J O U R N A L F O R N U R S E S I N S T A F F D E V E L O P M E N TVolume 24, Number 4, E13–E19CopyrightA2008 Wolters Kluwer Health | Lippincott Williams & Wilkins
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he benefits of Magnet status are well documented, but the process for achieving Magnet recogni- tion requires investing valuable time and resources (Jasovsky et al., 2005). During the Magnet application process, the Chief Nursing Officer (CNO) and nursing directors determined that evidence-based practice (EBP) had to be more deliberate and clear in hospital nursing policies, nursing job descriptions, and con- tinuing education activities. As a result, the process for writing nursing polices was rewritten to reflect an EBP approach. An evidence table with clinical practice recommendations, level of evidence, and evidence source was added. EBP and research in the staff registered nurse (RN) position descriptions were expanded to include the expectation that the staff nurses would use evidence-based interventions and treatments. This change obligated the hospital to provide education in EBP. Nurse leaders are respon- sible for providing the environment where nurses can promote evidence-based high-quality nursing care (Bliss-Holtz, Winter, & Scherer, 2004). Therefore, education regarding EBP was essential for all nurses ranging from directors to staff nurses. The trickle-down effect of this EBP culture change necessitated an education strategy that would be inexpensive, yet comprehensive enough to reach all nurses who work various shifts throughout a 1,000+-bed hospital. Tomeet this end, an independent study was developed to present nurses with introductory concepts related to EBP. This article describes the process of developing an independent study that focuses on basic EBP competency for nurses in the acute care clinical setting.
BACKGROUND
Evidence-based nursing is ‘‘the process by which nurses make clinical decisions using the best avail- able research evidence, their clinical expertise, and patient preferences’’ (American Nurses Credentialing Center [ANCC], 2005, p. 78). Force Six of the Magnet Recognition Program (ANCC), Quality of Care, involves providing evidence of educational activities to engage nurses in research and EBP (ANCC). Nurses with advanced education have had varying degrees of experience with nursing research and EBP as part of their university curriculum. Some master’s curricula include requirements for research efforts in the form of theses or EBP projects. Other curricula focus on clinical content requiring successful completion of comprehen- sive examination. However, a significant portion of nurses working in the hospital setting are associate degree or diploma-prepared RNs with minimal experi- ence in the research process. Belcher and Vonderhaar (2005) posed the important question, ‘‘How does one educate all nurses in some level of nursing research and evidence-based practice?’’ Self-directed learning, through an independent study, helps nurses
Increasing Knowledge Level of Evidence-Based Nursing Through
Self-Directed Learning
Lessons Learned for Staff Development
Inga M. Zadvinskis,MSN, APRN, BC
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ecent literature and Magnet standards emphasize the promotion of evidence-based practice in nursing. Nurses prepared over 5 years ago may not necessarily have received education regarding the principles of evidence-based practice. Therefore, an independent study was developed to educate staff nurses regarding the basics ofevidence-based practice. The development of a self-directed independent study is described, including the rationale, benefits, course content, and lessons learned when teaching evidence-based practice through self-directed learning.
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Inga M. Zadvinskis, MSN, APRN, BC, is Research Advanced Practice Nurse, Riverside Methodist Hospital, Columbus, Ohio.
understand the principles of EBP, which is essential for successful Magnet recognition.
RATIONALE FOR INDEPENDENT STUDY
A practical and easily understood approach is required to educate staff RNs regarding evidence-based nursing.
Traditional educational strategies such as conferences, guest lecturers, online courses, and circulating materi- als were considered. However, attending a live lecture (in the hospital or a national conference) was not practical for over 2,000 nurses, especially the night shift employees. Also, cost was an issue. Funds would be necessary for future conference planning when EBP implementation was operationalized. Time was of the essence because Magnet preparation had begun, and appraisers would be conducting a site visit within the year. Nursing management deter- mined that the independent study approach was most feasible, based on the logistics of educating all nurses, cost, and the time constraints. Preparing an independent study covering the introductory princi- ples of EBP was initiated and took approximately 2 months to complete.
BENEFITS OF SELF-DIRECTED LEARNING THROUGH INDEPENDENT STUDY
Self-directed learning has been used in nursing education for some time. In a literature review, O’Shea (2003) stated that much research about self-directed learning occurred in the 1980s. Since then, nurse education through self-directed learning has evolved to incorporate adult educational principles and the student perspective (O’Shea, 2003). Students and teachers have different perceptions of self-directed learning (O’Shea, 2003). To illustrate, Faucher and Everson (2004) developed a self-learning program to educate staff nurses about the continuum of care using a variety of educational materials for different types of learners (e.g., auditory, linguistic, and logical). When creating self-directed learning pro- grams, the nurse’s learning style and preferences must be considered (Faucher & Everson, 2004;
Levett-Jones, 2005; O’Shea, 2003).
The benefits of self-directed learning are numerous:
independence, increased choice, and motivation (O’Shea, 2003). Kuhn and Fasano (1984) discussed the benefits of using an independent study in nursing student curricula: creativity, flexibility, and the ability to choose a learning experience. Participants become responsible for their own learning experiences (Kuhn & Fasano, 1984). With independent learning, the faculty serves as a resource to facilitate learning (Kuhn & Fasano, 1984).
The self-directed learning approach has been used to promote nursing research and EBP. In the 1990s, the Army Nurse Corps developed an independent study series on research (Reineck, 1995). Pilot study results determined that the independent study approach met two learning needs: flexibility in time management and a self-paced structure with feedback (Reineck, 1995). In order to understand and appraise the nursing research literature critically, Ryan and Aloe (2005) developed self- study modules.
The concept of self-directed learning has expanded to online design, in an attempt to reach the new computer-savvy generation of nurses. Online learning provides the additional benefit of accessibility (Benson, 2004). Belcher and Vonderhaar (2005) developed a Web-delivered self-learning program to promote EBP prior to seeking Magnet certification. In theory, Web- based resources are ideal. However, there are addi- tional costs and resources to consider with online programming, such as information systems experts and computer access for all nurses. In addition, the additional time required to convert a program to an online format may not be feasible.
CONTENT OBJECTIVES OF THE INDEPENDENT STUDY
Myers and Meccariello (2006) offered hints for successful nursing research experiences: start small and keep it simple. The potential scope of EBP principles for learning is overwhelming. The Director of the Nursing Research and Excellence (NRE) depart- ment and the author worked together to determine the nurses’ learning needs related to EBP. The NRE Director was a former nurse educator, so her expertise with creating specific and realistic learning objectives and content was invaluable. In addition, the Director was functioning as the Magnet Coordinator, so she was very knowledgeable of Magnet standards requiring substantiation of nursing research and EBP. A straight- forward approach was used by answering two ques- tions: (a) ‘‘What are three basic EBP concepts that you would like the staff nurse to learn?’’ and (b) ‘‘What should the staff nurse know about nursing research and EBP?’’ Course objectives are listed in Table 1.
Bradley, Nordheim, De La Harpe, Innaver, and Thompson (2005) confirmed these learning needs.
They stated that interventions which promote EBP should enable participants to (1) formulate a question, (2) perform a literature search, (3) critically appraise the literature, (4) act on evidence, and (5) evaluate their practice. The goal of the independent study was to lay the foundation of EBP—develop a vocabulary and learn how to create a researchable question. This goal is supported by the following objectives.
TABLE 1 Objectives and Content of the EBP Independent Study
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Objectives Content (Topics)
1. Identify two definitions that relate to evidence-based nursing (EBN).
I. Definitions
A. Evidence-based medicine B. Evidence-based nursing C. Research utilization D. Benchmarking
E. Protocol F. Guideline G. Standard H. Clinical pathway 2. Describe the significance
of evidence-based nursing.
II. Significance
A. Why do nurses need EBN?
B. In this setting, why do nurses need EBN?
C. Levels of competence of EBN D. Benefits
E. Requirements to achieve EBN 3. Discuss three models for
evidence-based nursing practice.
III. Models A. Stetler B. Iowa
C. Rosswurm and Larrabee 4. Identify the essential components
of a researchable question.
IV. Details of the PICO Format A. Patient
B. Intervention C. Comparison D. Outcome 5. List EBN resources for
further assistance.
V. List of Resources
A. Academic Center for Evidence-Based Nursing at the University of Texas Health Science Center at San Antonio
B. Agency for Healthcare Research and Quality EBP Centers
C. Center for Evidence Based Practice at the University of Rochester School of Nursing
D. Cochrane Collaboration
E. Hartford Hospital Nursing Research and Research Utilization
F. McGill University Health Centre Research and Clinical Resources for EBN
(continues)
Learning Objective I: The Nurse Will Be Able to Identify Two Definitions Related to
Evidence-Based Nursing
The intent of this first objective was to introduce research vocabulary to the staff RN so that he or she could use these terms in conversation when commu- nicating research findings. In order to read, under- stand, interpret, and apply research, the nurse must have a grasp of research terms. A common terminology between members of the interdisciplinary team (espe- cially physicians) was needed for clinical practice and in preparation for the Magnet site visit. There must be adequate infrastructure of evidence-based nursing before it is usable to the clinician (Whall, Sinclair, &
Parahoo, 2006). Nurses should know how evidence- based medicine differs from evidence-based nursing or research utilization. When presenting how to write nursing policies to reflect EBP, it was observed that many nurses were confused about the difference between guidelines, protocols, standards, and clinical pathways. The table of definitions related to EBP provided brief explanations and the unique character- istics of each term.
Learning Objective II: The Nurse Will Be Able to Describe the Significance of Evidence-Based Nursing
The rationale for EBP must be understood in order for nurses to implement such practice. Specifically, each
nurse should be able to explain the need of EBP in general, why it is needed in this particular (acute care) setting, the benefits, and the structure required to support it. Through the independent study, the author makes the content specific and particular to the organization. For example, the author was able to quote the staff RN job description that requires using the best available evidence, including research, to guide nursing practice. Also, the author describes the new format for nursing policies reflecting EBP and the rationale for including reference lists for nursing education programs approved by the Continuing Education Review Committee.
Learning Objective III: The Nurse Will Be Able to Discuss Three Models of Evidence-Based Nursing Evidence-based nursing practice models provide an organizing framework for making changes in clinical practice based on evidence. The incorporation of three models of EBP was important in order to provide an overview of the possibilities. At the time of publication, the nursing research committee had not yet selected a model of evidence-based nursing practice, so the three most recognized models of evidence-based nursing practice were discussed within the independent study. The landmark article by Mohide and King (2003), which compared and graded various models of EBP, was used to justify the discussion of the top three rated models:
Rosswurm and Larrabee’s (1999) Model for Change
TABLE 1 Continued
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Objectives Content (Topics)
G. National Guideline Clearinghouse H. National Library of Medicine Health
Services/Technology Assessment Text (HSTAT)
I. New York University Libraries Tutorial: Nursing Resources:
Research Utilization and EBP
J. Oncology Nursing Society Evidence Based Practice Resource Area
K. Sarah Cole Hirsch Institute for Best Nursing Practice Based on Evidence at Case Western Reserve School of Nursing
L. Sigma Theta Tau International Honor Society of Nursing position statement on EBN
M. UNC Chapel Hill Health Sciences Library EBN Intro N. University of Minnesota EBN site
Note. PICO = Patient, Intervention, Comparison, and Outcome.
to Evidence-Based Practice, the Iowa Model of Evidence-Based Practice to Promote Quality Care (Titler et al., 2001) and the Stetler (2001) Model of Research Utilization to Facilitate Evidence-Based Practice. Rosswurm and Larrabee’s Model for Change to Evidence-Based Practice was described in more detail with a case study application. Rosswurm and Larrabee’s model was covered in detail because it was rated the best EBP model by Mohide and King.
Learning Objective IV: The Nurse Will Be Able to Identify the Essential Components of a Researchable Question
Before nurses can learn to search for evidence, they must be able to identify a question for which research can find a solution. The essential components of a researchable question can be made using the PICO (Patient, Intervention, Comparison, and Outcome) format (Nollan, Fineout-Overholt, & Stephenson, 2005). The PICO acronym is well known within the world of EBP, and there are many Web sites that refer to it, including the Agency for Healthcare Research and Quality. Searching for evidence has become clinician friendly by using the PICO format and searching PubMed with a handheld (U.S. National Library of Medicine, 2004). In this 1,000+-bed regional acute care facility, the family practice residents use the PICO approach when conducting medical rounds. Therefore, collaboration would be facilitated when presenting clinical questions using PICO format or during multidisciplinary EBP conferences.
The PICO format was validated in the independent study by presenting a case study with an elderly, confused, hospitalized man. A realistic patient scenario was presented along with clinical questions about therapy, etiology, diagnosis, prevention, prognosis, and meaning in the PICO format. Many nurses stated that the case study with the PICO format was the most
helpful part of the independent study because it was something that nurses could relate to on a clini- cal level.
The final section of the independent study contained a table of Internet resources for EBP. Experts with specialized practice and EBP skills are available internationally. Nurses were also directed to national level resources and finally to local experts. These resources are an asset for a staff nurse seeking information for a specific clinical issue. A table of EBP Internet sites was also included.
The format of the independent study is friendly, basic, and nonintimidating. It is written in the first person. The challenge for authors of independent studies lies in the ability to maintain interest and the reader’s concentration. Creative strategies such as the incorporation of humor, colorful text, and cartoons can help.
The Continuing Education Review Committee’s approval was based on quality of the learning activity including description of the objectives, target audi- ence, needs assessment, content, and evaluation. The study was designed to be completed in 1 hr, and the pilot study average was 60 min. The independent study was approved for 1.0 contact hour by the Continuing Education Review Committee.
EVALUATION OF THE INDEPENDENT STUDY METHOD
The independent study includes a 10-question multiple choice posttest and evaluation form. In addition to asking if the objectives were met, the evaluation form also uses open-ended questions to assess the effec- tiveness of the independent study (see Table 2). In general, nurses reported that the independent study method was ‘‘very’’ effective as a method of learning.
There is support to suggest that nurses have learned the basic principles of EBP. Independent study posttest
TABLE 2 Evaluation Form for the Independent Study
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Question Content
1. Were the following
objectives met? (yes/no format)
A. Identify two definitions related to evidence-based nursing.
B. Describe the significance of evidence-based nursing C. Discuss three models for evidence-based nursing D. Identify the essential components of
a researchable question 2. How effective was this method of learning?
3. Do you have any suggestions for future
presentations regarding evidence-based nursing?
4. How long did it take you to complete this independent study?
scores (required to earn the 1.0 contact hour) are nearly 100%. Interest and participation in the monthly nursing research journal club is growing. More nurses are consulting the NRE department for questions about conducting their own research and writing nursing policies that reflect EBP.
LESSONS LEARNED
Through the development of this self-directed inde- pendent study, the author recognized several behav- iors that are important to support learning.
1. Garner support and publicity to ensure success.
The CNO should endorse EBP and this method of self-learning. For example, the CNO set a goal for 50% of the nursing staff to complete the indepen- dent study by the end of the year. Once she set this decree, interest in EBP and the independent study blossomed. The nursing shared governance council was consulted for suggestions for compet- itive prizes for nursing units with the highest participation. Acknowledgment of the first nursing unit with a 100% completion rate in the hospital nursing publication and gasoline gift card awards were approved. Admittedly, nurse managers who designate the independent study as a mandatory assignment have the highest completion rates.
2. Post the independent study online. This will increase accessibility for all nurses, especially those who work off shifts. It is also more environmentally friendly with less paper waste. Currently, the author is part of a team developing an online independent study about how to write nursing policies incorpo- rating an evidence rating table. The online inde- pendent study also discusses the current model of EBP, which the hospital nursing research commit- tee endorses.
3. Allow enough time for development. Because of the need to make an educational strategy available quickly (in preparation for the Magnet site visit), the independent study was finished prior to the consensus of which EBP model to adopt. This is not ideal because staff nurses are unsure what model of EBP to use. Subsequent presentations regarding EBP have focused on the model of EBP that the NRE department now recommends.
4. Be flexible. The road to promote EBP in the acute care hospital setting requires an open mind because it involves a radical culture change. Listening to nurse colleagues and rereading key articles with a new perspective can change the hospital path of EBP. For example, writing the independent study contributed to broadening the author’s view of which EBP model to recommend for the hospital.
Upon further exploration, the author came to the conclusion that one model offered more resources for the implementation phase of EBP, and ulti- mately, this model was chosen by consensus.
5. Make it practical. Encourage staff nurses to talk about clinical problems during staff meetings.
Nurses desire a practical approach when exploring clinical issues for which research evidence may provide a solution. The independent study content incorporated a case study, which was deemed extremely helpful. More specific examples and case studies, which reflect the unique nursing units and diversity of care at the hospital, were requested by many nurses. A classroom literature search course (focused on nursing clinical issues) in conjunction with library scientists is being explored.
6. Follow up. Send reminder letters to nursing directors, nurse mangers, assistant nurse managers, and staff nurses in leadership positions to encour- age completion of the independent study. Encour- aging the accountability of the completion rate by both managers and peers increases the likelihood of reaching all of the nursing staff and meeting the goal of having as many nurses as possible complete the independent study.
7. Take the next steps. The next step of staff development should involve an interactive course (i.e., classroom or lecture setting) to promote EBP.
A face-to-face context encourages brainstorming and the exchanging of ideas between nurses from different units when using the PICO format. Nurses suggested that future presentations for evidence- based nursing practice include presentations with the opportunity for questions and discussion, the sharing of practices that evolved from evidence- based nursing, and the development of a routinely offered half-day workshop (train the trainers). As a result of these suggestions, a presentation regard- ing EBP and a nursing policy change was presented during nursing rounds. An evidence-based nursing practice conference is planned within the next 6 months. This conference will focus on implement- ing a change in nursing practice based on current research evidence.
SUMMARY
Teaching principles of EBP to nurses via independent study is efficient, practical, and cost-effective. Staff development educators can replicate or modify the course objectives and content when planning, imple- menting, and evaluating their own EBP educational activities. The willingness to implement EBP skills is directly linked to perception of the professional relevance (Bradley et al., 2005). The independent
study educational approach for teaching EBP is advantageous because of the ability to customize the content, thereby keeping the course relevant to the particular institution. Preparing nurses to understand the principles of EBP is essential for successful Magnet recognition.
AC K N O W L E D G M E N T S
The author acknowledges Gretchen Glasgow, PhD, RN, for her assistance with critiquing this manuscript and Jeanette Chambers, PhD, RN, for her vision and direction for EBP.
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ADDRESS FOR CORRESPONDENCE: Inga M. Zadvinskis, MSN, APRN, BC, Riverside Methodist Hospital, 3535 Olentangy River Road, Suite 205, North Medical Building, Columbus, OH 43214 (e-mail: [email protected]).
