EVIDENCE-BASED PRACTICE (EBP), by no means a

LEVELING EBP CONTENT FOR UNDERGRADUATE NURSING STUDENTS KATHALEEN C. BLOOM, PHD, BARBARA J. OLINZOCK, EDD, DOREEN RADJENOVIC, PHD, AND LUCY B. TRICE, PHD Integration of evidence into practice is an essential outcome for baccalaureate nursing students in this era of health care reform. Cultivation of a spirit of inquiry and appreciation for the role of evidence in shaping nursing practice is central to the development of requisite knowledge and skills. A baccalaureate nursing program curricular redesign placed a higher emphasis on evidencebased practice. The evidence-based practice focus of the undergraduate curriculum is a sequence of 3 undergraduate research courses designed to prepare the graduate to identify, locate, read, and critically appraise evidence at the individual study, systematic review, and clinical practice guideline levels. This curriculum lays the foundation for evidence-based practice in the clinical arena and in graduate nursing programs. (Index words; Baccalaureate nursing education; Teaching evidence-based practice) J Prof Nurs 29:217 224, 2013. 2013 Elsevier Inc. All rights reserved. EVIDENCE-BASED PRACTICE (EBP), by no means a new concept, is, nonetheless, relatively new to many nursing curricula. Typical models of teaching undergraduate research include using levels of evidence (Meeker, Jones, & Flanagan, 2008) or a model of diffusion innovation (Schmidt & Brown, 2007) for course structure and incorporating active innovative assignments in a single undergraduate research course (Heye & Stevens, 2009; McCurry & Martins, 2010; Smith-Strom & Nortvedt, 2008). Other approaches include shared learning activities between a research and a separate clinical course in the same semester (Kruszewski, Brough, & Killeen, 2009) and incorporation of evidence-based competencies with increasing difficulty in all clinical courses throughout the curriculum (Ross, Noone, Luce, & Sideras, 2009). Despite these recent reports of teaching strategies designed to address new concepts of EBP in undergraduate nursing programs, a comprehensive curriculum sequence of three undergraduate research courses has not been described. In 2008, the school of nursing (SON) underwent a curriculum revision, one of the outcomes of which was Professor and Associate Director for Undergraduate Studies, University of North Florida School of Nursing, Jacksonville, FL. Associate Professor, University of North Florida School of Nursing, Jacksonville, FL. Professor (Retired), University of North Florida School of Nursing, Jacksonville, FL. Address correspondence to Dr. Bloom: Professor and Associate Director for Undergraduate Studies, University of North Florida School of Nursing, 1 UNF Drive, Jacksonville, FL 32224. E-mail: kbloom@unf.edu 8755-7223/12/$ - see front matter emphasis on the essential nature of EBP in nursing. This revision resulted from the adoption of a new SON philosophy and conceptual framework and identification of baccalaureate program objectives focused on the key concepts of collaborative partnerships, professional values, nursing process, environment, cultural competence, and EBP. Subsequently, objectives, learning activities, and evaluation methods of courses in the SON curriculum were revised to reflect a paradigm shift from teaching steps in the conduct of research to the role of research as evidence for best practice (Melnyk & Fineout-Overholt, 2002). EBP learning activities were also built in to all of the clinical courses throughout the curriculum. There are seven steps in the EBP process: (a) cultivate a spirit of inquiry; (b) formulate an answerable question; (c) systematically search for the research evidence; (d) appraise the validity, relevance, and applicability of the research evidence; (e) integrate the research evidence with the clinical expertise of the practitioner and the wishes and desires of the patient and the family; (f) implement the EBP decision and evaluate the outcomes; and (g) disseminate the results (Melnyk, Fineout-Overholt, Stillman, & Williamson, 2010). In the SON, the first four steps are considered baccalaureate level competencies (Table 1). This is congruent with the baccalaureate competencies identified by the American Association of Colleges of Nursing (2008) and delineated in the consensus statement on essential competencies for EBP in nursing (Stevens, 2009). The undergraduate curriculum in the SON is designed to assist students in their development of beginning knowledge and skills with respect to the first four steps of the EBP process Journal of Professional Nursing, Vol 29, No. 4 (July/August), 2013: pp 217 224 217 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.profnurs.2012.05.015

218 BLOOM ET AL Table 1. Articulation of EBP Competencies With SON Course Outcomes EBP step Cultivate a spirit of inquiry Formulate an answerable question Search for the research evidence Appraise the research evidence Course objectives Nursing science I Nursing science II Nursing science III Discuss nursing knowledge and describe how it is advanced. Select a PICOT question from a list provided. Differentiate among various types of literature. Use a variety of resources in locating literature. Conduct a literature search. Distinguish between steps in the research and the EBP processes. Use a predetermined PICOT question. Recognize sources of scientific nursing literature for strength of research evidence according to a rating system. Critically appraise primary qualitative and quantitative research reports. Analyze factors that inhibit and facilitate evidence-based nursing practice. Discuss the application of evidence-based models as a basis for planned change. Develop a PICOT question. Locate and review systematic reviews, guidelines, and current original research studies related to your question. Critically appraise systematic reviews and clinical. (Melnyk et al., 2010). The accomplishment of EBP in nursing, however, requires going beyond the first four steps and moving on to include integration of the research evidence with the clinical expertise of the practitioner and the wishes and desires of the patient and the family, implementation of the EBP decision and evaluation of the outcomes, and dissemination of the results. To this end, knowledge and skills in EBP are progressively developed throughout the baccalaureate, master's, and doctoral levels in the SON (Figure 1). The following discussion focuses on the baccalaureate foundation for clinical practice and graduate study as it relates to EBP. This foundation is a series of three nursing science courses taught in back-toback semesters for all prelicensure and registered nurse bachelor of science in nursing (BSN) students. Starting the Journey Nursing Science I is the first of three courses dealing with EBP and is taught early in the nursing program. In this one-credit course, EBP concepts are introduced, as is the background of nursing as a science, and how that science was built. The process of reviewing the literature is explored, and the final project for the course is a literature search designed to identify the most current evidence available for a given topic. Teaching Learning Approaches Teaching Learning methods include lecture/discussion as well as group work and classroom practice. In addition, crossword puzzles are provided to assist the DNP Project Evidence-based Practice II Evidence-based Practice I DNP Program Nursing Thesis/Project Research Methods for Evidence-based Practice MSN Program Nursing Science III Nursing Science II Nursing Science I BSN Program Figure 1. The SON ladder for success in evidence-based practice.

LEVELING EBP CONTENT FOR UNDERGRADUATE NURSING STUDENTS 219 students with learning vocabulary and some of the concepts in each area. Students find these a helpful drill in studying for the two objective tests. The course begins with a brief introduction to science, what it is, and how the science of nursing has evolved. Students have the opportunity to compare and contrast the two major philosophies guiding the building of science positivism and naturalism as well as the qualitative and quantitative methods of research drawn from these philosophies. The students then explore the development of the science of nursing, looking at milestones in nursing history, beginning with Florence Nightingale through the 21st century. Particular attention is paid to the development of nursing education, the development and expansion of professional journals, theory and taxonomy development, and funding for research. EBP is introduced including a brief history and a discussion of representative models of EBP, including the Stetler model (Stetler, 2001), Melnyk's advancing research and clinical practice through close collaboration model (Melnyk & Fineout-Overholt, 2011), and the concept of levels of evidence (Schmidt & Brown, 2012). In addition, included in the EBP discussion is the PICOT format (Melnyk & Fineout-Overholt, 2011). The components of the PICOT format are introduced, and the utility of the format in providing direction for searching the literature is emphasized. Students explore the parts of the format and, later, choose a PICOT question from a list provided to complete the literature search project for the course. Among the PICOT questions from which the students may choose are the following: 1. Over a 6-month period, do patients with diabetes who follow a low-fat diet have better blood glucose control than those who simply restrict calories? 2. Do parents who are permitted to touch and/or hold their premature infants during the time the infants are in the neonatal intensive care unit bond with the infants better than those who are not able to touch/hold their infants during this time? In addition to EBP, this course also introduces students to the research process with discussion of where ideas for research come from, as well as the research question and what it represents, including the difference in purpose between a research question and an EBP question. Variables and populations are defined, and students have the opportunity to practice identifying each from research questions posed in class, including some drawn from actual studies. Review of literature is discussed in detail, including the definition and importance of the literature review to both the research process and to EBP. Discussion also includes the basic steps in performing and writing a literature review as well as techniques to assist in distinguishing between a research article and a theoretical article and to differentiate between a primary and a secondary source. Students have the opportunity to practice distinguishing types of articles through group work in which they are given a selection of abstracts drawn from the literature and asked to identify those abstracts that represent research articles. Additional abstracts are available for student practice on the course Web site. Prior to or during the first week of class, a library orientation is arranged to go over in detail how to navigate in Cumulative Index to Nursing and Allied Health Literature and MedLine, how to save searches, how to get a search history, and how to view abstracts. In addition, there is a short orientation to Internet searches. This library orientation is mandatory for all students in the course and is considered part of their participation grade. The literature search project affords students the opportunity to practice all the steps of the literature review process with the exception of writing the actual review itself. Students perform a literature search to identify both research and theoretical literature that provides the best evidence currently available in relation to the PICOT question they have chosen. Students are asked to highlight those articles on their search printout that represent research and those that represent primary sources. They make these determinations from reading the abstracts available in the database rather than from reading the articles themselves. An added incentive pointed out to students is that, if well done, this literature search could be used as the basis for a paper in another course without being considered double dipping. As part of the project, students are also asked to identify a Web site dealing with some aspect of their search topic. They evaluate the site based on a standard format (provided) and determine, among other things, that the information provided on the site is accurate and is presented in language understandable to a lay person. Evaluation of Outcomes Evaluation of outcomes is determined through objective tests, the literature search project, and classroom participation. Several methods of classroom participation are used to assist students in mastering the literature search process. In addition to the library orientation, the class is divided into groups of five to six students. Each group meets during a class period three times across the term. These class meetings are mandatory and are a major part of the class participation grade. During the first meeting, each student selects a PICOT question from the list provided. Each student in the group must select a different question. During the second meeting, students share their efforts to find appropriate literature relative to their individual question. This allows those who are having some difficulty with the search process to hear and learn from the techniques used by those in the group who have been more successful. At the third meeting, students share information about the Web sites they have evaluated and consider appropriate references for patients. A nice bonus is that at the end of this meeting, students have

220 BLOOM ET AL information about their own Web site and several others that are suitable for recommending to patients. The group work takes minimal time in class (10 minutes) but helps keep the students on target for finishing the project in a timely and successful manner. Lessons Learned Several circumstances work together to make this course somewhat challenging to teach. First, it is only 1 credit hour, and students understandably want to/will spend more time on those courses that have more credit hours. Secondly, it is research, and many students come with preconceived notions that research is not real nursing, boring, not useful, and so forth. Finally, the course is taught during the first or second semester of the program when students are also enrolled in clinical courses, giving the students the hands-on clinical experiences that they are so eager to have. A number of strategies are used to help overcome these challenges, make the course fun, and help the students learn while at the same time be successful in terms of their grades. Using classroom activities associated with the material is a challenge because of time constraints, but students both enjoy and learn from them. The in-class group meetings serve to help structure and pace the search project assignment, ensuring that students work on this project throughout the term rather than waiting until the last minute. Briefly discussing new research findings, how they fit with older findings, and how that may affect health helps illustrate the relevance of research and the fact that research is evidence not proof, a concept sometimes difficult for undergraduates to grasp. Faculty enthusiasm for the subject is essential to engendering enthusiasm on the part of the student. Understanding the Evidence Nursing Science II, the second course in the sequence, is offered in the third semester, and is a two-credit course. The course was designed to build on (a) Nursing Science I and (b) clinical work from the first two semesters. The emphasis of the course is on critical appraisal of a primary research report. In addition to required readings, lectures, in-class discussion, and study questions are used as instructional methods. Table 2. Levels of Research Evidence Level Level I Level II Level III Level IV Level V Level VI Source of evidence Systematic review or meta-analysis of randomized controlled trials Randomized controlled trials Quasi-experimental studies Case Control and cohort studies Systematic reviews of descriptive and qualitative studies Single descriptive or qualitative studies Note. Information from Evidence-based Practice in Nursing and Healthcare (2nd ed., p. 12), by B.M. Melnyk and E. Fineout-Overholt, 2011, Philadelphia: Lippincott Williams & Wilkins. Table 3. Lecture Organization by Research Article Structure Component Content Introduction Clinical problem and study purpose Research question (in contrast to EBP question) Literature review (previous studies; gap or inconsistency) Theoretical perspective Methods Design (quantitative = non experimental, experimental; qualitative) Variables and level of measurement Data collection Sampling Protection of human participants Results Data analysis (quantitative = hypothesis testing, descriptive statistics, inferential statistics; qualitative = thematic) Discussion Findings integrated with literature review and theory Study limitations Application of results to practice and future research Teaching Learning Approaches Throughout the semester, the EBP process is role modeled in class. Issues of finding the evidence using library databases and saving the evidence in RefWorks are reviewed from Nursing Science I. A set of class articles on the same clinical problem chest tube removal is used as an exemplar of levels of evidence. In the first week of class, the EBP question is presented: Is there a new intervention for chest tube removal that would work better to minimize pain in adults than the ones currently in use? The PICOT format (Melnyk & Fineout-Overholt, 2011) is used and applied to the EBP question with P = adults with chest tubes, I = relaxation exercise (or other nonpharmacological intervention) with opioids, C = opioids alone; O = pain; T = at the time of and after removal. This EBP question is introduced at the beginning of the course. Related articles presenting Levels I through VI quantitative evidences (Table 2) are examined each week. Qualitative methods are integrated into the lecture each week whenever appropriate, with one entire lecture devoted to reading a qualitative article. No qualitative studies were found related to chest tube removal and pain, so a grounded theory study about heart disease is used as the qualitative research sample. During Weeks 2 through 14, the research process is presented, and one chest tube removal article from each level of evidence is used as an example for the lecture and in-class discussion. Using these same chest tube removal articles, students may independently complete study questions and answers associated with each lecture. Lectures are organized by four components according to the structure of a research article (Table 3). The final class period is used to revisit the EBP question posed at the beginning of the semester: Is there

LEVELING EBP CONTENT FOR UNDERGRADUATE NURSING STUDENTS 221 Table 4. Sample Critique Questions Type of study Content area Sample items Quantitative Measurement Is there evidence of reliability for each instrument used to collect data in the study? Is there evidence of content validity for each new instrument used to collect data in the study? Is there evidence of construct validity for each instrument used to collect data in the study? Sampling Was random sampling used? Was there no mortality in the process of sampling during the study? Was power analysis conducted to determine sample size? Qualitative Sampling Did the researcher stipulate that information redundancy or data saturation was achieved? Were records of raw data sufficient to allow judgments to be made? Trustworthiness Are any issues of confirmability discussed? Are any issues of credibility discussed? Are any issues of dependability discussed? Are any issues of transferability discussed? a new intervention for chest tube removal that would work better to minimize pain in adults than the ones currently in use? To answer the question, we showed and collectively appraised in class the most up-to-date evidence from literature searches using keywords chest tube removal and major exact subject headings of chest tubes and tube removal. The highest level of evidence found was a 2006 literature review. However, one relevant 2004 primary research article was not included in this review, and three additional studies have been published since the review. Students are divided into four groups to critically appraise each of the four studies not included in the review article, and their results are added to the summary matrix from the literature review. Conclusions are made about the state of the science on chest tube removal after examining all available evidence. Evaluation of Outcomes Evaluation methods include two written exams with multiple-choice or matching items focusing primarily on interpretation of statements as they appear in a primary research report. Students are asked to read and analyze abstracts taken from current nursing literature searches to demonstrate application of concepts. Additional evaluation of outcomes is from two written critical appraisals of primary research reports selected by faculty using a critique form. The first part of the assignment is for the student to locate and highlight key components of the research article to correctly demonstrate the ability to read research. The second part of the assignment is to answer a set of yes/no questions designed so that yes answers represent a desired property of a research report. Sample questions from the critique forms are shown in Table 4. Lessons Learned In the transition from teaching the steps in the conduct of research in the past to the current emphasis on research as evidence for best practice as well as the shift in presenting lectures and administering examinations from a consumer perspective has been challenging. It is important to consistently make a connection between background terminology and research concepts presented and how they ultimately relate to critically reading a research report. Examinations have needed major revision to embrace this shift in emphasis on EBP, and most of the existing undergraduate research test bank questions are no longer relevant. Many test items were developed using excerpts from the literature for the learner to interpret. Students appreciate the opportunity to meet outside class to discuss the critical appraisal of primary research report assignments. Setting up the course schedule so that related components of the critique assignment are due before the midterm or final examination has encouraged students to actively prepare for the examinations. Research articles representing different levels of evidence with associated study questions and answers for the student to complete independently serve to prepare the student for both the critique assignments and examinations. Evidence-Based Decision-Making Skills Nursing Science III is a one-credit course in the final semester of undergraduate nursing studies and builds on EBP skills and knowledge introduced in the two prior nursing science courses. In this capstone course, students use evidence-based models to systematically practice decision-making skills related to a clinical question of interest to them. Classroom activities focus on using the evidence-based process as a simulated learning activity. The use of a simulated approach affords students the opportunity to participate in an evidence-based project in a nonjudgmental, safe way and to examine their role as a BSN professional in the evidence-based process in an open forum. Teaching Learning Approaches Innovative teaching learning approaches are used to reinforce research synthesis and evidence-based decision-making skills. Utilizing an interactive-simulated approach, students employ an evidence-based model to guide them through an abbreviated review process. Students work in groups as committees and use critical appraisal skills to investigate clinical questions.

222 BLOOM ET AL Table 5. Abbreviated AGREE Tool Please type in your answers to the following questions about the credibility and rigor of your selected practice guideline 1. What is the expertise of the authors/reviewers? Were both consumers and professionals included? 2. Do the reviewers clearly identify purpose and target population in introductory statements? 3. Do the reviewers describe in detail procedures for appraising the evidence? 4. Do the reviewers grade/rate the evidence included in the recommendations? How do they distinguish strong evidence from weak? 5. Are the recommendations organized and clear to read? 6. Do the recommendations make sense? Are they practical? 7. What clinical situations would they be useful for? 8. Is there any bias? (i.e., editorial, political, and financial gain?) Note. Information from The AGREE II Instrument (pp. 2 3), by AGREE NextSteps Consortium, http://www.agreetrust.org. Each group is required to identify a clinical question of interest to them, and because there are multiple student groups, there are multiple questions under review during the course. Through an intensive 8-week experience, students are first introduced to the big picture afforded to them through the use of evidence-based models. Subsequently, each class begins briefly with an overview of the EBP process, and students are assigned a weekly class activity to highlight an EBP step. The remainder of each class is used as a working session with students methodically working on their EBP question. In their appraisal work, students search for examples of credible systematic reviews and practice guidelines related to their question. Faculty serve as consultants and strive to create a supportive interactive learning environment. Students have many questions about the evidence they discover, and working sessions allow them to ask questions and dialog about the challenges of discovery of evidence. The course is divided into eight weekly topics, each of which focuses on one aspect or step of the evidence-based process. The first class begins with getting started during which evidence-based models are introduced and on-line resources including nursing evidence-based sites are made available to students. Time is allotted for discussion of clinical interests in preparation for identifying an EBP question. In asking a relevant question, students are encouraged to pursue a topic of clinical interest to them. They are referred to the Institute of Medicine (IOM) focus topics as one possible starting point, and the importance of selecting a timely topic for nursing is emphasized. Writing the PICOT question and search strategies are also reviewed. Students are encouraged to begin their literature searches by locating and appraising two examples of systematic reviews related to their topic and to compare the quality of reviews through a quick appraisal process. Class discussions focus on levels of evidence and the rigor, quality and credibility of the evidence they have located. The next step in the process is the examination of clinical practice guidelines. Students search databases and Internet resources, including the National Guidelines Clearinghouse, for one or two samples of clinical practice guidelines related to their topic. Students are introduced to the Appraisal of Guidelines Research and Evaluation (AGREE II) domains to examine the credibility of their selected guidelines (AGREE Next Steps Consortium, 2009). For the purposes of undergraduate students, an abbreviated format of the instrument, adapted especially for them by this instructor, is used in the written assignment (Table 5). Although students do not use the full instrument, this exercise reinforces for them the importance of appraisal as part of the evidence-based process. Finally, in preparation for their final recommendations, students search for any recent original research studies, if available, to insure that they have methodically addressed each step of the process. Often, new studies are published after the last reviews were completed, so they also learn that any new evidence also must be considered in the decision-making process. Having examined the systematic reviews, guidelines, and original research, students are now ready to think about their possible decisions and/or recommendations for practice. It is understood that the decisions are based on limited evidence of samples rather than an exhaustive process. Based upon what they have discovered in their examples, they are asked whether they would make a change and consider the ramifications of their decision or recommendations. Evaluation of Outcomes Unlike the previous two nursing science courses, which are graded A to F, this course is taught on a pass/fail basis, with specific indicators of what constitutes pass for each week. Weekly activities build toward a completed project for each group or committee. Each group organizes a PowerPoint presentation that focuses on their discovery findings, critical appraisal, and best practice recommendations related to their topic, with the understanding and disclaimer that this is a simulated exercise and findings are tentative at best. In addition, they address any potential facilitators and barriers to change and what they personally learned from participating in this project. Evidence-based best practice and projects conducted by students in this class have included smoking cessation for pregnant women, fall prevention for older adults, teaching methods for children with asthma, diabetes care, nonpharmacological pain practices, postoperative wound care, preventive lifestyle practices, and alternative healing approaches. Lessons Learned The logistics of using a nontraditional approach and an 8-week format present challenges. Because of time constraints, the search for evidence is nonexhaustive,

LEVELING EBP CONTENT FOR UNDERGRADUATE NURSING STUDENTS 223 and students search for examples only. If evidence does not exist or is loosely associated, students need guidance and support in tweaking keywords or identifying related examples. Students may become overwhelmed in their discovery searches and appraisals of the evidence. Challenges and frustrations encountered by students working on their searches and appraisals can be addressed immediately by faculty because they emerge during class. Students become more engaged in using the evidencebased process through a collaborative working relationship with faculty. In postcourse evaluations, students overwhelmingly indicate that they appreciate having autonomy and the opportunity to select their own area of interest and immersing themselves into the topic over the course of the project. They report that the pass/fail approach allows the missteps, without penalty, necessary in the learning process. They particularly enjoy the interactive nature of the course and working closely with faculty available to answer their questions. They appreciate working one step at a time and setting up their evidence-based tasks and building toward a finished product. More important, students take ownership of their projects and become engaged learners. Strategies for Success in Leveling EBP in the Curriculum During the initial preparation for revision of the nursing curriculum, two day-long sessions on EBP were conducted by invited national nursing experts and attended by all nursing faculty. Having consultants brought in to the university was more cost and change effective than sending selected individuals to attend EBP workshops. Next, faculty assigned to the three undergraduate research courses met to review and revise course and class objectives, select and appropriate undergraduate research text, and carefully design course activities that were complementary, building from one course to another, without unnecessary overlap. Since implementation of the curricular revisions, there has been an ongoing effort to continue refinement and improvement of these nursing science courses and to more fully incorporate EBP concepts into all nursing courses, both in the classroom and in the clinical area. Students integrate their EBP knowledge and skills in their clinical experiences through identification of the evidence for their nursing interventions in care plans and concept maps. They also have the opportunity to lead and participate in journal clubs with faculty and peers. In their final clinical course, students work with their preceptors to identify specific issues of concern to nursing. The student then locates and critically appraises evidence related to the issue and engages in discussion with the preceptor and other nurses on the unit about the research and its utility and feasibility in providing care for patients. EBP process knowledge and skills are essential for nursing, a point underlined in the recent report on the future of nursing from the IOM (2010) in their discussion of the rationale for more BSN-prepared nurses. These skills are essential for all health care in general because they afford health care practitioners the ability to take ownership of their practices and transform health care (Fineout-Overholt, Melnyk, & Schultz, 2005). The foundation achieved by baccalaureate graduates of the SON stand them in good stead as they pursue their clinical and academic careers, wherever those paths may lead them. References AGREE Next Steps Consortium. (2009). The AGREE II instrument. [Electronic version]. Retrieved from http://www. agreetrust.org. 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