on the U.S. public health and economy make it essential to identify the best methods of prevention and treatment. Current practice promotes the instillation of normal saline solution during endotracheal suctioning in order to loosen and dilute secretions in critically ill patients (Ridling, Martin, & Bratton, 2004). While this practice is accepted, it is highly debated. Recent study findings pertaining to saline instillation and development of VAP have shown mixed results. A study finding suggest that saline instillation prevents VAP, while other studies suggest that the addition of saline spreads bacteria into the lower respiratory tract and increases risk of infection (Caruso, Denari, Ruiz, & Deheinzelin, 2009; Hagler & Traver, 1994; Freytag, Thies, Konig, & Welte, 2003). This discrepancy is problematic and indicates that further research is necessary to improve current care guidelines for ventilated patients to prevent VAP. The function of this literature review is to analyze existing research on the efficacy of saline suction in patients with VAP, and to identify possible conclusions from current data. Ultimately, conclusions will be used to identify the most beneficial practices and how these practices can be implemented. Chlorhexidine gluconate vs. regular antimicrobial soap Every year, 51.4 million surgeries are performed in the United States (Centers for Disease Control and Prevention [CDC], 2010). This means roughly 1 in every 6 Americans will undergo a surgical procedure within a given year, and of those surgeries, it is estimated that 157,500 patients will experience some form of infection (CDC, 2010). In fact, surgical site infections (SSI) are the third most common hospital acquired infection and leads to longer hospital stays and increased costs for the patient (Jakobsson, Perlkvist, & Wan-Hansson, 2011). With widely used surgical interventions and the vast amount of the population affected by infection, it is important to determine the best method to prevent this in clinical practice. To currently prevent SSI, patients are encouraged to wash with an antimicrobial solution prior to undergoing surgical procedures. The use of a chlorhexidine gluconate (CHG) solution is a popular choice among healthcare providers “due to its superior antiseptic capabilities compared with povidone-iodine or alcohol” (Toomey, 2013). There is an abundance of research demonstrating the benefits of pre-surgical antimicrobial washes as well as comparisons between CHG, iodine, and alcohol; however, little is known about the effectiveness of CHG compared to regular antimicrobial soap (Edmiston, Okoli, Graham, Sinski, & Seabrook, 2010; Graling & Vasaly, 2013; Jakobsson et al., 2011; Silva, Carver, Ojano-Dirain, & Antonelli, 2013). One Cochrane review of seven randomized controlled trials (RCTs) showed there was no difference in effectiveness between preoperative showering with CHG, regular soap, or no washing; however, most of these studies were over 20 years old (Leaper & Ousey, 2015). It is clear that updated research is required to answer the question about which pre-surgical preparation is more effective. The aim of this literature review will be to research current studies to determine which skin preparation technique—CHG or antimicrobial soap—is more effective at preventing SSI. Conclusions drawn from this review will be used to determine the most safe and efficient practices to protect surgery patients from infection. Appendix B. Breakdown of search terms/vocabulary used to find articles in library databases All groups work within a single page/tab of a collaborative Google spreadsheet as a staging ground for breaking down their evidence-based practice (EBP) scenarios into search terms. Appendix C provides the prompts that will be used in the next step (the Article Searching Activity) where each group searches for individual articles on their scenarios in both PubMed and other library databases. Group name

EBP scenario

Nursing “You are a newly graduated nurse who Librarian recently accepted a position in a maternal and child health department of the xxx Medical center. In the new job you learned that postpartum haemorrhage is a common cause of maternal morbidity and mortality rates. Your supervisor who is a SU graduate asks you to do some literature searches for

What are the “primary” search terms for your scenario topic?

Record additional search terms related to your topic here. Remember that these terms can be synonyms, related terms or broader/narrower terms. Add to this list as you continue searching on your own later.

What are some search strategies that you could use in library databases to search for articles?

Primary: postpartum haemorrhage, morbidity, mortality Important but not as essential (will try these if initial searches aren't successful): evidence-based interventions, maternal, reduce

Postpartum: postnatal, post-delivery, perinatal, post-partum Haemorrhage: hemorrhage, blood loss, bleeding Morbidity: disease, sickness, illness Mortality: death, loss, decease

Search strategies: postpartum AND hemorrhage AND morbidity postpartum AND hemorrhage (morbidity OR mortality) (continued on next page)


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Appendix B (continued) (continued) Group name

What are the “primary” search terms for your scenario topic?

EBP scenario

Record additional search terms related to your topic here. Remember that these terms can be synonyms, related terms or broader/narrower terms. Add to this list as you continue searching on your own later.

What are some search strategies that you could use in library databases to search for articles? postpartum AND (haemorrhage OR hemorrhage) AND mortality AND reduc*

evidence-based interventions to reduce postpartum haemorrhage. She is an advocate of evidence-based practice and plans to implement the evidence in the unit. You tell your supervisor that since you did a great job in the nursing research course you are confident on the task.”

Appendix C. Prompts and sample searches from the collaborative article searching activity Instructions for students: Step 1: Each member of the group should try some searches in PubMed using the search terms generated in the previous exercise (see Appendix B). Each person should use a separate row to record responses to the questions below. Step 2: Each group member should try searching a different database from the Nursing Research Guide. Record responses to questions about your selected database. Note: For the library session activity, try to find at least one article from each database (per person). You can continue to use this space later to record information about other articles if it helps your group stay organized. Each group has a separate page/tab within the collaborative Google spreadsheet that includes the following prompts: Record the citation details (author, article title, Find at least one journal title, volume and issue numbers, year scholarly article that and page range) below. looks useful. Record the specific search strategy that you used to find this article.

Group member name

Search Search terms & PubMed strategies tried

Nursing Librarian

postpartum Search terms: haemorrhage AND postpartum maternal AND haemorrhage, mortality postpartum, haemorrhage, hemorrhage, maternal, morbidity, mortality Search strategies: postpartum hemorrhage AND maternal AND morbidity postpartum haemorrhage AND maternal AND mortality Name of Search terms & Find at least one database strategies tried scholarly article that looks useful. Record the search strategy that you used to find this article.

Search database of choice from the nursing guide

Jadon, A., & Bagai, R. (2014). Blood transfusion practices in obstetric anaesthesia. Indian Journal Of Anaesthesia, 58(5), 629636. doi:http://dx.doi.org/10.4103/00195049.144674

Record the citation details (author, article title, journal title, volume and issue numbers, year and page range) below. Hint: some databases have a citing feature that allows you to generate a citation and copy and paste the text. You may want to check for one.

Check to see if there is full text available. If you aren't able to locate the full text briefly describe the steps that you took to try and find it (e.g. ordering through Interlibrary Loan).

Add the article to the clipboard and then email it to yourself using the database email feature.

Yes, I located full text by using the SU Full Text search button in PubMed and then accessed the .pdf article through EBSCOhost Academic Search Complete. (There was also full text freely available online via PubMed Central.)


Check to see if there is full text available. If you aren't able to locate the full text please briefly describe the steps that you took to try and find it (e.g. ordering through Interlibrary Loan).

Email the article information to yourself using the database email feature (if there is one) or some other strategy.

Yes, Cochrane has a Yes, there is full text available. I Hofmeyr, G. J., Gülmezoglu, A. M., postpartum Search terms: The feature that allows you accessed it by clicking on the title of Novikova, N., & Lawrie, T. A. (2013). haemorrhage AND Cochrane postpartum to email a link to the the article which took me to a page maternal AND mortality Postpartum misoprostol for haemorrhage Library article. with an abstract and full text. preventing maternal mortality and AND maternal morbidity. Cochrane Database Syst Rev, AND mortality 7. Search strategies: postpartum haemorrhage AND maternal AND mortality Reflection Jot some notes for future reference: How do your articles relate to your group's EBP scenario? What specific information will each of them contribute to your systematic review? Feel free to discuss responses with other group members but record your own. Both of my articles provide useful perspectives on effective treatment for postpartum hemorrhage. Jadon et al. looks at blood transfusion as an essential way to reduce maternal mortality and provides a helpful overview of practice guidelines for blood banking/donation. Hofmeyr et al. is a full review and meta-analysis of randomized clinical trials where postpartum hemorrhage was treated with the drug misoprostol and effects on maternal mortality and morbidity rates.

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Appendix D. Systematic Review Table Authors Purpose of the study Gap Study design Subjects (participants)

Instruments (reliability/validity)

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Data analysis Results limitations Implications to nursing

Liou, S. R., Cheng, C. Y., Tsai, H. M., & Chang, C. H. (2013). Innovative strategies for teaching nursing research in Taiwan. Nursing Research, 62(5), 335–343. Llasus, L., Angosta, A. D., & Clark, M. (2014). Graduating baccalaureate students' evidencebased practice knowledge, readiness, and implementation. Journal of Nursing Education, 53(9 Suppl), 1–8. McCurry, M. K., & Martins, D. C. (2010). Teaching undergraduate nursing research: A comparison of traditional and innovative approaches for success with millennial learners. Journal of Nursing Education, 49(5), 276–279. Melnyk, B. M., & Fineout-Overhold, E. (2005). Evidence-based practice in nursing & healthcare: A guide to best practice. Philadelphia, PA: Lippincott Williams & Wilkins. National Academy of Sciences (2009). Leadership commitments to improve value in healthcare: Findings common ground: workshop summary. Retrieved from http:// www.ncbi.nlm.nih.gov/books/NBK52847/. Polit, D. F., & Beck, C. T. (2012). Nursing research: Generating and assessing evidence for nursing practice (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Ridling, D. A, Martin, L. D., & Bratton, S. L. (2004). Endotracheal suctioning with or without instillation of isotonic sodium chloride solution in critically ill children, 12(3), 212–219. Ryan, E. J. (2016). Undergraduate nursing students' attitudes and use of research and evidence-based practice - An integrative literature review. Journal of Clinical Nursing, 25(11−12), 1548–1556. Silva, R. C., Carver, R. A., Ojano-Dirain, C. P., & Antonelli, P. J. (2013). Efficacy of disinfecting solutions in removing biofilms from polyvinyl chloride tracheostomy tubes. Larygoscope, 123(1), 259–263. Toomey, M. (2013). Preoperative chlorhexidine anaphylaxis in a patient scheduled for coronary artery bypass graft: A case report. American Association of Nurse Anesthetists, 81(3), 209–214.

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