evidence based practice articles for nursing

Evidence Based Nursing Practice

• Articles & Journals
• Searching the Literature

Contact the Library

All Mayo staff with LAN IDs and passwords can use  Document Delivery  to receive copies of journal articles and book chapters.

If you require additional assistance, please contact the  Library .

Evidence Based Practice Resources

• Mayo Clinic Evidence Based Practice

Systems - integration of evidence with patient records Summaries - practice guidelines found via  Clinical Key &  UpToDate Synopses of Syntheses - focused journals:  Evidence-Based Nursing , Evidence-Based Medicine ,  ACP Journal Club Syntheses - m eta-analyses, systematic reviews and other evidence syntheses found through Cochrane , CINAHL , PubMed Synopses of Single Studies - focused journals:  Evidence-Based Nursing , Evidence-Based Medicine ,  ACP Journal Club Single Studies -  CINAHL , PubMed

• See McMaster University Nursing 6S Pyramid for additional details

Nursing Research Journals

Log-in to Current Awareness to get contents pages delivered to your e-mail!

• Current Awareness - Nursing Research Journals

Recent Articles from the CINAHL Database

• Next: Books >>
• Last Updated: Nov 20, 2023 3:07 PM
• URL: https://libraryguides.mayo.edu/evidencebasednursing

ANA Nursing Resources Hub

Search Resources Hub

What is Evidence-Based Practice in Nursing?

5 min read • June, 01 2023

Evidence-based practice in nursing involves providing holistic, quality care based on the most up-to-date research and knowledge rather than traditional methods, advice from colleagues, or personal beliefs. 

Nurses can expand their knowledge and improve their clinical practice experience by collecting, processing, and implementing research findings. Evidence-based practice focuses on what's at the heart of nursing — your patient. Learn what evidence-based practice in nursing is, why it's essential, and how to incorporate it into your daily patient care.

How to Use Evidence-Based Practice in Nursing

Evidence-based practice requires you to review and assess the latest research. The knowledge gained from evidence-based research in nursing may indicate changing a standard nursing care policy in your practice Discuss your findings with your nurse manager and team before implementation. Once you've gained their support and ensured compliance with your facility's policies and procedures, merge nursing implementations based on this information with your patient's values to provide the most effective care. 

You may already be using evidence-based nursing practices without knowing it. Research findings support a significant percentage of nursing practices, and ongoing studies anticipate this will continue to increase.

Evidence-Based Practice in Nursing Examples

There are various examples of evidence-based practice in nursing, such as:

• Use of oxygen to help with hypoxia and organ failure in patients with COPD 
• Management of angina
• Protocols regarding alarm fatigue
• Recognition of a family member's influence on a patient's presentation of symptoms
• Noninvasive measurement of blood pressure in children 

Improving patient care begins by asking how you can make it a safer, more compassionate, and personal experience. 

Learn about pertinent evidence-based practice information on our  Clinical Practice Material page .

Five Steps to Implement Evidence-Based Practice in Nursing

Evidence-based nursing draws upon critical reasoning and judgment skills developed through experience and training. You can practice evidence-based nursing interventions by  following five crucial steps  that serve as guidelines for making patient care decisions. This process includes incorporating the best external evidence, your clinical expertise, and the patient's values and expectations.

• Ask a clear question about the patient's issue and determine an ultimate goal, such as improving a procedure to help their specific condition. 
• Acquire the best evidence by searching relevant clinical articles from legitimate sources.
• Appraise the resources gathered to determine if the information is valid, of optimal quality compared to the evidence levels, and relevant for the patient.
• Apply the evidence to clinical practice by making decisions based on your nursing expertise and the new information.
• Assess outcomes to determine if the treatment was effective and should be considered for other patients.

Analyzing Evidence-Based Research Levels

You can compare current professional and clinical practices with new research outcomes when evaluating evidence-based research. But how do you know what's considered the best information?

Use critical thinking skills and consider  levels of evidence  to establish the reliability of the information when you analyze evidence-based research. These levels can help you determine how much emphasis to place on a study, report, or clinical practice guideline when making decisions about patient care.

The Levels of Evidence-Based Practice

Four primary levels of evidence come into play when you're making clinical decisions.

• Level A acquires evidence from randomized, controlled trials and is considered the most reliable.
• Level B evidence is obtained from quality-designed control trials without randomization.
• Level C typically gets implemented when there is limited information about a condition and acquires evidence from a consensus viewpoint or expert opinion.
• Level ML (multi-level) is usually applied to complex cases and gets its evidence from more than one of the other levels.

Why Is Evidence-Based Practice in Nursing Essential?

Implementing evidence-based practice in nursing bridges the theory-to-practice gap and delivers innovative patient care using the most current health care findings. The topic of evidence-based practice will likely come up throughout your nursing career. Its origins trace back to Florence Nightingale. This iconic founder of modern nursing gathered data and conclusions regarding the relationship between unsanitary conditions and failing health. Its application remains essential today.

Other Benefits of Evidence-Based Practice in Nursing

Besides keeping health care practices relevant and current, evidence-based practice in nursing offers a range of other benefits to you and your patients:

• Promotes positive patient outcomes
• Reduces health care costs by preventing complications 
• Contributes to the growth of the science of nursing
• Allows for incorporation of new technologies into health care practice
• Increases nurse autonomy and confidence in decision-making
• Ensures relevancy of nursing practice with new interventions and care protocols 
• Provides scientifically supported research to help make well-informed decisions
• Fosters shared decision-making with patients in care planning
• Enhances critical thinking 
• Encourages lifelong learning

When you use the principles of evidence-based practice in nursing to make decisions about your patient's care, it results in better outcomes, higher satisfaction, and reduced costs. Implementing this method promotes lifelong learning and lets you strive for continuous quality improvement in your clinical care and nursing practice to achieve  nursing excellence .

Images sourced from Getty Images

Related Resources

Item(s) added to cart

Lippincott ® NursingCenter ®

Evidence-based practice in nursing.

Translating Evidence into Clinical Practice

• Leads to highest quality care and patient outcomes
• Reduces health care costs
• Reduces geographic variations in the delivery of care
• Increases healthcare provider empowerment and role satisfaction
• Reduces healthcare provider turnover rate
• Increases reimbursement from 3rd party payers
• Reduces complications and payment denials
• Meets the expectation of an informed public.

Translating Evidence into Professional Practice

• Proper tools and resources, including evidence-based journals and databases
• Adequate numbers of computers throughout the institution with intranet and internet capability
• Clinical systems that incorporate EBP information
• Clinical practice policies and procedures based on evidence
• Journal clubs
• EBP rounds.

AJN's Evidence-Based Practice Series: Step by Step

Connect with nursingcenter.

Join NursingCenter on Social Media to find out the latest news and special offers

FIND YOUR NEXT JOB WITH NURSING JOBSPLUS

Ce resources.

• Account Login
• Search by Specialty
• Search by Category
• Recommended CE
• Licensure Renewals

Nursing Resources

• Career Articles
• Drug Updates
• Patient Education

About NursingCenter

• Advertise with us
• Evidence-Based Practice Network
• Contact Us / Help

Connect with NursingCenter

Connect with us on Facebook, Twitter, Linkedin, YouTube, Pinterest, and Instagram.

Masks Strongly Recommended but Not Required in Maryland, Starting Immediately

Due to the downward trend in respiratory viruses in Maryland, masking is no longer required but remains strongly recommended in Johns Hopkins Medicine clinical locations in Maryland. Read more .

• Vaccines  
• Masking Guidelines
• Visitor Guidelines  

Center for Nursing Inquiry

Evidence-based practice, what is ebp.

As nurses, we often hear the term evidence-based practice (EBP). But, what does it actually mean? EBP is a process used to review, analyze, and translate the latest scientific evidence. The goal is to quickly incorporate the best available research, along with clinical experience and patient preference, into clinical practice, so nurses can make informed patient-care decisions ( Dang et al., 2022 ). EBP is the cornerstone of clinical practice. Integrating EBP into your nursing practice improves quality of care and patient outcomes.

How do I get involved in EBP?

As a nurse, you will have plenty of opportunities to get involved in EBP. Take that “AHA” moment. Do you think there’s a better way to do something? Let’s turn to the evidence and find out!

When conducting an EBP project, it is important to use a model to help guide your work. In the Johns Hopkins Health System, we use the Johns Hopkins Evidence-Based Practice (JHEBP) model. It is a three-phase approach referred to as the PET process: practice question, evidence, and translation. In the first phase, the team develops a practice question by identifying the patient population, interventions, and outcomes (PICO). In the second phase, a literature search is performed, and the evidence is appraised for strength and quality. In the third phase, the findings are synthesized to develop recommendations for practice.

The JHEBP model is accompanied by user-friendly tools. The tools walk you through each phase of the project. Johns Hopkins nurses can access the tools via our Inquiry Toolkit . The tools are available to individuals from other institutions via the Institute for Johns Hopkins Nursing (IJHN) .

If you’re interested in learning more about the JHEBP model and tools, Johns Hopkins nurses have access to a free online course entitled JHH Nursing | Central | Evidence-Based Practice Series in MyLearning. The course follows the JHEBP process from beginning to end and provides guidance to the learner on how to use the JHEBP tools. The course is available to individuals from other institutions for a fee via the Institute for Johns Hopkins Nursing (IJHN) .

Where should I start?

All EBP projects need to be submitted to the Center for Nursing Inquiry for review. The CNI ensures all nurse-led EBP projects are high-quality and value added. We also offer expert guidance and support, if needed.

Who can help me?

The Center for Nursing Inquiry  can answer any questions you may have about the JHEBP tools. All 10 JHEBP tools can be found in our Inquiry Toolkit : project management guide, question development tool, stakeholder analysis tool, evidence level and quality guide, research evidence appraisal tool, non-research evidence appraisal tool, individual evidence summary tool, synthesis process and recommendations tool, action planning tool, and dissemination tool. The tools walk you through each phase of an EBP project.

The Welch Medical Library  serves the information needs of the faculty, staff, and students of Johns Hopkins Medicine, Nursing and Public Health. Often, one of the toughest parts of conducting an EBP project is finding the evidence. The informationist  assigned to your department can assist you with your literature search and citation management.

When do I share my work?

Your project is complete. Now what? It’s time to share your project with the scholarly community.

To prepare your EBP project for publication, use the JHEBP Dissemination Tool . The JHEBP Dissemination Tool (Appendix J) details what to include in each section of your manuscript, from the introduction to the discussion, and shows you which EBP appendices correspond to each part of a scientific paper. You can find the JHEBP Dissemination Tool in our Inquiry Toolkit . 

You can also present your project at a local, regional, or national conference. Poster and podium presentation templates are available in our Inquiry Toolkit .

To learn more about sharing your project, check out our Abstract & Manuscript Writing webinar and our Poster & Podium Presentations webinar !

Submit Your Project

Do you have an idea for an EBP project?

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Evidence-based nursing practice and improving pediatric patient care outcomes in the prevention of infection transmission: Emergency department findings

Affiliations.

• 1 Faculty of Nursing, Al-Ahliyya Amman University, Amman, Jordan.
• 2 Faculty of Health Sciences, Higher College of Technology, Abu Dhabi, United Arab Emirates.
• PMID: 38905253
• PMCID: PMC11192320
• DOI: 10.1371/journal.pone.0305001

Background: Reducing the risk of infection transmission by getting emergency care for pediatric patients is a challenging task.

Aim: The study aim was to assess emergency nurses' readiness to provide care for pediatric patients with infectious diseases.

Method: Two hundred Jordanian emergency department nurses were surveyed using a descriptive design.

Results: The study revealed that insufficient safety and infection control procedures were put into place, starting with family support to allow nurses to work 145 (78%), family care plans intended to assist caregivers 139 (74.7%), the availability of respiratory protection and a backup plan for standard precautions, training requirements, and equipment 131 (70.4%), create a unit pandemic safety strategy 124 (66.7%), have a plan for emergencies for at-risk staff 116 (62.4%), have a hospital pandemic safety plan 113 (60.8%), manage inventory 102 (54.8%), use reuse guidelines if there will be severe shortages 99 (53.2%), create a strategy for nurses' access to healthcare for themselves and their families 96 (51.6%), and end with any required system updates for new policies 88 (47.3%). Staff nurses made up a large proportion of participants (145; 78%; 115; 62.8%) who said they lacked experience with care for pediatric patients with infectious illnesses who were critically sick. A 62.8% of nurses reported they did not have training in infectious disease emergency prevention and control for pediatric patients. What nurses prioritize it was determined that the concept of crisis standards of care (34.9%) was the most important educational topic for training emergency room nurses to care for pediatric patients who are critically ill with infectious infections, while the clarity of communication pathways was ranked lowest.

Conclusion: More training and support are needed for emergency room nurses to properly care for children's patients with infectious illnesses.

Copyright: © 2024 Khraisat, Al-Bashaireh. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

PubMed Disclaimer

Conflict of interest statement

The authors have declared that no competing interests exist.

• Remppis J, Hilberath J, Ganzenmüller T, Slavetinsky C, Vasconcelos MK, Gnädig M, et al.. Infection control of COVID-19 in pediatric tertiary care hospitals: challenges and implications for future pandemics. BMC pediatrics. 2022;22(1):1–13. - PMC - PubMed
• Hartford EA, Keilman A, Yoshida H, Migita R, Chang T, Enriquez B, et al.. Pediatric emergency department responses to COVID-19: transitioning from surge preparation to regional support. Disaster medicine and public health preparedness. 2021;15(1):e22–e8. doi: 10.1017/dmp.2020.197 - DOI - PMC - PubMed
• Matera L, Nenna R, Rizzo V, Ardenti Morini F, Banderali G, Calvani M, et al.. SARS-CoV-2 pandemic impact on pediatric emergency rooms: a multicenter study. International journal of environmental research and public health. 2020;17(23):8753. doi: 10.3390/ijerph17238753 - DOI - PMC - PubMed
• Al-Shareef AS, Al Jabarti A, Babkair KA, Jamajom M, Bakhsh A, Aga SS. Strategies to Improve Patient Flow in the Emergency Department during the COVID-19 Pandemic: A Narrative Review of Our Experience. Emergency Medicine International. 2022;2022.
• Ducel G, Fabry J, Nicolle L. Prevention of hospital acquired infections: a practical guide. Prevention of hospital acquired infections: a practical guide. 2002;(Ed. 2).
• Search in MeSH

Related information

Grants and funding, linkout - more resources, full text sources.

• PubMed Central
• Public Library of Science

• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

Simpson Library

Nurs 410: evidence based nursing research.

• Databases / Articles
• Evidence Based Sources
• Video Tutorials

Peer-reviewed (Refereed) Articles

Refers to articles that have undergone a rigorous review process, often including revisions to the original manuscript, by peers in their discipline, before publication in a scholarly journal.

Scholarly information and evidence-based sources

Evidence-based practice involves providing the highest quality patient care by reviewing and assessing the scholarly research literature in nursing - not by relying on newspapers, magazines, opinions from colleagues, or personal beliefs. 

Scholarly research allows new discoveries and knowledge to be communicated to health care professionals; therefore, scholarly information can improve patient care and improve nursing practice.  

Try to think of scholarly Information in two ways:

• Primary (unfiltered) sources: include original research studies, randomized controlled trials, and case-control studies.  These studies have not undergone additional analysis and review beyond that of the peer review process.  
• Secondary (filtered) sources: include sources that evaluate and analyze existing research and often provide recommendations for practice.  Systematic reviews, critically-appraised topics, and meta-analyses are considered filtered information.

CINAHL and the Evidence Pyramid

To find scholarly sources that support your topics, you need to use a database like CINAHL - do not rely on more commons options like Wikipedia, magazines, newspapers, or a basic Google search.

CINAHL has many related search features like randomized control trial, clinical trials, and meta-analysis, but you should be cautious in using these limits too quickly.  First, start with a very broad search, evaluate the results, then consider using some of the specific search features in order to find a more focused set of research articles.

As always, pay attention to the requirements outlined by your instructor which might require very specific articles such as "limited by date" or "first author is a nurse."

Evidence Pyramid

Primary Sources: Unfiltered

• Research Articles
• Pilot/prospective studies
• Cohort study -  Identifies two groups (cohorts) of patients, one which did receive the exposure of interest, and one which did not, and following these cohorts forward for the outcome of interest.
• Survey research
• Case control study -  Individuals with a particular condition or disease (the cases) are selected for comparison with individuals who do not have the condition or disease (the controls)
• Clinical trials
• Randomized controlled trials/RCTs - An experiment where individuals are randomly assigned to an experimental or control group to test the value or efficiency of a treatment or intervention

Secondary Sources: Filtered

• Review articles
• Systematic reviews - are articles in which the authors have systematically searched for and summarized all of the medical literature for a specific topic.
• Meta-analysis - is a systematic review that uses quantitative methods to summarize the results.
• Critically appraised topic -   Authors of critically-appraised topics evaluate and synthesize multiple research studies.
• Clinical practice guidelines
• Clinical care notes
• Patient education information

Background Information/Expert Opinion

• Background Information/Expert Opinion -  Handbooks, encyclopedias, and textbooks often provide a good introduction to a topic, but only provide very brief or generalized information.
• << Previous: Books
• Next: PICO >>
• Last Updated: Jun 25, 2024 10:13 AM
• URL: https://library.umw.edu/nurs410

• Research article
• Open access
• Published: 07 January 2021

Evidence-based practice beliefs and implementations: a cross-sectional study among undergraduate nursing students

• Nesrin N. Abu-Baker   ORCID: orcid.org/0000-0001-9971-1328 1 ,
• Salwa AbuAlrub 2 ,
• Rana F. Obeidat 3 &
• Kholoud Assmairan 4  

BMC Nursing volume  20 , Article number:  13 ( 2021 ) Cite this article

147k Accesses

1 Altmetric

Metrics details

Integrating evidence-based practice (EBP) into the daily practice of healthcare professionals has the potential to improve the practice environment as well as patient outcomes. It is essential for nurses to build their body of knowledge, standardize practice, and improve patient outcomes. This study aims to explore nursing students’ beliefs and implementations of EBP, to examine the differences in students’ beliefs and implementations by prior training of EBP, and to examine the relationship between the same.

A cross-sectional survey design was used with a convenience sample of 241 nursing students from two public universities. Students were asked to answer the questions in the Evidence-Based Practice Belief and Implementation scales.

This study revealed that the students reported a mean total belief score of 54.32 out of 80 ( SD  = 13.63). However, they reported a much lower implementation score of 25.34 out of 72 ( SD  = 12.37). Students who received EBP training reported significantly higher total belief and implementation scores than those who did not. Finally, there was no significant relationship between belief and implementation scores ( p  > .05).

To advance nursing science, enhance practice for future nurses, and improve patient outcomes, it is critical to teach nursing students not only the value of evidence-based knowledge, but also how to access this knowledge, appraise it, and apply it correctly as needed.

Peer Review reports

Evidence-based practice (EBP) integrates the clinical expertise, the latest and best available research evidence, as well as the patient’s unique values and circumstances [ 1 ]. This form of practice is essential for nurses as well as the nursing profession as it offers a wide variety of benefits: It helps nurses to build their own body of knowledge, minimize the gap between nursing education, research, and practice, standardize nursing practices [ 2 ], improve clinical patient outcomes, improve the quality of healthcare, and decrease healthcare costs [ 3 ]. Thus, clinical decision-making by nurses should be based on the best and most up-to-date, available research evidence [ 4 ].

Earlier studies of EBP implementation by nurses in their everyday clinical practice have shown that it is suboptimal [ 5 , 6 , 7 ]. Implementation of EBP is defined as its application in clinical practice [ 8 ]. Findings from previous studies indicate that nurses’ implementation of EBP can be promoted by improving their belief about EBP. Belief is the perception of the value and benefits of EBP and the perceived self-confidence in one’s knowledge and skills of EBP [ 8 ]. Nurses with a strong belief in EBP implement it more than nurses with a weak belief in the same [ 7 , 9 ].

Preparing nurses for practice and ensuring that they have met a set of minimum core competencies at the point of graduation is achieved through their undergraduate education [ 10 ]. Several formal entities such as the Institute of Medicine (IOM) [ 4 ] and the Accreditation Commission for Education in Nursing (ACEN) [ 11 ] consider EBP as one of the core competencies that should be included in health care clinicians’ education. However, this does not necessarily guarantee the actual implementation of EBP in everyday clinical practice [ 12 ]. It is essential to educate undergraduate nursing students on EBP to improve their knowledge about it, to strengthen their belief regarding its benefits to patients and nurses, and to enhance their self-efficacy in implementing EBP. In order to effect this change, it is crucial to improve the education process and to focus more on the knowledge and implementation of EBP.

There is consistent evidence showing that while undergraduate nursing students hold positive beliefs about EBP and its value in patient care, they also report many challenges regarding its actual implementation in clinical practice. For instance, a mixed-methods study indicated that 118 American undergraduate nursing students found it difficult to distinguish between EBP and research. Students were able to search for evidence, but were less able to integrate evidence to plan EBP changes or disseminate best practices [ 13 ]. Additionally, a correlational study was conducted in Jordan using a sample of 612 senior nursing students. The study reported that students held positive attitudes towards research and 75% of them agreed on using nursing research in clinical practice. Students strongly believed in the usefulness of research. However, they did not believe strongly in their ability to conduct research [ 14 ]. A cross-sectional study was conducted among 188 Saudi undergraduate nursing students. Students reported positive beliefs about EBP; however, they reported a low mean score in EBP implementation (22.57 out of 72). Several significant factors have been reported as influencing EBP implementation, such as age, gender, awareness, and training on EBP [ 15 ]. A comparative survey comprised of 1383 nursing students from India, Saudi Arabia, Nigeria, and Oman. The study reported that having no authority in changing patient care policies, the slow publication of evidence, and the lack of time in the clinical area to implement the evidence were major barriers in implementing EBP according to the participating students [ 16 ].

In Jordan, evidence-based knowledge with critical thinking is one of the seven standards for the professional practice of registered nurses that were released by the Jordan Nursing Council [ 17 ]. Despite the plethora of studies on undergraduate nursing students’ beliefs about EBP and its implementation in everyday clinical practice, this topic has not been fully addressed among Jordanian undergraduate nursing students. Thus, the purpose of this study is to explore the self-reported beliefs and implementations of EBP among undergraduate nursing students in Jordan. The specific aims of this study were to (1) explore nursing students’ beliefs and implementations of EBP, (2) examine the differences in students’ beliefs and implementations by prior training of EBP, and (3) examine the relationship between nursing students’ beliefs and implementations of EBP.

Design and setting

A cross-sectional, correlational research survey design was used to meet the study aims. Recruitment of study participants was undertaken at two governmental universities in the northern part of Jordan. The two universities offer a four-year undergraduate nursing program aimed at graduating competent general nurses with baccalaureate degrees. The nursing research course is included as a compulsory course in the undergraduate nursing curricula in both universities.

Population and sample

The target population of this study was the undergraduate nursing students in Jordan. The accessible population was undergraduate nursing students who are currently enrolled in the four-year BSN program in two governmental universities in the northern region of Jordan. We calculated the sample size using the G*Power software (2014). Using a conventional power estimate of 0.8, with alpha set at 0.05, and medium effect size, it was estimated that for a Pearson Correlation test, a total of 100 participants would need to be recruited to examine the relationship between the beliefs and implementations of EBP. To counteract anticipated non-response and to enhance the power of the study, 300 students were approached. The inclusion criteria of the study participants were as follows: a) senior nursing students who are in the 3 rd or 4th-year level, b) students who are currently taking a clinical course with training in a clinical setting/hospital, c) and students who have successfully passed the nursing research course.

Measurement

A structured questionnaire composed of two parts was used for data collection. The first part aimed to gather the demographic data of the participants: gender, age, study year level, university, and any previous EBP training received in the nursing research course. The second part contained the EBP Belief Scale and EBP Implementation scale developed by Melnyk et al. (2008) [ 18 ]. Both scales had previous satisfactory psychometric properties with a Cronbach’s alpha of more than 0.9 and good construct validity. The Evidence-Based Practice Belief Scale (EBPB) consists of 16 statements that describe the respondent’s beliefs of EBP. Students were asked to report on a five-point Likert scale their agreement or disagreement with each of the 16 statements in the scale. Response options on this scale ranged from strongly disagree (1 point) to strongly agree (5 points). All statements were positive except for two statements (statements 11 and 13), which were reversed before calculating the total and mean scores. Total scores on the EBPB ranged from 16 to 80, with a higher total score indicating a more positive belief toward EBP. In the current study, the scale showed satisfactory internal consistency reliability with a Cronbach’s Alpha of .92 for the total scale.

The Evidence-Based Practice Implementation Scale (EBPI) consists of 18 statements related to the respondent’s actual implementation of EBP in the clinical setting. Students were asked to report the frequency of the application of these statements over the past 8 weeks. The answers were ranked on a Likert scale that ranged from 0 to 4 points (0 = 0 times, 1 = 1–3 times, 2 = 4–5 times, 3 = 6–8, and 4 ≥ 8 times). The total score ranged from 0 to 72, with the higher total score indicating a more frequent utilization of EBP.

Both scales were introduced to the participating students in their original language of English because English is the official language of teaching and instruction in all schools of nursing in Jordan.

Ethical considerations

The Institutional Review Board (IRB) at the first author’s university granted ethical approval for this study (Reference #19/122/2019). The code of ethics was addressed in the cover letter of the questionnaire. The principal investigator met the potential eligible students, provided them with an explanation about the study purpose and procedures, and gave them 5 min to read the questionnaires and to decide whether to participate in the study or not. Students who agreed to participate in the study were assured of voluntary participation and the right to withdraw from the study at any time. Questionnaires were collected anonymously without any identifying information from the participating students. The principal investigator explained to participating students that the return of completed questionnaires is an implicit consent to participate in the study. Permission to use the EBP belief scale and the EBP implementation scale for the purpose of this study was obtained from the authors of the instrument.

Data collection procedure

After ethical approval was granted to conduct the study, data was collected during the second semester of the academic year 2018/2019 (i.e., January through June 2019). The questionnaires were distributed to the nursing students during the classroom lectures after taking permission from the lecturer. The researchers explained the purpose, the significance of the study, the inclusion criteria, and the right of the students to refuse participation in the study. Students were screened for eligibility to participate. Students who met the eligibility criteria and agreed to participate were provided with the study package that included a cover letter and the study questionnaire. Students were given 20 min to complete the questionnaire and return it to the principal investigator who was available to answer students’ questions during the data collection process.

Data analysis

Descriptive statistics (e.g., means, standard deviations, frequencies, and percentages) were performed to describe the demographic characteristics of the participating students and the main study variables. For the belief scale, the two agreement categories (4 = agree, 5 = strongly agree) were collapsed to one category to indicate a positive belief. For the implementation scale, the three categories (2 = 4–5 times, 3 = 6–8, and 4 ≥ 8 times in the past 8 weeks) were collapsed to one category as (≥ 4 times) to indicate frequent implementation. Pearson’s correlation test was used to determine the relationship between the total scores of the EBP belief and implementation scales. A chi-square test was used to examine the difference between trained and untrained students in terms of agreement toward each EBP belief (disagreement vs. agreement) and in terms of frequency of each EBP implementation (less than 4 times vs. 4 times or more in the past 8 weeks). Finally, an independent samples t -test was used to examine the difference between trained and untrained students in terms of the total mean scores of EBP beliefs. The Statistical Package for Social Sciences (SPSS) software (version 22) was used for data analysis.

Among the 300 approached students, 35 students did not meet the inclusion criteria and 24 students refused to participate. Thus, a total of 241 undergraduate nursing students from both universities completed the study questionnaire for a response rate of 91%. The mean age of the participants was 22.09 years ( SD  = 1.55). The majority of the participants were females (73.4%) and in the fourth year of the undergraduate nursing program (85.1%). Further, more than half of the participants (67.6%) stated that they received EBP training before (Table  1 ).

The total mean score of the EBP belief scale was 54.32 out of 80 ( SD  = 13.63). Overall, between 50.5 and 73.4% of students agreed or strongly agreed on the 16 statements on the EBP belief scale, which indicates positive beliefs. However, students held a more positive belief regarding the importance and the usefulness of EBP in quality patient care than in their ability to implement EBP. For example, while the majority of students believed that “EBP results in the best clinical care for patients” and that “evidence-based guidelines can improve clinical care” (73.4 and 72.2%, respectively), only about 54% of them cited that they “knew how to implement EBP sufficiently enough to make practice changes” or were “confident about their ability to implement EBP where they worked”. Students who received previous training on EBP reported more agreements (i.e., more positive beliefs) toward all items of EBP compared to those who did not receive training; however, the difference between the two groups was not always significant. For example, 60.7% of trained students believed that “they are sure that they can implement EBP” compared to 41% of untrained students χ 2 (1, n  = 241) = 8.26, p  = .004. Furthermore, 58.3% of trained students were “clear about the steps of EBP” compared to 41% of untrained students χ 2 (1, n  = 241) = 6.30, p  = .021 (Table  2 ).

In contrast, students reported a much lower total score on the EBP implementation scale: 25.34 out of 72 ( SD  = 12.37). Less than half the students reported implementing all the listed EBPs four times or more in the last 8 weeks. For example, only about one-third of all students reported that they “used evidence to change their clinical practice”, “generated a PICO question about clinical practice”, “read and critically appraised a clinical research study”, and “accessed the database for EBP four times or more in the past eight weeks” (32.4, 33.6, 31.9, and 31.6%, respectively). The only EBP that was implemented by more than half of the students (54.8%) four times or more in the past 8 weeks was “collecting data on a patient problem”. Students who had previous training on EBP reported more frequent implementations of all listed EBPs compared to those who did not receive training; however, the difference between the two groups was not always significant. For example, 50.9% of trained students reported that they “shared an EBP guideline with a colleague” four times or more in the past 8 weeks compared to 30.8% of untrained students χ 2 (1, n  = 241) = 8.68, p  = .003. Almost 50 % of the trained students “shared evidence from a research study with a patient/family member” four times or more in the past 8 weeks, compared to 28.2% of the untrained students χ 2 (1, n  = 241) = 9.95, p  = .002 (Table  3 ).

There was a significant difference between students’ total scores on the EBP belief scale with respect to previous training on EBP. Students who received previous training on EBP had a significantly higher mean score on the EBP belief scale compared to students who did not receive previous training on EBP ( t (239) = 2.04, p  = .042). In addition, there was a significant difference in the total score of EBP implementation by previous training on EBP. Students who received previous training on EBP had a significantly higher mean score on the EBP implementation scale compared to students who did not receive previous training on EBP ( t (239) = 3.08, p  = .002) (Table  4 ).

Finally, results of the Pearson correlation test revealed that there was no significant association between the total score of the EBP belief scale and the total score of the EBP implementation scale ( r  = 0.106, p  = 0.101).

This study aimed to explore the self-reported beliefs regarding and implementation of EBP among undergraduate nursing students in Jordan. It is observed that Jordanian undergraduate nursing students valued EBP and its importance in delivering quality patient care as over 70% of them believed that EBP results in the best clinical care for patients and that evidence-based guidelines can improve clinical care. However, a lower percentage of students believed in their ability to implement EBP where they worked and an even lower percentage of them actually implemented EBP frequently in their everyday clinical practice. For illustration, only one-third of the students accessed a database for EBP, have read and critically appraised a clinical research study, or used evidence to change their clinical practice four times or more in the last 8 weeks. Our results are consistent with previous studies among Jordanian nursing students which also showed students had positive attitudes towards research and its usefulness to providing quality patient care but had insufficient ability to utilize research evidence in clinical practice [ 14 ]. Further, a recent study has shown that nursing students in Jordan had low knowledge about EBP regardless of their admitting university [ 19 ]. These results indicate that there could be a gap in the education process of undergraduate nursing students in Jordan about EBP. Thus, schools of nursing in Jordan have to critically review their current educational strategies on EBP and improve it to enhance students’ knowledge of EBP as well as their abilities to implement evidence in clinical practice.

The results of the current study revealed that despite the positive beliefs of the nursing students, their implementation of EBP was very low. There was no significant relationship between the total score of EBP belief and the total score of EBP implementation. Our results are consistent with those reported among Saudi as well as American nursing students who also had positive beliefs about EBP but implemented it less frequently in their everyday clinical practice [ 13 , 15 ]. Moreover, in line with previous studies which showed that training on EBP was one of the significant predictors of beliefs and implementation [ 15 ], students who previously received EBP training had significantly higher total belief and implementation scores than those who did not, in this study. This finding is expected as EBP training has been shown to improve knowledge, self-efficacy in implementation, and by extension, implementation practices among nurses and nursing students [ 20 , 21 , 22 ]. On the other hand, in this study, we asked students whether they have received training on EBP during the nursing research course taught at their universities. More than one-third of participating students in our study cited that they had not received previous training on EBP even though all of them have successfully passed the nursing research course offered at their universities. One possible explanation for this finding could be that there is an inconsistency in the way the nursing research course is taught. It seems that EBP practice is not always included in the content taught in this course. Thus, nursing schools in Jordan have to revise their curricula to ensure that EBP is included and is taught to all students before graduation.

The results of the current study have several international implications that involve academic education and nursing curricula. There is a pressing need to enhance the education process and to focus more on the knowledge and skills of EBP. Incorporating EBP into the nursing curricula, especially the undergraduate program is critical as it is the first step to prepare the students for their professional roles as registered nurses. Sin and Bliquez (2017) stated that creative and enjoyable strategies are fundamental in order to encourage students’ commitment to and learning about EBP [ 23 ]. One of these effective strategies is teaching the EBP process by asking a clinical question, acquiring and searching for evidence, appraising then applying this evidence, and finally evaluating the effectiveness of its application in clinical practice [ 8 ]. A thematic review study demonstrated that various interactive teaching strategies and clinically integrated teaching strategies have been emphasized to enhance EBP knowledge and skills [ 24 ].

Gaining knowledge about undergraduate nursing students’ beliefs and their ability to implement EBP in a clinical setting is essential for nursing educators at the national and the international level. This knowledge might help them to evaluate and improve the current strategies utilized to educate undergraduate students about EBP. Furthermore, academic administrators and teachers should design their courses to apply EBP concepts. They should promote EBP training courses, workshops, and seminars. For example, the research course should focus more on this topic and should include clinical scenarios that involve the application of EBP. In addition, clinical courses should include assignments for the purpose of integrating EBP within their clinical cases. The scale used in this study could be implemented in clinical courses to evaluate students’ practical skills concerning EBP. Finally, nursing instructors, leaders, and practitioners should always update their EBP knowledge and skills through continuous education and workshops. Since they are the role models and instructors, they should be competent enough to teach and evaluate their students. They should also cooperate to facilitate the implementation of EBP in clinical settings to overcome any barrier.

Study limitations and recommendations

This study sheds light on the existing gap between the belief in and the implementation of EBP among nursing students. However, convenience sampling, using two universities only, and self-report bias are all limitations of this study. In addition, the researchers did not investigate the type of EBP training that was received by the students in this study. More studies are needed in Jordan and the Middle Eastern region about EBP using larger random samples in different settings. It is also recommended to investigate the barriers that prevent nursing students from implementing EBP other than not receiving training on it. Furthermore, conducting qualitative studies might help examine and understand students’ perceptions as well as provide suggestions to bridge the gap between education and practice. Finally, future experimental studies are needed to test the effect of certain interventions on enhancing the implementation of EBP among nursing students.

Evidence-based practice is essential for nursing students worldwide. However, having strong beliefs about EBP and its benefits does not necessarily mean that it is frequently implemented. On the other hand, providing training courses on EBP is an essential step in the enhancement of EBP implementation. This means that in order to advance nursing science and enhance nursing care for future nurses, it is vital to incorporate EBP within the nursing curricula. It is also critical to teach nursing students the value of evidence-based knowledge as well as how to access this knowledge, appraise it, and apply it correctly as needed. This can be achieved through rigorous cooperation between nursing administrators, clinicians, teachers, and students to enhance the implementation process.

Availability of data and materials

Data are available from the corresponding author upon reasonable request and with permission of Jordan University of Science and Technology.

Abbreviations

Evidence-Based Practice

Institute of Medicine

Accreditation Commission for Education in Nursing

Evidence-Based Practice Belief Scale

Evidence-Based Practice Implementation Scale

The Statistical Package for Social Sciences

Straus SE, Glasziou P, Richardson WS, Haynes RB. Evidence-based medicine: how to practice and teach it. Edinburgh: Churchill Livingstone Elsevier; 2011.

Google Scholar  

Stevens K. The impact of evidence-based practice in nursing and the next big ideas. Online J Issues Nurs. 2013;18(2):4.

PubMed   Google Scholar  

Emparanza JI, Cabello JB, Burls AJ. Does evidence-based practice improve patient outcomes? An analysis of a natural experiment in a Spanish hospital. J Eval Clin Prac. 2015;21(6):1059–65. https://doi.org/10.1111/jep.12460 .

Article   Google Scholar  

Institute of Medicine. The future of nursing: Focus on education. 2010. http://iom.nationalacademies.org/Reports/2010/The- Future-of-Nursing-Leading-Change . Accessed 15 May 2019.

AbuRuz ME, Hayeah HA, Al-Dweik G, Al-Akash HY. Knowledge, attitudes, and practice about evidence-based practice: a Jordanian study. Health Sci J. 2017;11(2):1.

Thorsteinsson HS. Icelandic nurses’ beliefs, skills, and resources associated with evidence-based practice and related factors: a national survey. Worldviews Evid-Based Nurs. 2013;10(2):116–26.

Article   PubMed   Google Scholar  

Verloo H, Desmedt M, Morin D. Beliefs and implementation of evidence-based practice among nurses and allied healthcare providers in the Valais hospital. Switzerland J Eval Clin Pract. 2017;23(1):139–48.

Melnyk BM, Fineout-Overholt E. Evidence-based practice in nursing & healthcare: a guide to best practice. Philadelphia: Lippincott Williams & Wilkins; 2015.

Stokke K, Olsen NR, Espehaug B, Nortvedt MW. Evidence-based practice beliefs and implementation among nurses: a cross-sectional study. BMC Nurs. 2014;13(1):8.

Article   PubMed   PubMed Central   Google Scholar  

Lopez V. Implementing evidence-based practice to develop nursing curriculum. Nurs Pract Today. 2015;2(3):85–7.

Accreditation Commission for Education in Nursing. Accreditation manual. Section III Standards and criteria glossary. 2013. https://www.ncsbn.org/SC2013.pdf . Accessed 15 May 2019.

Moch SD, Cronje RJ, Branson J. Part 1. Undergraduate nursing evidence-based practice education: envisioning the role of students. J Prof Nurs. 2010;26(1):5–13.

Lam CK, Schubert C. Evidence-based practice competence in nursing students: an exploratory study with important implications for educators. Worldviews Evid-Based Nurs. 2019;16(2):161–8.

Halabi JO, Hamdan-Mansour A. Attitudes of Jordanian nursing students towards nursing research. J Res Nurs. 2010;17(4):363–73.

Cruz JP, Colet PC, Alquwez N, Alqubeilat H, Bashtawi MA, Ahmed EA, Cruz CP. Evidence-based practice beliefs and implementation among the nursing bridge program students of a Saudi University. Int J Health Sci. 2016;10(3):405.

Labrague LJ, McEnroe-Pettite D, Tsaras K, D’Souza MS, Fronda DC, Mirafuentes EC, Yahyei AA, Graham MM. Predictors of evidence-based practice knowledge, skills, and attitudes among nursing students. Nurs Forum. 2019;54(2):238–45.

Jordanian Nursing Council. National Nursing and Midwifery Strategy: A Road Map to 2025. 2016. www.jnc.gov.jo . Accessed 30 May 2019.

Melnyk BM, Fineout-Overholt E, Mays MZ. The evidence-based practice beliefs and implementation scales: psychometric properties of two new instruments. Worldviews Evid-Based Nurs. 2008;5(4):208–16.

Al Qadire M. Undergraduate student nurses’ knowledge of evidence-based practice: a short online survey. Nurse Educ Today. 2019;72:1–5.

Spiva L, Hart PL, Patrick S, Waggoner J, Jackson C, Threatt JL. Effectiveness of an evidence-based practice nurse mentor training program. Worldviews Evid-Based Nurs. 2017;14(3):183–91.

Ramos-Morcillo AJ, Fernández-Salazar S, Ruzafa-Martínez M, Del-Pino-Casado R. Effectiveness of a brief, basic evidence-based practice course for clinical nurses. Worldviews Evid-Based Nurs. 2015;12(4):199–207.

Mena-Tudela D, González-Chordá VM, Cervera-Gasch A, Maciá-Soler ML, Orts-Cortés MI. Effectiveness of an evidence-based practice educational intervention with second-year nursing students. Rev Lat Am Enfermagem. 2018;26:e3026.

Sin MK, Bliquez R. Teaching evidence-based practice to undergraduate nursing students. J Prof Nurs. 2017;33(6):447–51.

Horntvedt ME, Nordsteien A, Fermann T, Severinsson E. Strategies for teaching evidence-based practice in nursing education: a thematic literature review. BMC Med Educ. 2018;18(1):172.

Download references

Acknowledgments

This study was funded by Jordan University of Science and Technology Grant # (20190141). The funding source had no role in the design of the study and collection, analysis, and interpretation of data or in writing the manuscript.

Author information

Authors and affiliations.

Faculty of Nursing, Community and Mental Health Nursing Department, Jordan University of Science & Technology, P.O Box 3030, Irbid, 22110, Jordan

Nesrin N. Abu-Baker

Faculty of Irbid College, Department of Applied Sciences, Al-Balqa Applied University, P.O. Box 1293, Irbid, Jordan

Salwa AbuAlrub

Faculty of Nursing, Zarqa University, 247D Khawarezmi Building, Zarqa, Jordan

Rana F. Obeidat

Faculty of Nursing, Al-Albayt University, P.O Box 130040, Mafraq, 25113, Jordan

Kholoud Assmairan

You can also search for this author in PubMed   Google Scholar

Contributions

All authors; NA, SA, RO, and KA had active contributions to the conception and design and/or collecting and analysis of the data and/or the drafting of the paper. NA and RO also made critical revisions for important content and finalized the final version of the manuscript. All authors approved the final version of the manuscript.

Corresponding author

Correspondence to Nesrin N. Abu-Baker .

Ethics declarations

Ethics approval and consent to participate.

Obtained from the Institutional Review Board (IRB) at Jordan University of Science and Technology (Reference # 19/122/2019). All participants were asked to sign a consent form before data collection.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing or conflict of interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Abu-Baker, N.N., AbuAlrub, S., Obeidat, R.F. et al. Evidence-based practice beliefs and implementations: a cross-sectional study among undergraduate nursing students. BMC Nurs 20 , 13 (2021). https://doi.org/10.1186/s12912-020-00522-x

Download citation

Received : 12 May 2020

Accepted : 15 December 2020

Published : 07 January 2021

DOI : https://doi.org/10.1186/s12912-020-00522-x

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Implementations
• Evidence-based practice
• Nursing students

BMC Nursing

ISSN: 1472-6955

• General enquiries: [email protected]

NUR 237: Evidence Based Nursing: Earn

• Course Resources
• Nursing Journals
• Nursing Books
• Nursing Databases: Finding Nursing Articles

Find an Evidence-Based Practice Article

How to find an evidence-based practice article:.

• CINAHL  Complete  
• NIH/NLM ( PubMed )
• Search Google Scholar  
• Search foundations - Example: Cochrane.org  (look for .org)

Featured eResources

A comprehensive nursing and allied health research database, providing full-text access to top journals, evidence-based care sheets, and quick lessons. It equips healthcare students and faculty with authoritative research, teaching, and clinical practice resources.

Explore a wealth of scholarly nursing and academic resources, ideal for students and professionals seeking authoritative information on healthcare practices and research. Covers a wide range of topics including nursing theory, patient care, pharmacology, and evidence-based practice.

A go-to for healthcare professionals and researchers, this resource covers a vast array of medical topics, including diseases, treatments, medications, and clinical studies, ensuring access to up-to-date and authoritative information for evidence-based practice and medical research.

Explore this essential compilation featuring six leading journals from Lippincott Williams & Wilkins, curated by Ovid's experienced nurse professionals. Dive into the full-text coverage of prestigious publications like The American Journal of Nursing (AJN) and Nursing, providing invaluable insights for college students aspiring to excel in the field.

Ideal for healthcare students and professionals seeking career insights and educational resources, covering topics like medical specialties, healthcare trends, job outlooks, and professional development opportunities. It provides up-to-date information and practical guidance tailored to the health and medicine sector.

Search here for reliable health information, suitable for professionals, students, and the public. It covers diverse medical topics, providing evidence-based summaries and guidelines. Access varies, including both paid and open-access articles, ensuring comprehensive coverage.

Explore a wide range of digital texts catering to healthcare professionals and students seeking authoritative information on medical topics. Covers medical textbooks and reference materials, making it essential for those in the healthcare field seeking reliable resources.

Using PubMed for finding Nursing articles

Featured Online Journals

• Journal of Trauma Nursing
• MedSurg Nursing
• Pediatric Nursing
• Urologic Nursing
• << Previous: Nursing Books
• Last Updated: Jun 20, 2024 11:16 AM
• URL: https://libguides.midlandstech.edu/nur237

Library Hours  | My Account | Contact Us | Chat with A Librarian

Log in using your username and password

• Search More Search for this keyword Advanced search
• Latest content
• Current issue
• Write for Us
• BMJ Journals

You are here

• Volume 1, Issue 1

Nursing, research, and the evidence

• Article Text
• Article info
• Citation Tools
• Rapid Responses
• Article metrics

• Anne Mulhall , MSc, PhD
• Independent Training and Research Consultant West Cottage, Hook Hill Lane Woking, Surrey GU22 0PT, UK

https://doi.org/10.1136/ebn.1.1.4

Statistics from Altmetric.com

Request permissions.

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Why has research-based practice become so important and why is everyone talking about evidence-based health care? But most importantly, how is nursing best placed to maximise the benefits which evidence-based care can bring?

Part of the difficulty is that although nurses perceive research positively, 2 they either cannot access the information, or cannot judge the value of the studies which they find. 3 This journal has evolved as a direct response to the dilemma of practitioners who want to use research, but are thwarted by overwhelming clinical demands, an ever burgeoning research literature, and for many, a lack of skills in critical appraisal. Evidence-Based Nursing should therefore be exceptionally useful, and its target audience of practitioners is a refreshing move in the right direction. The worlds of researchers and practitioners have been separated by seemingly impenetrable barriers for too long. 4

Tiptoeing in the wake of the movement for evidence-based medicine, however, we must ensure that evidence-based nursing attends to what is important for nursing. Part of the difficulty that practitioners face relates to the ambiguity which research, and particularly “scientific” research, has within nursing. Ambiguous, because we need to be clear as to what nursing is, and what nurses do before we can identify the types of evidence needed to improve the effectiveness of patient care. Then we can explore the type of questions which practitioners need answers to and what sort of research …

Read the full text or download the PDF:

Evidence-Based Practice in Nursing: Recommended Databases

• Recommended Databases
• Journals on Nursing and Public Health
• Recommended Websites
• Books and eBooks

Databases for Nursing Students

• << Previous: Home
• Next: Journals on Nursing and Public Health >>
• Last Updated: Jun 25, 2024 5:33 PM
• URL: https://slulibrary.saintleo.edu/Nursing_EBP

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Int J Environ Res Public Health

The Effectiveness of an Evidence-Based Practice (EBP) Educational Program on Undergraduate Nursing Students’ EBP Knowledge and Skills: A Cluster Randomized Control Trial

Daniela cardoso.

1 Health Sciences Research Unit: Nursing, Nursing School of Coimbra, Portugal Centre for Evidence-Based Practice: A Joanna Briggs Institute Centre of Excellence, 3004-011 Coimbra, Portugal; tp.cfnese@osodracf (A.F.C.); tp.cfnese@oiregor (R.R.); moc.liamg@7ramed (M.A.R.); tp.cfnese@olotsopa (J.A.)

2 FMUC—Faculty of Medicine, University of Coimbra, 3000-370 Coimbra, Portugal

Filipa Couto

3 Alfena Hospital—Trofa Health Group, Health Sciences Research Unit: Nursing, Nursing School of Coimbra, 3000-232 Coimbra, Portugal; moc.liamg@otuoccdapilif

Ana Filipa Cardoso

Elzbieta bobrowicz-campos.

4 Health Sciences Research Unit: Nursing, Nursing School of Coimbra, 3004-011 Coimbra, Portugal; [email protected] (E.B.-C.); tp.cfnese@stnasasiul (L.S.); tp.cfnese@ohnituocv (V.C.); tp.cfnese@otnipaleinad (D.P.)

Luísa Santos

Rogério rodrigues, verónica coutinho, daniela pinto, mary-anne ramis.

5 Mater Health, Evidence in Practice Unit & Queensland Centre for Evidence Based Nursing and Midwifery: A Joanna Briggs Institute Centre of Excellence, 4101 Brisbane, Australia; [email protected]

Manuel Alves Rodrigues

João apóstolo, associated data.

The data presented in this study are available on request from the corresponding author. The data are not publicly available because this issue was not considered within the informed consent signed by the participants of the study.

Evidence-based practice (EBP) prevents unsafe/inefficient practices and improves healthcare quality, but its implementation is challenging due to research and practice gaps. A focused educational program can assist future nurses to minimize these gaps. This study aims to assess the effectiveness of an EBP educational program on undergraduate nursing students’ EBP knowledge and skills. A cluster randomized controlled trial was undertaken. Six optional courses in the Bachelor of Nursing final year were randomly assigned to the experimental (EBP educational program) or control group. Nursing students’ EBP knowledge and skills were measured at baseline and post-intervention. A qualitative analysis of 18 students’ final written work was also performed. Results show a statistically significant interaction between the intervention and time on EBP knowledge and skills ( p = 0.002). From pre- to post-intervention, students’ knowledge and skills on EBP improved in both groups (intervention group: p < 0.001; control group: p < 0.001). At the post-intervention, there was a statistically significant difference in EBP knowledge and skills between intervention and control groups ( p = 0.011). Students in the intervention group presented monographs with clearer review questions, inclusion/exclusion criteria, and methodology compared to students in the control group. The EBP educational program showed a potential to promote the EBP knowledge and skills of future nurses.

1. Introduction

Evidence-based practice (EBP) is defined as “clinical decision-making that considers the best available evidence; the context in which the care is delivered; client preference; and the professional judgment of the health professional” [ 1 ] (p. 2). EBP implementation is recommended in clinical settings [ 2 , 3 , 4 , 5 ] as it has been attributed to promoting high-value health care, improving the patient experience and health outcomes, as well as reducing health care costs [ 6 ]. Nevertheless, EBP is not the standard of care globally [ 7 , 8 , 9 ], and some studies acknowledge education as an approach to promote EBP adoption, implementation, and sustainment [ 10 , 11 , 12 , 13 , 14 , 15 ].

It has been recommended that educational curricula for health students should be based on the five steps of EBP in order to support developing knowledge, skills, and positive attitudes toward EBP [ 16 ]. These steps are: translation of uncertainty into an answerable question; search for and retrieval of evidence; critical appraisal of evidence for validity and clinical importance; application of appraised evidence to practice; and evaluation of performance [ 16 ].

To respond to this recommendation, undergraduate nursing curricula should include courses, teaching strategies, and training that focus on the development of research and EBP skills for nurses to be able to incorporate valid and relevant research findings in practice. Nevertheless, teaching research and EBP to undergraduate nursing students is a challenging task. Some studies report that undergraduate students have negative attitudes/beliefs toward research and EBP, especially toward the statistical components of the research courses and the complex terminology used. Additionally, students may not understand the importance of the link between research and clinical practice [ 17 , 18 , 19 ]. In fact, a lack of EBP and research knowledge is commonly reported by nurses and nursing students as a barrier to EBP. It is imperative to provide the future nurses with research and EBP skills in order to overcome the barriers to EBP use in clinical settings.

At an international level, several studies have been performed with undergraduate nursing students to assess the effectiveness of EBP interventions on multiple outcomes, such as EBP knowledge and skills [ 20 , 21 , 22 , 23 ]. The Classification Rubric for EBP Assessment Tools in Education (CREATE) [ 24 ] suggests EBP knowledge should be assessed cognitively using paper and pencil tests, as EBP knowledge is defined as “learners’ retention of facts and concepts about EBP” [ 24 ] (p. 5). Additionally, the CREATE framework suggests EBP skills should be assessed using performance tests, as skills are defined as “the application of knowledge” [ 24 ] (p. 5). Despite these recommendations, few studies have assessed EBP knowledge and skills using both cognitive and performance instruments.

Therefore, this study aims to evaluate the effectiveness of an EBP educational program on undergraduate nursing students’ EBP knowledge and skills using a specific cognitive and performance instrument. The intervention used in this study was recently developed [ 25 ], and this is the first study designed to assess its effectiveness in undergraduate EBP.

2. Materials and Methods

2.1. design.

A cluster randomized controlled trial with two-armed parallel group design was undertaken (ClinicalTrials.gov Identifier: {"type":"clinical-trial","attrs":{"text":"NCT03411668","term_id":"NCT03411668"}} NCT03411668 ).

2.2. Sample Size Calculation

The sample size was calculated using the software G*Power 3.1.9.2. (Heinrich-Heine-Universität Dusseldorf, Düsseldorf, Germany) Recognizing that there were no studies performed a priori using a cognitive and performance instrument to assess the effectiveness of an EBP educational program on undergraduate nursing students’ EBP knowledge and skills, we used an effect size of 0.25, which is a small effect size as proposed by Cohen [ 26 ]. A power analysis based on a type I error of 0.05; power of 0.80; effect size f = 0.25; and ANOVA repeated measures between factors determined a sample size of 98 as total.

Taking into account that our study used clusters (optional courses) and that each one had an average of 25 students, we needed at least four clusters to cover the total sample size of 98. However, to cover potential losses to follow-up, we included a total of six optional courses.

2.3. Participants’ Recruitment and Randomization

We recruited participants from one Portuguese nursing school in 2018. From the 12 optional clinical nursing courses (such as Community Nursing Intervention in Vulnerable Groups; Ageing; Health and Citizenship; The Child with Special Needs: Diagnoses and Interventions in Pediatric Nursing; Liaison Psychiatry Nursing; Nursing in the Emergency Room; etc.) in the 8th semester of the nursing program (last year before graduation), students from three clinical nursing courses were randomly assigned to the experimental group (EBP educational program) and students from another three clinical nursing courses were randomly assigned to the control group (no intervention— education as usual ) before the baseline assessment. An independent researcher performed this assignment using a random number generator from the random.org website [ 27 ]. This assignment was performed based on a list of the 12 optional courses provided through the nursing school’s website.

2.4. Intervention Condition

The participants in the intervention group received education as usual plus the EBP educational program, which was developed by Cardoso, Rodrigues, and Apóstolo [ 25 ]. This intervention included EBP contents regarding models of thinking about EBP, systematic reviews types, review question development, searching for studies, study selection process, data extraction, and data synthesis.

This program was implemented in 6 sessions over 17 weeks:

• Sessions 1–3—total of 12 h (4 h per session) during the first 7 weeks using expository methods with practice tasks to groups of 20–30 students.
• Sessions 4–6—total of 6 h (2 h per session) during the last 10 weeks using active methods through mentoring to groups of 2–3 students.

Due to the nature of the intervention, it was not possible to blind participants regarding treatment assignment nor was it feasible to blind the individuals delivering treatment.

2.5. Control Condition

The participants in the control group received only education as usual; i.e., students allocated to this control condition received the standard educational contents (theoretical, theoretical–practical, practical) delivered by the nursing educators of the selected nursing school.

2.6. Assessment

All participants were assessed before (week 0) and after the intervention (week 18) using a self-report instrument. EBP knowledge and skills were assessed by the Adapted Fresno Test for undergraduate nursing students [ 28 ]. This instrument was adapted from the Fresno Test, which was originally developed in 2003 to measure knowledge and skills on EBP in family practice residents [ 29 ]. The Adapted Fresno Test for undergraduate nursing students has seven short answer questions and two fill-in-the-blank questions [ 28 ]. At the beginning of the instrument, two scenarios, which suggest clinical uncertainty, are presented. These two scenarios are used to guide the answers to questions 1 to 4: (1) write a clinical question; (2) identify and discuss the strengths and weaknesses of information sources as well as the advantages and disadvantages of information sources; (3) identify the type of study most suitable for answering the question of one of the clinical scenarios and justify the choice; and (4) describe a possible search strategy in Medline for one of the clinical scenarios, explaining the rationale. The next three short answer questions require that the students identify topics for determining the relevance and validity of a research study and address the magnitude and value of research findings. The last two questions are fill-in-the-blank questions. The answers are scored using a modified standardized grading system [ 28 ], which was adapted from the original [ 29 ]. The instrument has a total minimum score of 0 and a maximum score of 101. The inter-rater correlation for the total score of the Adapted Fresno Test was 0.826 [ 28 ]. The rater that graded the answers to the Adapted Fresno Test was blinded to treatment assignment.

Despite the fact that in the study proposal we did not consider any kind of qualitative analysis in order to assess EBP knowledge and skills in a more practical context, we decided during the development of the study to perform a qualitative analysis of monographs at the posttest. The monographs were developed by small groups of nursing students and were the final written work submitted by the students for their bachelor’s degree course. In this work, the students were asked to define a review question regarding the context of clinical practice where they were performing their clinical training. Students then proceeded to answer the review question through a systematic process of searching and selecting relevant studies and extracting and synthesizing the data. From the 58 submitted monographs (30 from the control group and 28 from the intervention group), 18 were randomized for evaluation (nine from the control group and nine from the intervention group) by an independent researcher using the random.org website [ 27 ] based on a list provided by the research team. Three independent experts (one psychologist with a doctoral qualification and two qualified nurses, one with a master’s degree) performed a qualitative analysis of the selected monographs. All experts had experience with the EBP approach and were blinded to treatment assignment. The experts independently used an evaluation form to guide the qualitative analysis of each monograph. This form presented 11 guiding criteria regarding review questions, inclusion/exclusion criteria, methodology (namely search strategy, study selection process, data extraction, and data synthesis), results presentation, and congruency between the review questions and the answers to them that were provided in the conclusion section. Thereafter, the experts met to discuss any discrepancies in their qualitative analysis until consensus was reached.

2.7. Statistical Analyses

The data were analyzed using Statistical Package for the Social Sciences (SPSS; version 24.0; SPSS Inc., Chicago, IL, USA). Differences in sociodemographic characteristics of study participants and outcome data at baseline were analyzed using Pearson’s chi-squared test for nominal data and independent the t -test for continuous data.

Taking into account the central limit theorem and that ANOVA tests are robust to violation of assumptions [ 30 ], we decided to perform two-way mixed ANOVA to compare the outcome between and within groups. The Wilcoxon signed-rank test was used to analyze how many participants had improved their EBP knowledge and skills item-by-item, how many remained the same, and how many had decreased performance within each group. Statistical significance was determined by p -values less than 0.05.

To minimize the noncompliance impact, an intention-to-treat (ITT) analysis was used to analyze participants in the groups that they were initially randomized to [ 31 ] by using the last observation carried forward imputation method.

2.8. Ethics

This study was approved by the Ethical Committee of the Faculty of Medicine of the University of Coimbra (Reference: CE-037/2017). The institution where the study was carried out provided written approval. All participants gave informed consent, and the data were managed in a confidential way.

Twelve potential clusters (optional courses in the 8th semester of the nursing program) were identified as eligible for this study. Of these, three were randomized for the intervention group and three for the control group. During the intervention, eight participants (two in the intervention group and six in the control group) were lost to follow-up because they did not fill-in the instrument in the post-intervention. Figure 1 shows the flow of participants through each stage of the trial.

Consolidated Standards of Reporting Trials (CONSORT) diagram showing the flow of participants through each stage of the trial. ITT: intention-to-treat.

3.1. Demographic Characteristics

As Table 1 displays, 148 undergraduate nursing students with an average age of 21.95 years (SD = 2.25; range: 21–41) participated in the study. A large majority of the sample were female ( n = 118, 79.7%), had a 12th grade educational level ( n = 144, 97.3%), and had participated in some form of EBP training ( n = 121, 81.8%).

Socio-demographic characterization of the sample—ITT analysis.

* Defined as any kind and duration of evidence-based practice (EBP) training, such as EBP contents in a course, a workshop, a seminar.

At baseline, the experimental and control groups were comparable regarding sex, age, education, EBP training, and performance on the Adapted Fresno Test ( Table 1 and Table 3). The baseline data were similar with dropouts excluded; therefore, only ITT analysis results are presented.

3.2. EBP Knowledge and Skills

3.2.1. adapted fresno test.

The two-way mixed ANOVA showed a statistically significant interaction between the intervention and time on EBP knowledge and skills, F (1, 146) = 9.550, p = 0.002, partial η 2 = 0.061 ( Table 2 ). Excluding the dropouts, the two-way mixed ANOVA analysis was similar. Thus, only the ITT analysis results are presented.

Main effects of time and group and interaction effects on EBP knowledge and skills—ITT analysis.

To determine the difference between groups at baseline and post-intervention, two separate between-subjects ANOVAs (i.e., two separate one-way ANOVAs) were performed. At the pre-intervention, there was no statistically significant difference in EBP knowledge and skills between groups: F (1,146) = 0.221, p = 0.639, partial η 2 = 0.002. At the post-intervention, there was a statistically significant difference in EBP knowledge and skills between groups: F (1,146) = 6.720, p = 0.011, partial η 2 = 0.044 ( Table 3 ).

Repeated measures ANOVA and between-subjects ANOVA—ITT analysis.

To determine the differences within groups from the baseline to post-intervention, two separate within-subjects ANOVAs (repeated measures ANOVAs) were performed. There was a statistically significant effect of time on EBP knowledge and skills for the intervention group: F (1,73) = 53.028, p < 0.001, partial η 2 = 0.421 and for the control group: F (1,73) = 13.832, p < 0.001, partial η 2 = 0.159 ( Table 3 ).

The results of repeated measures ANOVA and between-subjects ANOVA analysis are similar if we exclude the dropouts; therefore, only ITT analysis results are presented.

The results of the Wilcoxon signed-rank test for each item of the Adapted Fresno Test are presented in Table 4 . The results of this analysis revealed that students in both the intervention and control groups significantly improved their knowledge and skills in writing a focused clinical question (Item 1) (intervention group: Z = −4.572, p < 0.000; control group: Z = −2.338, p = 0.019), in building a search strategy (item 3) (intervention group: Z = −4.740, p < 0.000; control group: Z = −4.757, p < 0.000), in identifying and justifying the study design most suitable for answering the question of one of the clinical scenarios (item 4) (intervention group: Z = −4.508, p < 0.000; control group: Z = −3.738, p < 0.000), and in describing the characteristics of a study to determine its relevance (item 5) (intervention group: Z = −2.699, p = 0.007; control group: Z = −1.980, p = 0.048).

Within groups comparison with Wilcoxon signed-rank test for each item of the Adapted Fresno Test—ITT analysis.

The students in the control group significantly improved their knowledge and skills in describing the characteristics of a study to determine its validity (item 6) ( Z = −2.714, p = 0.007). The students in the intervention group significantly improved their knowledge and skills in describing the characteristics of a study to determine its magnitude and significance (item 7) ( Z = −2.543, p = 0.011). No other significant differences were detected.

The results of the within groups comparison with the Wilcoxon signed-rank test are similar if we exclude the dropouts; therefore, only ITT analysis results are presented.

3.2.2. Qualitative Analysis of Monographs

Based on the experts’ consensus report of each monograph, the analysis of the intervention group monographs showed that the students’ groups clearly defined their review questions and inclusion/exclusion criteria. These groups of students effectively searched for studies using appropriate databases, keywords, Boolean operators, and truncation. Additionally, we found thorough descriptions from students concerning the selection process, data extraction, and data synthesis. However, only three students’ groups provided a good description of the review findings with an appropriate data synthesis as well as a clear answer to the review question in the conclusion section of their monographs. It is noted that the criteria for the results and conclusion sections were more difficult to successfully achieve, even in the intervention group.

The monographs of the control groups showed weaknesses throughout. From the nine monographs of the control group, only two presented the review question in a way that was clearly defined. In all of the monographs, the inclusion/exclusion criteria were either not very informative, unclear, or did not match with the defined review questions. Additionally, the search strategies were not clear and demonstrated limited understanding, such as lack of use of appropriate synonyms, absent truncations, and no definition of the search field for each word or expression to be searched. None of the monographs from the control group reported information about the methods used to study the selection process, to extract data, or to synthesize data. In the conclusion section, students from the control group also demonstrated difficulties in synthesizing the data and limitations by providing a clear answer to the review question.

4. Discussion

This study sought to evaluate the effectiveness of an EBP educational program on undergraduate nursing students’ EBP knowledge and skills. Even though both groups improved after the intervention in EBP knowledge and skills, the study results showed that the improvement was greater in the intervention group. This result was reinforced by the results of the qualitative analysis of monographs.

To the best of our knowledge, this is the first study to use a cognitive and performance assessment instrument (Adapted Fresno Test) with undergraduate nursing students, as suggested by CREATE [ 24 ]. Additionally, it is the first study conducted using the EBP education program [ 25 ]. Therefore, comparison of our findings with similar studies in terms of the type of assessment instrument and intervention is limited.

However, comparing our study with other previous research using other types of instruments and interventions demonstrates similar results [ 20 , 21 , 22 , 23 ]. In a quasi-experimental study [ 20 ], it was found that an EBP educational teaching strategy showed positive results in improving EBP knowledge in undergraduate nursing students. A study showed that undergraduate nursing students who received an EBP-focused interactive teaching intervention improved their EBP knowledge [ 21 ]. Another study indicated that a 15-week educational intervention in undergraduate nursing students (second- and third-year) significantly improved their EBP knowledge and skills [ 22 ]. In addition, a study by Zhang, Zeng, Chen, and Li revealed a significant improvement in undergraduate nursing students’ EBP knowledge after participating in a two-phase intervention: a self-directed learning process and a workshop for critical appraisal of literature [ 23 ].

Despite the effectiveness of the program in improving EBP knowledge and skills, the students included in the present study had low levels of EBP knowledge and skills as assessed by the Adapted Fresno Test at the pretest and posttest. These low levels of EBP knowledge and skills, especially at the pretest, might have influenced our study results. As a matter of fact, the Adapted Fresno Test is a demanding test since it requires that students retrieve and apply knowledge while doing a task associated with EBP based on scenarios involving clinical uncertainty. Consequently, this kind of test is very useful to truly assess EBP knowledge retention and abilities in clinical scenarios that do not allow guessing the answers. Notwithstanding, due to these characteristics, the Adapted Fresno Test may possibly be less sensitive when small changes occur or when students have low levels of EBP knowledge and skills. Nevertheless, even using instruments with Likert scales, other studies also showed that students have low levels of EBP knowledge and skills [ 21 , 22 , 23 ].

The low levels of EBP knowledge and skills of the undergraduate nursing students may be a reflection of a persistent, traditional education with regard to research. By this we mean that the focus of training remains on primary research—preparing students to be “research generators” instead of preparing them to be “evidence users” [ 32 ]. Furthermore, the designed and tested intervention used in this study was limited in time (only 17 weeks), was provided by only two instructors, and was delivered to fourth-year undergraduate nursing students, which are limitations for curriculum-wide integration of EBP.

Indeed, a curriculum that promotes EBP should facilitate students’ acquisition of EBP knowledge and skills over time and with levels of increasing complexity through their participation in EBP courses and during their clinical practice experiences [ 32 , 33 , 34 , 35 ]. As Moch, Cronje, and Branson suggest, “It is only in such practical settings that students can experience the challenges intrinsic to applying scientific evidence to the care of real patients. In these clinical settings, students can experience both the frustrations and the triumphs inevitable to integrating scientific knowledge into patient care.” [ 35 ] (p. 11). Therefore, in future studies, other broad approaches for curriculum-wide integration of EBP as well as its long-term effects should be evaluated.

Previously in the Discussion, we highlighted the limitations of the proposed intervention in terms of time constraints (only 17 weeks), instructors’ constraints (only two instructors provided the intervention), and participants’ constraints (fourth-year undergraduate nursing students). In addition, the study was also restricted to one Portuguese nursing school, which can limit the generalization of the results. However, our study tried to address some of the fragilities identified in other studies [ 20 , 21 , 22 , 23 ] on the effectiveness of EBP educational interventions by including a control group and by measuring EBP knowledge and skills with an objective measure and not a self-reported measure.

Bearing this in mind, future studies in multiple sites should assess the long-term effects of the EBP educational intervention and the impact on EBP knowledge and skills of potential variations in contents and teaching methods. In addition, studies using more broad interventions for curriculum-wide integration of EBP should also be performed.

5. Conclusions

Our findings show that the EBP educational program was effective in improving the EBP knowledge and skills of undergraduate nursing students. Therefore, the use of an EBP approach as a complement to the research education of undergraduate nursing students should be promoted by nursing schools and educators. This will help to prepare the future nurses with the EBP knowledge and skills that are essential to overcome the barriers to EBP use in clinical settings, and consequently, to contribute to better health outcomes.

Acknowledgments

This paper contributed toward the D.C. PhD in Health Sciences—Nursing. The authors gratefully acknowledge the support of the Health Sciences Research Unit: Nursing (UICISA: E), hosted by the Nursing School of Coimbra (ESEnfC) and funded by the Foundation for Science and Technology (FCT). Moreover, the authors gratefully thank Catarina Oliveira for all the support as a Ph.D. supervisor and Isabel Fernandes, Maria da Nazaré Cerejo, and Irma Brito for help and facilitation of data collection.

Author Contributions

Conceptualization, D.C., M.A.R., and J.A.; methodology, D.C., M.A.R., and J.A.; validation, D.C., M.A.R., and J.A.; formal analysis, D.C., F.C., and A.F.C.; investigation, D.C., F.C., A.F.C., E.B.-C., L.S., R.R., V.C., D.P., M.-A.R., M.A.R., and J.A.; resources, D.C., M.A.R., and J.A.; data curation, D.C., F.C., and A.F.C.; writing—original draft preparation, D.C.; writing—review and editing, F.C., A.F.C., E.B.-C., L.S., R.R., V.C., D.P., M.-A.R., M.A.R., and J.A.; supervision, M.A.R. and J.A.; project administration, D.C. All authors have read and agreed to the published version of the manuscript.

This work was funded by National Funds through the FCT—Foundation for Science and Technology, I.P., within the scope of the project Ref. UIDP/00742/2020.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by Ethical Committee of Faculty of Medicine of the University of Coimbra (protocol code: CE-037/2017 and date of approval: 22 May 2017).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

News & More is your official source for what's happening at the IHP.

• Features & Spotlights
• Awards & Accolades
• In The Media
• Campus Culture
• Communication Sciences & Disorders
• Diversity & Inclusion
• Education & Careers

Innovations in Nursing: How DNP-Prepared Nurses are Leading Change

Nurses are inherently positioned at the forefront of patient care and system-wide healthcare improvements. Nurses with a Doctor of Nursing Practice (DNP) degree are uniquely positioned to drive innovation and lead change. DNP-prepared nurses combine advanced clinical expertise with leadership skills, enabling them to spearhead nurse-led change and implement nursing innovations that enhance patient outcomes and healthcare delivery. This article explores how DNP-prepared nurses are making significant contributions to the healthcare field through leadership and innovation.

The Role of DNP-Prepared Nurses in Healthcare

DNP-prepared nurses are educated to practice at the highest level of nursing, enabling them to take on roles that influence patient care, policy, and practice within healthcare systems. Their education focuses on areas critical to healthcare advancement, including evidence-based practice, quality improvement, and systems leadership.

Leading Nursing Innovations

Innovation is at the heart of nursing practice, and DNP-prepared nurses are often the catalysts for new ideas and approaches in healthcare. Their contributions to nursing innovations include:

• Developing New Care Models: DNP-prepared nurses design and implement care models that address gaps in healthcare delivery, such as transitional care models to reduce hospital readmissions.
• Technology Integration: They lead efforts to integrate healthcare technologies, such as electronic health records (EHRs) and telehealth services, to improve patient care and access.
• Patient Safety Initiatives: Initiatives aimed at reducing medical errors and improving patient safety are frequently driven by DNP-prepared nurses, utilizing their deep understanding of clinical practice and quality improvement principles.

DNP Leadership in Practice

Leadership is a core component of the DNP curriculum , preparing nurses to lead teams, manage projects, and influence policy. The impact of DNP Leadership includes:

• Interprofessional Collaboration: DNP-prepared nurses lead interprofessional teams , fostering collaboration among healthcare professionals to improve patient care and outcomes.
• Health Policy Advocacy: They are advocates for health policy changes, using their expertise to influence policies that affect nursing practice and patient care.
• Organizational Change Management: DNP-prepared nurses are skilled in change management, leading efforts to implement evidence-based practices and innovations within healthcare organizations.

Driving Nurse-Led Change

Nurse-led change is a hallmark of DNP-prepared nurses, demonstrating their ability to lead improvements in healthcare. Examples of nurse-led change include:

• Quality Improvement Projects: DNP-prepared nurses often lead quality improvement projects, using data to identify areas for improvement and measure the impact of interventions.
• Community Health Initiatives: They design and implement community health programs targeting underserved populations, addressing social determinants of health, and improving community health outcomes.
• Education and Mentoring: By serving as mentors and educators, DNP-prepared nurses play a key role in preparing the next generation of nurses, sharing their knowledge and expertise to foster a culture of excellence and innovation.

MGH Institute of Health Professions DNP Program

The MGH Institute of Health Professions, a graduate school affiliate of Mass General Brigham, offers a DNP program that offers two tracks – a clinical track for advanced practice RNs with an MS in Nursing in non-leadership roles, or an executive track for nurse executives in a leadership role or aspiring to be in this type of role.  Highlights of the MGH IHP's DNP program include:

• Interprofessional Education: Students benefit from opportunities to interact  with other health professions, preparing them for collaborative practice.
• Focus on Innovation and Leadership: The curriculum emphasizes leadership, innovation, and evidence-based practice, enabling graduates to drive change in healthcare.
• Clinical and Capstone Projects: Students engage in clinical practice and capstone projects that address real-world healthcare challenges, demonstrating the practical application of their knowledge.

DNP-prepared nurses are so important to advancement in the world of healthcare; at the forefront of nursing innovations, leadership, and nurse-led change - playing a crucial role in transforming healthcare delivery and improving patient outcomes.  

Leadership in Nursing

Take the next step

• Clinical Affiliations

• Subscribe to journal Subscribe
• Get new issue alerts Get alerts

Secondary Logo

Journal logo.

Colleague's E-mail is Invalid

Your message has been successfully sent to your colleague.

Save my selection

Reducing Lung Injury from Blind Insertion of Small-Bore Feeding Tubes

Jahn, Teresa MSN, APRN, CNS; Overgaard, Jenelle BSN, RN; Mondloch, Mallory BS, RN; Plante, Elizabeth BSN, RN; Burris, Jennifer MA, APRN, CNS; Suresh, Mithun MD; Berndt, Jodi PhD, RN

Teresa Jahn is an advanced practice nurse at CentraCare Heart and Vascular Center, St. Cloud Hospital, St. Cloud, MN, where Jenelle Overgaard is a nurse clinician in the ICU, Mallory Mondloch is a nurse clinician in the surgical care unit, Elizabeth Plante is a nurse clinician in the neuroscience/spine unit, Jennifer Burris is director of inpatient and outpatient nursing practice and innovation, and Mithun Suresh is a hospitalist. Jodi Berndt is associate professor at the College of Saint Benedict and Saint John's University, St. Joseph, MN. Contact author: Teresa Jahn, [email protected] . The authors and planners have disclosed no potential conflicts of interest, financial or otherwise.

• Infographic

Using a blind insertion technique to insert small-bore feeding tubes can result in inadvertent placement in the lungs, leading to lung perforation and even mortality. In a Magnet-designated, 500-bed, level 2 trauma center, two serious patient safety events occurred in a four-week period due to nurses blindly inserting a small-bore feeding tube. A patient safety event review team convened and conducted an assessment of reported small-bore feeding tube insertion events that occurred between March 2019 and July 2021. The review revealed six lung perforations over this two-year period. These events prompted the creation of a multidisciplinary team to evaluate alternative small-bore feeding tube insertion practices. The team reviewed the literature and evaluated several evidence-based small-bore feeding tube placement methods, including placement with fluoroscopy, a two-step X-ray, electromagnetic visualization, and capnography. After the evaluation, capnography was selected as the most effective method to mitigate the complications of blind insertion. In this article, the authors describe a quality improvement project involving the implementation of capnography-guided small-bore feeding tube placement to reduce complications and the incidence of lung perforation. Since the completion of the project, which took place from December 13, 2021, through April 18, 2022, no lung injuries or perforations have been reported. Capnography is a relatively simple, noninvasive, and cost-effective technology that provides nurses with a means to safely and effectively insert small-bore feeding tubes, decrease the incidence of adverse events, and improve patient care.

The authors describe a quality improvement project involving the implementation of capnography-guided small-bore feeding tube placement to reduce complications and the incidence of lung perforation in adult patients.

Acute or critically ill patients who are unable to swallow or obtain adequate oral nutrition often require a small-bore feeding tube to sustain enteral feedings to meet their metabolic needs. 1 Small-bore feeding tubes are inserted through the nostril, into the pharynx, into the esophagus, and finally into the stomach. Although there is ongoing debate among clinicians about the optimal feeding strategy during the initial stages of critical illness, including how quickly caloric and protein intake should be increased, the Society of Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition recommend that critically ill patients who are malnourished or at high risk for malnutrition have enteral nutrition initiated within the first 24 to 48 hours of admission. 2-4 Studies have shown many benefits associated with adequate nutritional support, including but not limited to improved wound healing, preservation of gastric mucosa, decreased mortality, skeletal muscle wasting, and critical care length of stay. 2, 3, 5, 6

Given the evidence for the benefits of adequate nutritional support, the ability to obtain secure enteral access to safely provide nutrition is important. Nurses routinely insert small-bore feeding tubes in patients at the bedside in acute and critical care settings to provide enteral access. 7 Some of these patients may be intubated or sedated, have a decreased level of consciousness, or have a diminished gag reflex, all of which may predispose them to aspiration. 8 Accidental feeding tube insertion into the trachea is also relatively common in such patients. 3

Many providers prefer to use smaller-bore tubes for enteral feeding. A key advantage of small-bore tubes over larger feeding tubes is the smaller tube diameter (commonly less than 12-French), which makes them more comfortable for patients. 9 Despite the small diameter, small-bore feeding tubes inserted into the respiratory tract can still cause harm. Sparks and colleagues reported that out of 187 small-bore feeding tubes inadvertently placed in the respiratory tract, there were 35 (18.7%) instances of pneumothorax (air in the pleural space). 10 This complication can have significant consequences, as Zhan and Miller reported that iatrogenic pneumothoraxes (those that have developed secondary to an invasive procedure) are associated with statistically significant excess lengths of stay (4.38 days), excess charges ($17,312), and excess mortality (6.99%). 11

The proper positioning of a small-bore feeding tube can also be complicated by the presence of an endotracheal tube. 12 Endotracheal tubes, which often have cuffs that are appropriately inflated to a pressure of 20 to 30 cm H 2 O in order to create a seal within the airway, 13 are inserted into the trachea to provide oxygen and inhaled gases to the lung.

Description of the problem . In 2021, the patient safety event review committee at our Magnet-designated, 500-bed, level 2 trauma center began receiving reports of a concerning trend regarding small-bore feeding tube placement. The team reviewed insertion events between March 2019 and July 2021, and found that six small-bore feeding tubes placed blindly at the bedside had entered the trachea instead of the esophagus, and upon advancement four had caused pneumothoraxes, while two terminated in the lung base and did not cause a pneumothorax. While our institution does not track the volume of insertions, the trend was notable and warranted further investigation. After examination of each of these cases, it became clear that this complication was not isolated to a specific hospital unit or department. Furthermore, multiple providers were involved in the patients' care at the time of the tube placement.

To help prevent improper small-bore feeding tube placement, the procedure in place at the time included observing for respiratory distress, such as cyanosis or severe coughing. Some organizational guidelines, however, caution against relying on signs of respiratory distress, as these can be absent even when the tube is inserted into the respiratory tract. 7, 14, 15 This procedure was then followed by another, an abdominal X-ray, to confirm correct placement. This insertion method was based on the method in the AACN Procedure Manual for High Acuity, Progressive, and Critical Care for insertion and care of small-bore feeding tubes. 16 Upon chart review and discussion with RNs, the patient safety event review committee found that most of these patients did not demonstrate respiratory distress as a result of their clinical condition and misplaced tubes were only recognized during radiographic verification.

To address these reported events, a multidisciplinary team was assembled consisting of a hospitalist, two clinical nurse specialists (CNSs), a respiratory therapist, and three RNs hired as nurse clinicians. The team was tasked with developing and implementing an evidence-based quality improvement (QI) project to eliminate complications associated with small-bore feeding tube insertions in adult patients requiring enteral nutrition. Prior to this QI initiative, RNs received nonstandardized education on feeding tube insertion through the general orientation program for new nurses. A follow-up component of the QI project was to develop a competency checklist and provide standardized training for RNs performing small-bore feeding tube insertions.

The nurse clinicians and CNSs on the multidisciplinary team gathered information by direct observation of nurses' insertion techniques at the bedside and chart review. At the same time, they completed a comprehensive literature review focused on improving the identification of improper placement during insertion rather than waiting for radiography to identify it. The team narrowed the scope to three possible practices: electromagnetic placement devices, the two-step X-ray method, and capnography (see Table 1 17-19 ).

Based on limited resources within the organization, the implementation of electromagnetic placement devices and the two-step X-ray method were eliminated as possible options. Obstacles to the use of electromagnetic placement devices included the time required for training and maintenance of staff competency. The two-step X-ray method required coordination between radiology and patient care units, additional patient exposure to radiation, and concerns about delayed enteral nutrition.

Capnography, the third strategy we considered, measures the relative concentration of end-tidal carbon dioxide (ETCO 2 ) in expired air; therefore, if a small-bore feeding tube is inserted into the respiratory tract, ETCO 2 emanating from the tube will indicate incorrect placement. The use of capnography to help facilitate proper feeding tube placement has been demonstrated in several studies 19, 20 and identified as an acceptable practice, along with radiographic verification, in the American Association of Critical-Care Nurses' “Practice Alert: Initial and Ongoing Verification of Feeding Tube Placement in Adults.” 21 A meta-analysis by Chau and colleagues has described capnography as a valid and reliable strategy for ensuring proper placement of nasogastric tubes, having a sensitivity of 0.88 to 1, specificity of 0.95 to 1, positive likelihood ratio of 15.22 to 283.35, and negative likelihood ratio of 0.01 to 0.25 for verification of tube placement and differentiating between respiratory and gastrointestinal tract placement. 20

As the time frame of this QI project coincided with the COVID-19 pandemic, factors such as staff and product availability were also considered when determining the most appropriate verification method. Incorporating capnography into small-bore feeding tube insertion procedures best suited the organizational needs and limited resources of our hospital. The multidisciplinary team agreed that attaching the capnography device to the end of the small-bore feeding tube during insertion was the least expensive and most reliable evidence-based intervention.

Specific aims . The purpose of this QI project was to reduce pulmonary complications (such as pneumothorax and lung base placement) associated with blind bedside small-bore feeding tube insertions by using capnography to help ensure proper tube placement. An important follow-up component was to develop a competency checklist and provide training for the RNs who would perform the tube insertions, both of which were found to need formalization. The project was acknowledged by the hospital's nursing research review board and deemed exempt by the institutional review board. Support and approvals were received from the hospital's shared governance structures, which included nurse, patient care, and leadership practice committees.

Interventions . The institution's insertion procedure was enhanced by optimizing endotracheal tube cuff pressure prior to insertion, adding capnography monitoring during insertion, and obtaining radiographic verification following insertion. Figure 1 16 (go to https://links.lww.com/AJN/A261 ) outlines the procedure that was used during the project and that later served as the hospital's competency checklist.

All adult patients with orders for a small-bore feeding tube were considered for participation in this QI project. Patients came from multiple areas throughout the hospital: a 29-bed multisystem ICU, 14-bed cardiac ICU, 25-bed COVID-19 unit, 52-bed general surgical unit, nine-bed surgical progressive care unit, 19-bed medical progressive care unit, 27-bed medical unit, 39-bed medical oncology unit, 38-bed neuroscience/spine unit, and eight-bed neuro progressive care unit. For patients who were intubated, an endotracheal tube cuff inflator with manometer was used to assess and adjust the cuff pressure, if needed, to approximately 20 to 30 cm H 2 O by the respiratory therapist prior to insertion of the tube. Patients were placed in high Fowler's position to determine the appropriate length of insertion; nurses measured the tube length from the tip of the nose to the earlobe tragus and then to the xiphoid process. One to two inches (2.5 to 5 cm) were added to this length to achieve position via the esophagus to 5 cm below the level of the carina. Initially, 8-French small-bore feeding tubes were used for all adult patients, but these were changed to 10-French during the project because of supply availability. A 10-French tube was preferred to the 8-French tube because of its larger inner diameter, which reduced the risk of tube clogging; however, the outer diameters of the 6-French through the 12-French were all within an acceptable range, 22 and therefore there was no effect on patient comfort or risk of mucosal injuries to the nares. The 8-French tube also required water-soluble lubricant to be added to the end of the tube, which increased the risk that the lubricant could remain at the tip, obstructing the opening, and preventing the capnography monitoring device from detecting ETCO 2 if the tube was inadvertently placed in the bronchopulmonary tract. To minimize this risk, air was flushed into the tube prior to insertion to clear the lubricant away. The 10-French tubes were self-lubricating upon dipping into water and no additional lubricant was needed.

After the small-bore feeding tube was prepared per manufacturer guidelines, capnography tubing was attached to the auxiliary port, as the stylet was left in place in the main feeding port (see Figure 2 ). The tubing was then attached to a bedside capnography monitor. The small-bore feeding tube was inserted to 30 cm and held in place for 60 seconds. Capnography waveform detection monitoring occurred during this time (see Figure 3 ).

Measures . The absence of ETCO 2 indicates appropriate small-bore feeding tube placement in the esophagus; alternatively, ETCO 2 may also be absent in the event of an occlusion of the tube due to folding or something present in the tube. If ETCO 2 was detected, it was likely indicative of tracheal placement. If ETCO 2 was not detected and the patient was not exhibiting coughing, choking, or other indications of respiratory distress, the small-bore feeding tube was advanced to the predetermined length. The use of capnography was intended to enhance the detection of improper tube placement during insertion. The use of radiography to verify gastrointestinal placement was still required following insertion.

Data collection took place from December 13, 2021, through April 18, 2022. During this time, a total of 40 patients received small-bore feeding tubes inserted with the use of capnography. Initially, the CNSs and nurse clinicians who developed the practice change completed all insertions. Additional RNs were trained using direct observation of the original team members.

Since the inclusion of capnography monitoring with tube insertion was an additional step in the hospital's standard procedure and was new to staff, staff were somewhat reluctant to adopt it because of the additional time and equipment it required. This reluctance was addressed by the QI team members (RNs and CNSs) who met with staff individually and provided the rationale for the practice change. This included heightening nurses' awareness and understanding of the complications associated with blind insertion of small-bore feeding tubes and of actual patient safety events that had occurred over the two-year period from March 2019 to July 2021, as well as developing a systematic process to teach staff how to use capnography during small-bore feeding tube insertion.

A total of 42 adult patients had a small-bore feeding tube inserted between December 13, 2021, and April 18, 2022. However, because capnography use was not verified in two of those patients, the sample size for this QI project was 40 adult patients (see Table 2 for demographic details). During this QI project, no lung injuries or perforations were reported. A total of 44 small-bore feeding tube insertions with capnography were attempted on the 40 patients because of tubes requiring reinsertion (see Table 3 ).

During 16 of the 44 insertion attempts, ETCO 2 was detected, which resulted in RNs withdrawing and reinserting the small-bore feeding tubes until ETCO 2 was not measurable. During five of the 16 insertion attempts, the patients had no other indications of intolerance, such as coughing, respiratory distress, or tachypnea. Nurses stated that, had capnography not been used, they would have proceeded to insert the small-bore feeding tube in these instances. Thirty-nine of the 44 insertions were determined to be successful after abdominal X-ray confirmation. Two of the five insertion attempts did not have measurable ETCO 2 ; however, X-ray verification found the small-bore feeding tube to terminate in the right mainstem bronchus, validating the need for radiographic verification. Of the five insertion attempts not verified by abdominal X-ray, two resulted in the small-bore feeding tube coiling in the esophagus and required fluoroscopy for insertion. Additionally, one insertion was aborted after measurable ETCO 2 was detected with no other signs of intolerance.

Pulmonary complications including but not limited to pneumothoraxes and pneumonia from misplaced small-bore feeding tubes are well documented in the literature. 23 The intended goal of this QI project was to reduce pulmonary complications associated with blind bedside insertion of small-bore feeding tubes by incorporating ETCO 2 monitoring. This single-site QI project developed a procedure to detect improper placement of small-bore feeding tubes in the respiratory tract during blind insertion at the bedside.

The literature reveals that the use of capnography is not new, and previous studies have shown that while capnography has traditionally been used to assess the adequacy of ventilation, it can also be used to effectively detect small-bore feeding tube placement in the respiratory tract. Capnography represents a low-cost, simple, and easy-to-learn approach that can be performed at the bedside. 24 During the QI project period, 40 patients had small-bore feeding tubes placed using this technique. Capnography devices are readily available in critical and acute care settings and placing small-bore feeding tubes and interpreting ETCO 2 are not new skills for nurses to acquire. Requiring a CNS or nurse clinician to assist with all insertions was not realistic.

Once the new technique was formally approved by the hospital shared governance committees, the insertion procedure was updated in May 2022. In addition, the organization's education committee recognized the importance of having a competency checklist to train RNs in the placement of small-bore feeding tubes using this new technique, as a checklist such as this had not been formalized prior to this QI project. The use of a standardized competency model for feeding tube placement and verification helps to ensure consistent and correct performance of this procedure among all RNs inserting small-bore feeding tubes. 19

Starting September 26, 2022, additional RNs were trained based on unit need using the competency checklist. Units that had frequent insertion needs trained all RNs, whereas units that had infrequent insertions trained only RNs working in a charge nurse role. Five daylong sessions were scheduled over three weeks to provide the opportunity for competency completion. RNs registered for 20-minute time slots to receive the training and testing by simulating small-bore feeding tube placement on a manikin. Upon successful completion of the test, the competency checklist was signed and given to the nurse's unit educator as documentation of competency. It is intended that this competency be completed once and then repeated as needed. For newly hired RNs on units with a higher frequency of small-bore feeding tube insertion (such as critical care), this competency checklist is incorporated into their orientation and onboarding process. Competency sessions using a didactic and simulation-style environment were offered to RNs and were supervised by the original project team members who developed the process. Didactic material included review of the institution's updated small-bore feeding tube placement policy, contraindications for feeding tube placement, and observable indications of tracheal placement. During simulation experiences, participants inserted a small-bore feeding tube into a manikin following the steps in the competency checklist. If the nurse participating in the educational session was unsuccessful in completing the competency checklist, real-time correction and remediation was undertaken, and retesting was required. Remediation was required most often for failing to pause for the full 60 seconds to monitor for the presence of the ETCO 2 waveform. After the RNs completed the competency checklist under direct observation, they were able to independently place small-bore feeding tubes with capnography at the bedside.

Following the initial QI project period and implementation of the small-bore feeding tube insertion policy, 173 small-bore feeding tube insertions were attempted with 162 successful insertions involving 102 patients between May 1, 2022, and December 31, 2022. Although one tube was identified in the left bronchus on radiographic verification, no insertions resulted in lung perforation. Continued surveillance of adverse events associated with malposition of small-bore feeding tubes, including lung perforations, occurs monthly through the organization's event reporting system.

Limitations . Several limitations should be considered when attempting to understand the results of this project. The sample size was relatively small and the project was limited to a single site. There was variation in the tube size because of product supply limitations. Although the sample size was small and the duration of the project short, the practice change was implemented because of the absence of pulmonary complications. Nursing documentation had its limitations as well. The data had to be retroactively reviewed, as some initial documentation did not indicate whether the tube was small bore or large bore, so it is possible some data were missed. Difficulties with data collection also included the inability to determine in the electronic health record when capnography was used due to inconsistent documentation. The incidence of missed insertion attempts could not be accurately assessed because of the lack of documentation and may be underreported. The primary focus of the study was to decrease the incidence of lung perforations; however, the effect on nursing workflow and the culture of safety was not addressed. The authors recommend additional research on best practices and other insertion techniques. Future studies should focus on the incidence of success via different monitoring techniques at a larger facility over a longer time frame.

CONCLUSIONS

Although small-bore feeding tubes are traditionally placed at the bedside, there are risks to blind insertion. While the sample size of our study is small, results of this QI project confirm that sole reliance on signs of respiratory distress, such as cyanosis or severe coughing, is not adequate to evaluate small-bore feeding tube placement. Due to the success of this QI project, which met the goal of reducing pulmonary complications, use of capnography during blind small-bore feeding tube insertion became standard practice in our facility for adult patients. Literature evaluating the placement of small-bore feeding tubes includes not only capnography but also other methods to monitor insertion, such as electromagnetic imaging, fluoroscopy, or real-time camera guidance. These additional methods, however, can be costly and time intensive. The use of capnography can be a cost-effective method to help reduce inadvertent pulmonary placement during small-bore feeding tube insertions at the bedside.

• Cited Here |
• View Full Text | PubMed | CrossRef |
• Google Scholar
• PubMed | CrossRef |

capnography; enteral feeding; lung perforation; nasogastric tube; small-bore feeding tube

• + Favorites
• View in Gallery

Readers Of this Article Also Read

Addressing burnout, first over-the-counter oral contraceptive approved, nursing care for patients after urostomy surgery, advancing the primary health care mandate for nursing, writing your manuscript: structure and style.