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 the role of clinical learning environment on the adoption of evidence-based practice (EBP) competencies in clinical practice among senior nursing students, and to count the views of the students regarding the development of EBP competencies over the course of the baccalaureate program during the pre-practice period.

Hypothesis or Research Question

None of the formal/alternative hypotheses is made. The objectives/questions that were used in the study are not stated clearly: (1) What are the impacts of the clinical learning environment on the integration of EBP competencies by senior nursing students? and (2) How do students perceive the integration of EBP competence into their curriculum as they become practitioners? (They are not stated as hypothesis testing).

Theoretical Framework

The article does not appeal to either a specific theory or a mid-range theory of nursing. Rather, it is based on principles of competency-based and practice-translation: the work is placed within competency frameworks of the formulated EBP competencies and concepts of the NCSBN Transition to Practice/TTP model, and a notion of clinical learning environment, and measured through the EBP Work Environment Scale. In short: practice-competency/construction of the working environment, and not a systematic theoretical model.

Research Design

The research employed a sequential mixed-methods study design that involved quantitative and qualitative methods.

During the quantitative part, the students of nursing in their senior years were supposed to fill out the Evidence-Based Practice (EBP) Work Environment Scale to identify the ways their clinical learning settings were helpful in terms of EBP integration.

The qualitative stage included semi-structured interviews to have a better understanding of the perception and experience of students in terms of EBP competence development.

Statistical Methods

Data were collected in the form of quantitative data and analyzed with descriptive statistics (including means, standard deviations, frequencies) and paired samples t-test with the purpose of comparing the EBP Work Environment Scale results between capstone and transition-to-practice (TTP) clinical courses.

Thematic content analysis was used to analyze qualitative data, involving transcripts coded, categorized, and interpreted by two researchers to determine recurrent themes and ensure reliability in terms of triangulation between investigators.

Variables

A. Dependent Variable:

• Perceived Evidence-Based Practice (EBP) competence and EBP work environment scores of first-year nursing students.

B. Independent Variables:

• Kind of clinical learning setting (capstone vs. transition-to-practice).
• Structuring of the course (preceptor-led or instructor-led).
• Access to EBP materials and the role modeling of nurses and instructors.

Setting / Population / Sample

The research was conducted in a state university within Virginia, USA, which was providing a traditional Bachelor of Science in Nursing (BSN) program.

Population: BSN students in senior level (two final clinical courses at the end of the school, capstone, and transition-to-practice courses).

Sample: A convenience sample of 45 individuals who returned quantitative survey questionnaires (27 percent response rate) and 14 individuals who took part in qualitative follow-up interviews.

Setting: Several hospitals in Virginia and the District of Columbia that were Magnet-designated, where students were on their clinical rotations.

Validity / Reliability

The research showed that the methodology was valid, as it involved the use of the Evidence-Based Practice (EBP) Work Environment Scale (which is psychometrically validated with a =.96 of leadership and a =.86 of work environment). The paired-sample t-test design enhanced the internal validity since it was able to compare two course settings within the participant (capstone vs. TTP).

The qualitative results were also triangulated with the investigator to ensure the reliability of the results since two researchers conducted and reconciled the thematic analysis. Nevertheless, the sample size (n=45 survey; n=14 interviews) used is small and reflects on the external validity of the research (self-report measures) and there is a risk of the possibility of a response bias. In sum, the research experiment had excellent instrument validity and reasonable reliability in mixed-method research.

Generalizability

The generalizability is moderate to limited because the research was held in one public university in Virginia, and only one model of BSN curriculum was involved. The majority of the participants were of a young age (19-22 years) and female (95%), which decreased diversity in terms of demographics. The contextual relevance to other accredited nursing programs in other U.S. academic-clinical partnerships, however, is augmented by the multi-site clinical placements in multiple Magnet-designated hospitals. The results are most applicable to the conventional BSN programs of capstone and transition-to-practice elements, but not to accelerated and international nursing programs.

Findings

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

·       The Capstone experiences facilitated greater interactions with EBP, autonomy, and access to EBP resources (M = 4.18 vs. 2.96 in TTP).

·       Online EBP were most commonly used by the students during clinical shifts (Google, Micromedex, DynaMed Plus).

·       Qualitative themes were identified as:

·       Perception of EBP depended upon course structure – preceptor-directed education was more apt to encourage the incorporation of EBP practices; group clinicals were restrictive.

·       Novice to advanced beginner – The EBP awareness of students changed as the procedural orientation was transformed to outcome-oriented reasoning.

·       Valued faculty and preceptors who modeled EBP behaviors and curricula, which increasingly incorporated EBP content, were valued by students.

·       The researchers found that the clinical learning environment has a very significant impact on the development of EBP competence prior to practice.

Implications of the research for

a.     nursing

b.     education

c.     policy making

a. Nursing Practice:

• Identifies the need to use EBP mentorship by preceptors in clinical environments that removes gaps between theory and practice.
• Promotes the use of EBP mentors, preceptors, and staff nurses to cultivate a sustained evidence-based culture within the healthcare organizations.
• The significance of positive working conditions and leadership that appreciates the integration of EBP.

b. Nursing Education:

• Makes a substantial focus on integrating EBP competencies into the undergraduate nursing curriculum, and not just in upper semesters.
• Promotes experiential and immersive educational frameworks (e.g., Dedicated Education Units) that engage students directly in the EBP processes in the real world.
• Implicates that teachers should be trained in EBP instruction to help students to translate research into practice in the best way possible.

c. Policy Making:

• Proponents of competency-based education systems (CBE) with EBP skills graduation requirements.
• Endorses the NCSBN Transition to Practice (TTP) model and suggests the addition of organized EBP modules to residency and orientation courses.

• Encourages state boards and accrediting agencies to require evidence of EBP integration in both curricula and clinical partnerships.

Limitations

·       The single-site academic sample restricts the external validity and the comparison between different programs.

·       The low response rate (27) can result in self-selection bias, whereby students who were more certain about EBP are included.

·       Similar demographic population (mostly young, female) decreases representativeness.

·       The timing of cross-sectional does not allow assessment of EBP competence in the long term after graduation.

·       No control of differences in clinical sites (resources, quality of mentorship, acuity of patients) was done, which would confound results.

·       There was no direct evaluation of preceptor or instructor EBP competence, and this may have provided further information on environmental influence.

Bias

There are several biases that the research is prone to. The self-selection bias is further contributed to by a convenience sample and low response rate (27) since the students who were more assured about EBP may have been more inclined to answer. The reporting is biased by using self-reporting as per the surveys, and the small and small samples are homogeneous and hence limiting representativeness. It is also conceivable that differences between clinical sites- i.e., differences in preceptor experience, resources, or organizational culture- may have further affected student perceptions but were not controlled, and may have left site-level bias.

Recommendations

The sample size can be expanded in the future to involve more people in different universities to increase its generalizability. There would also be longitudinal designs that would help them test EBP competence in the post-graduate and early practice. It would be possible to assess the preceptors and instructors’ EBP competence and improve the knowledge of environmental influence. The nursing programs must aim at the following outcomes: enhancing the formal EBP mentoring, penalizing the integration of EBP in course activities, enlisting clinical agencies to create resource-enriched environments that facilitate the EBP behaviors.

Synthesis of the article

The study also claims that the clinical learning environment is the most important in the acquisition of the EBP competence of nursing students as they move to practice. Capstone courses under the guidance of a preceptor produced the highest support to EBP, autonomy, and exposure to the real world in decision-making as compared to courses under TTP led by instructors. These attitudes toward their novice changed to one of almost graduate level and displayed the necessity to receive mentorship and the availability of resources, along with the regular incorporation of EBP throughout the study. An integration of both quantitative and qualitative data will allow making a conclusion that the EBP competence is not gained only in the classroom but depends on the experiential learning and the supportive clinical environment to a great extent.

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

Yes, it is an EBP value article because the article provides a significant amount of information about the impact of clinical learning environments on the intention of students to engage in evidence-based care. Mixed-method approach improves the findings, as it brings the quantifiable data and experience of the students together. The sample is only one university, although small, but the results give practical information to the educator, preceptors, and policymakers regarding the process of integrating EBP. The study is also seen as valid in evidence-based education practices and evidence of where nursing education and clinical affiliates can enhance EBP mentoring, which would be useful in informing the curriculum development and models of clinical training.