APA reference

Lam, C. K., Schubert, C. F., & Herron, E. K. (2020). Worldviews on Evidence-Based Nursing, 17(6), 418–426. https://doi.org/10.1111/wvn.12479

Purpose

To identify how the clinical learning environment affects the development of evidence-based practice (EBP) competencies in clinical practice among senior-level nursing students, and to take into account the views of the students regarding the development of EBP competencies during the baccalaureate program during the pre-practice stage.

Hypothesis or Research Question

No alternative/formal hypothesis is taken. The objectives/questions used in the study are not as clear: (1) What are the influences of the clinical learning environment on the incorporation of EBP competencies by senior nursing students? and (2) How do students perceive the incorporation of EBP competence into their curriculum as they become practitioners? (They are more in the form of aims/objectives, rather than hypothesis testing.

Theoretical Framework

The article has not appealed to a specific theory or mid-range theory of nursing. Rather, it is rooted in competency-based and practice-translation principles; the work is framed within the competency frameworks of the formulated EBP competencies and concepts of the NCSBN Transition to Practice/TTP model, and the notion of clinical learning environment, and evaluated with the EBP Work Environment Scale. In short: practice-competency/creation of the work environment, and not a theoretical model.

Research Design

The research applied a sequential mixed-method design consisting of quantitative and qualitative methods.

During the quantitative phase, the Evidence-Based Practice (EBP) Work Environment Scale was used to assess the extent to which the clinical learning environments helped integrate EBP among senior nursing students.

During the qualitative stage, the semi-structured interviews with students have been used to learn more about their perceptions and experiences of EBP competence development.

Statistical Methods

The EBP Work Environment Scale data were analyzed with the help of descriptive statistics (means, standard deviations, frequencies) and paired-sample t-tests to compare the EBP Work Environment Scale scores of two clinical courses: capstone and transition-to-practice (TTP).

Thematic content analysis was used to analyze qualitative data, which involved coding, categorizing, and interpreting transcripts by two independent researchers to reveal recurring themes and provide reliability by triangulating investigators.

Variables

A. Dependent Variable:

• Perceived Evidence-Based practice (EBP) competence scores and EBP work environment scores of senior nursing students.

B. Independent Variables:

• Capstone or transition-to-practice type of clinical learning environment.
• Organization of courses (preceptors or instructors).
• EBP resources availability and nurse and instructor role modeling.

Setting / Population / Sample

The research was conducted at a state university in Virginia, USA, where the traditional Bachelor of Science in Nursing (BSN) degree is offered.

Population: Students at the senior level of the BSN program undertaking their last two clinical courses (capstone and transition-to-practice).

Sample: A convenient sample of 45 people who filled out the quantitative survey (response rate of 27 percent) and 14 people who took part in follow-up qualitative interviews.

Setting: Various Magnet-designated hospitals in Virginia and the District of Columbia, where students have had their clinical rotations.

Validity / Reliability

The research was methodologically valid because its instrument was the Evidence-Based Practice (EBP) Work Environment Scale, which is psychometrically reliable (Cronbach’s alpha =.96 in leadership and.86 in work environment). The paired-sample t-test design maximized the level of internal validity because it was used to compare two course settings (capstone vs. TTP) within subjects.

The quality of collected qualitative data was further strengthened by investigator triangulation because the thematic analysis was coded and reconciled by two researchers. Nevertheless, the small sample size (n=45, survey; n=14, interview) and self-reported measures restrict external validity and provide a possibility of bias in the responses. In general, the instrument validity and moderate reliability of mixed-method research in the study were high.

Generalizability

The level of generalizability is moderate to low since the study was carried out in one public university located in Virginia and one model of the BSN curriculum. Demographic diversity was low as most of the participants were young (19-22 years) and female (95%). Nevertheless, the multi-site clinical placements within multiple Magnet-designated hospitals enhance contextual transferability to the other accredited nursing programs within other U.S. academic-clinical sites. The results can be most favorably extrapolated to the traditional BSN programs whose capstone and transition-to-practice parts are present, but not to accelerated or international nursing programs.

Findings

·       Capstone (preceptor-led) clinical environments were rated much higher than transition-to-practice (TTP, instructor-led) courses on EBP support (p <.001 on five of seven scale items).

·       Capstone experiences facilitated better involvement with EBP, independence, and availability of EBP resources (M = 4.18 vs. 2.96 TTP).

·       The online EBP resources were most commonly used by students on clinical shifts (Google, Micromedex, DynaMed Plus).

·       Qualitative themes that were identified include:

·       The perceived perception of EBP was influenced by course design – preceptor-based learning was more conducive to the incorporation of EBP into clinical practice; group clinicals were more restrictive.

·       Beginner to advanced – EBP awareness among students changed its courses as procedural to result-oriented reasoning.

·       Students appreciated faculty and preceptors who demonstrated EBP behaviors and a curriculum that gradually incorporated EBP content.

·       The researchers have also found that the clinical learning environment has a strong impact on the development of EBP competence prior to entering the working environment.

Implications of the research for

a.     nursing

b.     education

c.     policy making

a. Nursing Practice:

• Illuminates how EBP preceptors are required to mentor clinical environments to fill the theory-practice gaps.
• Takes the lead in encouraging healthcare organizations to train preceptors and staff nurses in mentoring EBP to promote a culture of sustained evidence-based practice.
• Emphasizes the role of favorable working conditions and leadership that appreciates the integration of EBP.

b. Nursing Education:

• Stresses the incorporation of EBP skills into the undergraduate nursing program, not in the last semesters.
• Promotes experiential and immersive learning models (e.g., Dedicated Education Units) that immerse students in the actual EBP process.
• Implicates that the teachers should be prepared to teach about EBP in a formal manner in order to be able to help learners in translating the research into practice.

c. Policy Making:

• Proponents of competency-based education (CBE) incorporate EBP skills upon graduation.
• Endorses the NCSBN Transition to Practice (TTP) model and suggests that structured EBP modules should be incorporated in residency and orientation programs.
• Promotes evidence of EBP integration in the curricula and clinical partnerships of state boards and accrediting agencies.

Limitations

·       An academic sample in a single site does not allow external validity and comparison with various programs.

·       The poor response rate (27) can lead to self-selection bias to target students who are more confident about EBP.

·       An unrepresentative homogeneous demographic category (mostly young, female) lowers the representativeness.

·       A cross-sectional time bar does not allow the assessment of EBP competence in the long term after graduation.

·       The resource and quality of mentorship in clinical sites were also not controlled, which may confound the results.

·       They did not have any direct measure of preceptor or instructor EBP competence, which would have given further information on the influence of the environment.

Bias

Recommendations

Synthesis of the article

Is this a valuable article for EBP? Why or why not?