Identify the type of quantitative research design used and explain how the researchers implemented the design.
Identify the type of quantitative research design used and explain how the researchers implemented the design
Evaluating Research Questions, Hypotheses, and Quantitative Research Designs
a critique of the research study in which you:
Evaluate the research questions and hypotheses using the Research Questions and Hypotheses Checklist as a guide
1.Identify the type of quantitative research design used and explain how the researchers implemented the design
2.Analyze alignment among the theory, problem, purpose, research questions and hypotheses, and design
Research Questions and Hypotheses Checklist
Use the following criteria to evaluate an author’s research questions and/or hypotheses.
Look for indications of the following:
•Is the research question(s) a logical extension of the purpose of the
•Does the research question(s) reflect the best question to address
•Does the research question(s) align with the design of the study?
•Does the research question(s) align with the method identified
for collecting data?
If the study is qualitative, does the research question(s)do as follows?
•Relate the central question to the qualitative approach
•Begin with What or How (not Why)
•Focus on a single phenomenon
•Use exploratory verbs
•Use no directional language
•Use an open-ended format
•Specify the participants and research site If the study is
•Do the descriptive questions seek to describe responses to major
•Do the inferential questions seek to compare groups or relate.
•Do the inferential questions follow from a theory?
•Are the variables positioned consistently from independent
/predictor to dependent/outcome in the inferential questions?
•Is a null and/or alternative hypothesis provided as a
•Is the hypothesis consistent with its respective research question?
•Does the question(s) and/or hypothesis specify the participants and
If the study is mixed methods, do the research questions and/or
hypotheses do the following?
•Include the characteristics of a good qualitative research question (as
•Include the characteristics of a good quantitative research and/or
hypothesis (as listed above)
•Indicate how the researcher will mix or integrate the two approaches
of the study
•Specify the participants and research site
•Convey the overall intent of the study that calls for a mixed method
Original Article Faculty Perception of the Effectiveness of EBP Courses for Graduate Nursing Students Ren´ata Zelen´ikov´a, RN, PhD•Michael Beach, DNP, ACNP-BC, PNP• Dianxu Ren, MD, PhD•Emily Wolff•Paula Sherwood, RN, PhD, CNRN, FAAN
Keywords evidence-based practice, faculty, teaching, curricula
ABSTRACT Background: Effective teaching is key in preparing students to become successful evidence- based healthcare professionals. The effectiveness of graduate evidence-based practice (EBP) pedagogy is not often a subject of research studies. Purpose: The purpose of this study was to determine how faculty from the 50 top graduate nursing schools in the United States perceived the effectiveness of EBP courses for graduate nursing students. Methods: A descriptive cross-sectional design was used to explore faculty perception of the effectiveness of EBP courses. A web-based survey was used for data collection. A total of 45 questionnaires were subjected to statistical analysis. Results: The mean perception of the effectiveness of EBP courses for the whole sample, on a scale from 1 to 7, was 5.58 (min. 4.29; max. 6.73), a higher score signifying higher perceived effectiveness. The highest rated item concerned a school’s access to different databases. The strongest correlations were found between the total score and the scores for items describing students’opportunitiestostrengthenandapplytheirEBPskills(rs=.66).Theinternalconsistency of the Perception of Effectiveness of EBP Courses scale, based on standardized Cronbach’s alpha, was .84, which signi?es strong internal consistency. Faculty perceived themselves as most competent at the following EBP skills: (a) “Asking questions regarding patients’ care” (6.56), (b) “Considering patient preferences when implementing EBP” (6.40), and (c) “Critically appraising the relevant body of evidence to address clinical questions” (6.40). Discussion: To strengthen the effectiveness of EBP courses, students should have more oppor- tunities to implement their EBP knowledge and skills after completing EBP courses. Linking EvidencetoAction:EvaluationoffacultyperceptionsoftheeffectivenessofEBPcourses can help to guide the development of nursing school curricula that better integrate EBP. Further evaluation of the psychometric properties of the instrument used to measure perception of the effectiveness of EBP courses is required along with objective measures of faculty knowledge and skills in teaching EBP.
BACKGROUND AND SIGNIFICANCE Worldwide, evidence-based practice (EBP) has emerged as a major healthcare initiative (Thiel & Ghosh, 2008). One of the most consistent ?ndings in health service research is the gap betweenbestpractice(asdeterminedbyscienti?cevidence)and actual clinical care (Flores-Mateo & Argimon, 2007). To accel- erate the translation of research ?ndings into clinical practice, two major outcomes must be achieved: (a) Advanced practice and direct care nurses must acquire suf?cient EBP knowledge and skills as well as strong beliefs about the value of EBP in clinicalsettings,and(b)educatorsmustteachtheirstudentsthe EBPprocesstoinstillinthemlifelongskillsandthemotivation todeliverthehighestqualityofcare(Melnyk,Fineout-Overholt, Feinstein, Sadler, & Green-Hernandez, 2008).
FindingsfromarecentnationalsurveybyMelnyk,Fineout- Overholt, Gallagher-Ford, and Kaplan (2012) indicated that nurses surveyed across the country are ready for and do value EBP.Themajorityofparticipantswhorespondedtothesurvey reportedwantingtogainmoreknowledgeandskillsinorderto deliver evidence-based care in their institutions. Nurses cited a top requirement for helping them implement EBP in daily practice as education. For students to become evidence-based healthcare profes- sionals, the teaching of EBP has to be effective (Spek, Wolf, Dijk, & Lucas, 2012). Little has been published about teach- ing EBP to nursing students (Stif?er & Cullen, 2010). Though therearesystematicreviewsandmeta-analysesofteachingEBP inschoolsofmedicine,thereisadearthofresearchinnursing,
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especiallyinregardtograduate-levelEBPpedagogy.According to Fineout-Overholt and Johnston (2005), further research is needed to assess effective teaching and evaluation strategies for EBP. Teaching EBP to nursing students is usually based on the basic steps of EBP. Melnyk and Fineout-Overholt (2011) added two more steps to the ?ve basic steps of EBP, which include: (a) cultivate a spirit of inquiry; (b) ask the burning clinical question in PICOT (P = patient population; I = intervention orareaofinterest;C=comparisoninterventionorgroup;O= outcomes; and T=time) format; (c) search for and collect the mostrelevantbestevidence;(d)criticallyappraisetheevidence; (e) integrate the best evidence with one’s clinical expertise and patient preferences and values in making a practice decision or change; (f) evaluate outcomes of the practice decision or change based on evidence; and (g) disseminate the outcomes of the EBP decision or change. The seven steps of EBP can serve as a structure around which to build EBP curriculum for graduate nursing students. The effectiveness of graduate EBP pedagogy is not often a subject of research studies. One of the problems is the com- plexity of the EBP process and the dif?culty of assessing all aspects of its effectiveness. Shaneyefelt and colleagues (2006) performed a systematic review of EBP instruments. Their re- sults showed that the majority of instruments targeted stu- dents and postgraduate trainees, whereas nonphysicians were rarely evaluated. The available instruments most commonly evaluatedEBPskills(predominantlyfocusingonthecriticalap- praisalofevidence),knowledge,attitudes,andbehaviors.Most instruments are designed for speci?c purposes, such as the evaluation of theoretical EBP courses (instruments to assess cognitive skills), or the evaluation of EBP in clinical practice (instruments to assess performance-based skills and applica- tion; Ilic, 2009). The instrument used in this study for measuring the per- ception of the effectiveness of EBP courses was inspired by the ARCC-E (advancing research and clinical practice through close collaboration and education) conceptual model for teaching EBP (Melnyk & Fineout-Overholt, 2011). This model shows that organizational support, the identi?cation of curricular strengths and barriers to teaching EBP and use of faculty EBP mentors play an important role in the effectiveness of EBP pedagogy. Based on this model, the parameters of effective EBP courses were set. The neces- sary conditions for successful EBP courses are: curricular strengths, organizational support, teachers’ mastery of EBP, and teachers’ involvement in EBP learning. In our instru- ment, we focused on the evaluation of the effectiveness of EBP courses from a faculty perspective. Therefore, items re- ?ected faculty perception of the integration of EBP in the curriculum, faculty involvement in learning and expectations they had of their students, mastery of subject matter, and or- ganizational support. The instrument for measuring faculty perception of their own and students’ competence in EBP skills was designed to
addressallsevenstepsoftheEBPprocessbasedonamodi?ed version of the list of EBP skills in Melnyk et al. (2008). EBP skills can be divided into three groups:
Skills related to the implementation and dissemina- tion of EBP (e.g., applying synthesized evidence to initiate change, mentoring/teaching EBP to others).
Skills in searching for and appraising evidence (e.g., searching ef?ciently for evidence, critically apprais- ing the relevant body of evidence to address clinical questions).
Skills relating to cooperation with the clinical envi- ronment (e.g., assessing the clinical environment for readiness for EBP, asking questions regarding pa- tients’ care).
Teacher competency is one of the most important factors in the learning process. To be able to deliver EBP knowledge and skills properly, faculty have to be experts in these skills. However,thereisalackofstudiesfocusingonthecompetence of teachers of EBP courses and on how they perceive their own EBP skills. It is not well known how competent graduate nursing faculty members are in EBP knowledge and skills. This study focuses particularly on faculty perception of the effectiveness of EBP courses and faculty perception of their own competence in EBP skills. Inclusion of a core EBP course ingraduatenursingcurriculaisessentialtoestablishingafoun- dationfromwhichEBPknowledgeandskillscanbefurtherde- veloped in the remainder of the students’ didactic and clinical coursework (Melnyk et al., 2008). Evaluation of the effective- ness of EBP courses can inform the improvement of future programs. Three main research questions guided this study:
(1) What are faculty perceptions of the effectiveness of EBP courses for graduate nursing students?
(2) What are faculty perceptions of their own compe- tence in EBP skills?
(3) As judged by their teachers, how competent in EBP skillsarestudentsuponcompletionofEBPcourses?
PURPOSE Thepurposeofthisdescriptivecross-sectionalstudywastode- termine how faculty from the 50 top graduate nursing schools intheUnitedStatesperceivedtheeffectivenessofEBPcourses for graduate nursing students.
METHODS Study Design and Methods A descriptive cross-sectional design was used to explore per- ception of the effectiveness of EBP courses and perception of competence in EBP skills. A web-based survey was used
402 Worldviews on Evidence-Based Nursing, 2014; 11:6, 401–413. C 2014 Sigma Theta Tau International
for data collection. Data collection was conducted by sending potential respondents an e-mail with a hyperlink to the web- basedsurvey.Facultymembersagreeabletoparticipatingwere required to click on the link in the e-mail directing them to a study-speci?c, secured Survey Monkey website. The website consisted of a questionnaire that was developed by the investi- gatorstoassessperceptionsoftheeffectivenessofEBPcourses and perceptions of EBP skills. The questionnaire took approx- imately 5–10 minutes to complete.
Sample and Data Collection The sample population consisted of faculty from the top 50 graduate nursing schools across the United States according to the Top Universities in U.S. website (http://www.university-list.net/us/rank/univ-20131118.htm), who taught EBP courses for graduate nursing students. Sixty-two nursing schools were contacted through their deans’of?ces.E-mailsweresenttothedeans.Eache-mailcon- tainedacoverletteraddressedtothedeanandacoverletterfor facultymembersinvolvedinteachingEBPcourses.Deanswho wereagreeabletotheirfacultyparticipatinginthestudywerere- questedtoforwardane-mailincludingthelattercoverletterand astudy-speci?c,secure,andde-identi?edlinktotheweb-based survey to faculty members involved in teaching EBP courses. Deansof?venursingschoolsdidnotagreetotheirfacultypar- ticipating in the study. E-mails were sent only once. Data were collected from the middle of January 2013 through the middle of March 2013. The study was conducted in three steps. Step 1: Development of a questionnaire for evaluating the effectiveness of teaching EBP in nursing. The survey items weredevelopedbytheauthors.Surveyitemswerederivedfrom theliteratureandfromtheauthors’teachingexperiences.Items measuringperceptionoftheeffectivenessofEBPcourseswere devised in consultation with an expert from the Center for InstructionalDevelopmentandDistanceEducationattheUni- versity of Pittsburgh. The survey was comprised of the following sets of ques- tions:
(1) Fifteen questions on the survey employed a scale of 1(strongly disagree) to 7 (strongly agree) to assess per- ception of the effectiveness of EBP courses. These questions covered four areas: perception of the in- tegration of EBP in the curriculum, faculty involve- ment in EBP learning and the expectations they had ofstudents,masteryofsubjectmatter,andorganiza- tional support.
(2) Fourteenquestionsincludedinthesurveyemployed ascaleof1(notatallcompetent)to7(extremelycompe- tent) to assess faculty perceptions of their own com- petenceinEBPskills.AlistofEBPskillswasadapted fromMelnykandcolleagues(2008)withtheconsent of the ?rst author. The list of skills did not include those with an immediate bearing on patient care.
These skills were added following an analysis of the de?nition of EBP by the researchers, and re?ected a consensus reached among them. Besides this modi- ?cation,someitemsontheoriginallistwereomitted and others were paraphrased to make the question- naire more accessible to participants.
(3) Fourteen questions employed a scale of 0 (not well at all) to 7 (extremely well) to measure faculty per- ceptions of students’ competence in EBP skills af- ter completing EBP courses. Faculty members were asked how well students who had completed EBP courses had mastered a speci?c set of EBP skills. The list of EBP skills was the same as the list of EBP skills for faculty.
(4) Samplecharacteristics (e.g., gender,age, years of ex- perience teaching EPB courses, number of years as a faculty member, and training in teaching EBP).
(5) Questions regarding teaching strategies (e.g., barri- ers to teaching EBP, the most important EBP skills to focus on).
Once the survey items were developed, they were reviewed for content validity and clarity by an interdisciplinary group of EBP experts. Step2:Conversionofpapersurveytoweb-basedsurveyand pilottesting. Thepapersurveywasconvertedtoawebversion and piloted by the authors and several colleagues. Issues and limitations with the design of the web-based survey were dis- cussedwithintheresearchteamandmodi?cationsweremade to increase ease of use. Step 3: Web-based survey. Questionnaires were completed online via SurveyMonkey, which keeps data private, safe, and secure.
ETHICAL CONSIDERATIONS Approval was obtained from the Institutional Review Board of theUniversityofPittsburghpriortoparticipantrecruitment.A cover letter explaining the aim of the study was attached to all surveys.Thecoverletteralsoaddressedthevoluntarynatureof thesurveyandguaranteedcon?dentialitytothefullestpossible extent. Completing the questionnaire served as a participant’s consenttotakepartintheresearchstudy.Thetotaldurationof subjectparticipationwasthetimetakentocompleteaone-time questionnaire.
STATISTICAL ANALYSIS Descriptive statistics were used to describe the sample char- acteristics and perceptions of effectiveness of EBP courses as well as perceptions of competence in EBP skills. The Spear- man Correlation coef?cient was used to examine the correla- tionbetweenthetotalscorefortheinstrumentandthescorefor eachitem.ReliabilityofthescalewasmeasuredbyCronbach’s
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Alpha. Interitem correlations were calculated and an item- totalanalysiswasperformed.TheKaiser-Meyer-OlkinMeasure of Sampling Adequacy and Bartlett’s Test of Sphericity were conducted before factor analysis. Factor analysis (extraction method: principal component analysis) with Varimax rotation was performed. Statistical analyses were conducted using the Statistical Package for the Social Sciences 16.0 for Windows (SPSS, Chicago, IL, USA).
RESULTS Fifty-seven nursing schools deemed likely to agree to partici- pate were contacted. In response, 74 questionnaires from fac- ulty were received, though not all of them were complete. A total of 45 completed questionnaires (60%) had less than 5% ofthedatamissingandwereusedinthestatisticalanalysis.The majorityofparticipantswereinvolvedinteachingEBPcourses. Approximatelytwo-thirdsoftheparticipantswereteachingEBP courses for graduate students (62.3%), others were teaching EBP courses for both graduate and undergraduate students (15.5%), or were teaching EBP courses for undergraduate stu- dents (13.3%), or else included EBP content in other courses (8.9%). Of the entire sample, 42 (93.3%) participants were fe- male and 3 were male (6.7%). The largest segment of the sam- ple, 24 (53.4%), were 56 years old or older, whereas 15 (33.3%) were 46–55 years old. More than 80% of those surveyed had been faculty members for more than 6 years. Approximately two-thirds of participants had been teaching EBP courses for 4 or more years. Of all the participants, 30 (66.7%) cited self- studyastheirprimarytrainingintheteachingofEBP,whereas 12 (26.7%) received several days of training, and 3 (6.6%) of the participants used online training (see Table 1).
Teaching Strategies Faculty from the top 50 graduate nursing schools across the United States cited lectures (n = 32; 71.1%), projects (n = 32; 71.1%), group work (n = 31; 68.9%), computer-based teach- ing strategies (n = 26; 57.8%), training students to critically appraise a published article (n=26; 57.8%), and training stu- dents to develop clinical protocols (n = 8; 17.8%) as the most frequently used teaching strategies in EBP courses. The num- ber of students enrolled in EBP courses was 5–20 (n = 21; 46.6%), 21–40 students (n=12; 26.7%), and 41 or more (n= 12; 26.7%).
Barriers to the Teaching of EBP The main barriers to the teaching of EBP identi?ed by faculty were (a) time (n = 8) “limited class time and competition for thattimewithsomanyotherskillsandtheory,”(b)insuf?cient statisticalandresearchbackgroundofstudents(n=5),(c)lack of faculty experts in the area of EBP (n=4), and (d) large class size (n=3).
The Most Important EBP Skills to Teach According to our sample, the most important EBP skills to focus on when teaching EBP courses are:
Critically appraising the relevant body of evidence to address clinical questions (n=37; 82.2%); Searching ef?ciently for evidence that answers the clinical questions (n=29; 64.4%); Synthesizing evidence to make decisions about pa- tient care (n=27; 60%); Formulating searchable, answerable clinical ques- tions in PICOT format (n=24; 53.3%); Selecting the best evidence from what is found in the search (n=21; 46.7%); Analyzingoutcomesofevidence-based interventions, practice changes, and clinical guidelines (n = 20; 44.4%).
Perception of the Effectiveness of EBP Courses The mean perception of the effectiveness of EBP courses mea- sured on a scale from 1 to 7 was 5.58 (s2 0.45; min. 4.29; max. 6.73)forthewholesample,andthemeanperceptionoffaculty competence in EBP skills was 6.16 (s2 0.06; min. 5.73; max. 6.56). In both cases, a higher score signi?es higher perceived effectiveness or competency (see Table 1). Reliability. The interitem correlations of the 15 items ranged from-.16to.98,withthemajoritybeingaround.40.Theinter- nalconsistencyofthescale,basedonstandardizedCronbach’s alpha,was.84,whichsigni?esstronginternalconsistency.The item-totalanalysisshowedarangeforCronbach’salphaifitem deleted from .81 to .85, showing that every item contributes to the overall reliability. Factor analysis of perception of the effectiveness of EBP courses. A factor analysis (extraction method: principal com- ponentanalysis)withVarimaxrotationinSPSSwasperformed on the 15 items of the Perception of the Effectiveness of EBP Courses scale. A ratio of 3:1 (subject-to-variables) was used in the sample. The minimum sample size according to Mund- from, Shaw, and Ke (2005), with good level for variables-to- factors ratio set at seven and the number of factors set at three, is 40–65. The Kaiser-Meyer-Olkin Measure of Sam- pling Adequacy was .647, above the .6 suggested minimum. Bartlett’s Test of Sphericity was signi?cant (<.001). Four fac- tors emerged with eigenvalues over 1.0 (5.47; 2.44; 1.34; 1.2). The results for the four factors can be found in Table 2. The ?rst factor explains 36.3% of the variance; the second fac- tor explains 16.3% of the variance; the third factor explains 8.9% of the variance, and the fourth factor explains 8% of the variance. The ?rst factor, labeled “Integration EBP in cur- riculum,” contains ?ve items and assesses a school’s commit- ment to teaching EBP, the integration of EBP concepts in the
404 Worldviews on Evidence-Based Nursing, 2014; 11:6, 401–413. C 2014 Sigma Theta Tau International
Table 1. Sample Characteristics (n=45)
Characteristics n %
Gender Female 42 93.3 Male 3 6.7 Age 36–45years 6 13.3 46–55years 15 33.3 56orover 24 53.4 Yearsasafacultymember 1–5years 8 17.8 6–10years 12 26.7 11–20years 9 20 21–30years 9 20 31ormoreyears 7 15.5 EBPcoursestaught Forgraduatestudents 28 62.3 Forundergraduatestudents 6 13.3 Forgraduateandundergraduatestudents 7 15.5 Asapartofothercourses 4 8.9 YearsofteachingEBPcourses 1–3years 15 33.3 4–6years 13 28.9 7–10years 8 17.8 11ormoreyears 5 11.1 Notapplicable 4 8.9 TraininginteachingEBP Self-study 30 66.7 Severaldaysoftraining 12 26.7 Onlinetraining 3 6.6 SourcesusedforprimarytraininginEBP Readingjournals 34 75.6 Readingtextbooks 31 68.9 Conferences 22 48.9 Conversationswithotherinstructors 18 40 Workshops 13 28.9 Webinars 11 24.4 Onlinetutorials 11 24.4 Mean(s2) Min;Max(range) PerceptionofeffectivenessofEBPcourses(numberofitems:15) 5.58(.45) 4.29;6.73(2.44) PerceptionoffacultycompetenceinEBPskills(numberofitems:14) 6.16(.06) 5.73;6.56(.82)
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Table 2. The 15 Items of “Perception of the Effectiveness of EBP Courses Scale” Arranged According to Four Factor Model (n=45)
Factor1—IntegrationEBPincurriculum(?veitems) ItispartofthephilosophyormissionofmyschooltoteachEBP 0.678 EBPconceptsareintegratedinthecurriculumofmyschool 0.799 MyschoolsupportsteachingEBPinseparateEBPcourses 0.767 MyschoolsupportsteachingEBPinothercourses(i.e.,clinicalcourses) 0.794 StudentscompletingEBPcoursestypicallyhaveopportunitieselsewhereinthecurriculumtostrengthen andapplytheirEBPskills 0.522 Factor2—Teacher’sinvolvementinEBPlearningandexpectations(?veitems) IserveasanEBPmentortootherhealthcareprofessionals 0.662 IwouldliketoserveasanEBPmentortootherhealthcareprofessionals 0.803 IhavehighexpectationsofwhatgraduatenursingstudentscanachieveinEBPcourses 0.671 EBPcoursesareveryusefulforgraduatenursingstudents 0.638 GraduatenursingstudentsviewEBPcoursesfavorablyincomparisontoothercourses 0.716 Factor3—Teachers’mastery(threeitems) TherearelibrarianswhohaveEBPknowledgeinvolvedinteachingEBPcourses 0.430 Ihavesuf?cientknowledgeofEBP 0.895 IhaveadequateEBPskills 0.916 Factor4—Organizationalsupport(twoitems) Myschoolhasaccesstodifferentsearchdatabases(i.e.,PubMed,CINAHL) 0.882 EducatorsfrommyschoolcooperatewithhealthcareinstitutionstoincorporateEBPinclinicalpractice 0.474
curriculum,support forteachingEBPinseparate EBPcourses and as part of other courses, and students’ opportunities for strengthening and applying EBP skills in the curriculum. The second factor, labeled “Teacher’s involvement in EBP learning and expectations,” contains ?ve items and assesses EBP men- torship and willingness to serve as an EBP mentor to other healthcare professionals, perception of the popularity and use- fulness of EBP courses for graduate nursing students, and faculty expectations concerning student achievement in EBP courses.Thethirdfactor,labeled“Teacher’smastery,”contains threeitemsandassessesperceptionofknowledgeandskills,as well as librarians’ involvement in teaching EBP courses. The fourth factor, labeled “Organizational support,” contains two items and assesses a school’s access to different databases and the cooperation of its personnel with healthcare institutions. Perception of the effectiveness of EBP courses was mea- sured using a 15-item instrument (Perception of the Effective- ness of EBP Courses scale). Respondents were asked to rate on a scale of 1 (strongly disagree) to 7 (strongly agree) how they
perceivedtheeffectivenessofEBPcoursesforgraduatenursing students.Theaveragetotalscoreforperceptionoftheeffective- nessofEBPcoursesforallitemswas84.76(SD12.14;min.46; max. 105), with 105 a maximum possible score (the potential range was 15 to 105). Thehighestrateditemwas,“Myschoolhasaccesstodiffer- entsearchdatabases”(6.73).Otherhighlyrateditemswerethe following: “EBP courses are very useful for graduate nursing students” (6.51), and “I have high expectations of what gradu- ate nursing students can achieve in EBP courses” (6.16). The item“IserveasanEBPmentortootherhealthcareprofession- als” was ranked the lowest (4.29), with the item “I would like to serve as an EBP mentor to other healthcare professionals” ranked just above it (4.36; see Table 3). All correlations between the score for each item and the total score for perception of the effectiveness of EBP courses werepositive.Theweakestcorrelation(.28)wasfoundbetween thescorefortheitem“Myschoolhasaccesstodifferentsearch databases”andthetotalscore.Thiswastheonlynonsigni?cant
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Original Article Table 3. Perception of Effectiveness of EBP Courses for Graduate Nursing Students (n=45)
Statement Mean* Range SD
Myschoolhasaccesstodifferentsearchdatabases(i.e.,PubMed,CINAHL) 6.73 4—7 .75 EBPcoursesareveryusefulforgraduatenursingstudents 6.51 4—7 .82 IhavehighexpectationsofwhatgraduatenursingstudentscanachieveinEBPcourses 6.16 3—7 1.07 ItispartofthephilosophyormissionofmyschooltoteachEBP 6.02 2—7 1.36 StudentscompletingEBPcoursestypicallyhaveopportunitieselsewhereinthecurriculumtostrengthenand applytheirEBPskills 5.80 3—7 1.25 MyschoolsupportsteachingEBPinothercourses(i.e.,clinicalcourses) 5.69 1—7 1.49 EBPconceptsareintegratedinthecurriculumofmyschool 5.69 1—7 1.52 IhaveadequateEBPskills 5.60 1—7 1.34 TherearelibrarianswhohaveEBPknowledgeinvolvedinteachingEBPcourses 5.58 1—7 1.90 Ihavesuf?cientknowledgeofEBP 5.49 1–7 1.44 EducatorsfrommyschoolcooperatewithhealthcareinstitutionstoincorporateEBPinclinicalpractice 5.29 1—7 1.63 MyschoolsupportsteachingEBPinseparateEBPcourses 5.27 1—7 1.80 GraduatenursingstudentsviewEBPcoursesfavorablyincomparisontoothercourses 5.24 2—7 1.40 IwouldliketoserveasanEBPmentortootherhealthcareprofessionals 4.36 1—7 2.12 IserveasanEBPmentortootherhealthcareprofessionals 4.29 1—7 2.16
*1( stronglydisagree )to7( stronglyagree ).
correlation.Thestrongestcorrelationswerefoundbetweenthe total score and the scores for items describing (a) students’ opportunities to strengthen and apply their EBP skills (.66), (b) the incorporation of EBP education as part of the mission of the school (.66), (c) students’ attitude to EBP courses (.64), (d) teachers’ high expectations of what students can achieve in EBP courses (.64), (e) adequacy of teachers’ knowledge (.61) of EBP and adequacy of their EBP skills (.59), and (f) whether librarians were involved in teaching EBP courses (.55).
Perception of Faculty Competence in EBP Skills Perception of faculty competence in EBP skills was measured usinga14-iteminstrument.Ascaleof1(not at all competent)to 7(extremely competent) was employed. The average total score for perception of the effectiveness of EBP courses was 83.71 (SD 12.6; min. 52; max. 98), with 98 the maximum score (the potential range was 14–98). Reliability. The initial testing of the 14 items comprising the Perception of Competence in EBP Skills scale was conducted with a group of 45 faculty from the 50 top nursing graduate schools across the United States. The interitem correlations of the 15 items ranged from .08 to .95, with the majority being around .50. The reliability analysis yielded a Cronbach’s alpha coef?cient of .93. The item-total analysis showed a range for
Cronbach’salpha ifitem deletedfrom.92to.94,showingthat every item contributes to the overall reliability. Factor analysis of the perception of competence in EBP skills scale. A factor analysis (extraction method: principal component analysis) with Varimax rotation in SPSS was per- formed on the 14 items of the Perception of Faculty Compe- tence in EBP Skills scale. The Kaiser-Meyer-Olkin Measure of Sampling Adequacy was .818. Bartlett’s Test of Sphericity was signi?cant (<.001). Three factors (see Table 4) emerged with eigenvalues over 1.0 (7.76; 1.84; 1.23). The ?rst factor explained 55.5% of the variance; the second factor explained 13.2% of the variance; the third factor explained 8.8% of the variance. The ?rst factor, labeled “Skills for Implementation andDissemination,”containedsixitemsandassessedtheabil- ity to challenge current institutional or unit-based practices, to apply synthesized evidence to initiate change, to analyze the outcomes of evidence-based interventions, to mentor others in EBP, to communicate best evidence to the patient, and to consider patient preferences when implementing EBP. The second factor, labeled “Skills for Searching and Appraising Evidence,” contained four items and assessed the ability to ef- ?ciently search for evidence that answers clinical questions, to select the best evidence, critically appraise the evidence and synthesize it to make decisions about patient care. The third
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Table 4. The 14 Items of “Perception of Faculty Competence in EBP Skills Scale” Arranged According to the Three Factor Model (n=45)
Factor1—SkillsforimplementationanddisseminationEBP(sixitems) Challengingcurrentinstitutionalorunit-basedpractices 0.847 Applyingsynthesizedevidencetoinitiatechange 0.792 Analyzingoutcomesofevidence-basedinterventions,practicechanges,andclinicalguidelines 0.753 Mentoring/teachingtheEBPprocesstoothers 0.528 Communicatingbestevidencetothepatient 0.790 ConsideringpatientpreferenceswhenimplementingEBP 0.794 Factor2—Skillsforsearchingandappraisingtheevidence(fouritems) Searchingef?cientlyforevidencethatanswerstheclinicalquestions 0.849 Selectingthebestevidencefromwhatisfoundinthesearch 0.885 Criticallyappraisingtherelevantbodyofevidencetoaddressclinicalquestions 0.922 Synthesizingevidencetomakedecisionsaboutpatientcare 0.873 Factor3—Skillsforcooperationwithclinicalenvironment(fouritems) Askingquestionsregardingpatients’care 0.452 Formulatingsearchable,answerableclinicalquestionsinPICO(TS)format 0.899 AssessingtheclinicalenvironmentforreadinessforEBPaswellasbarrierstoandfacilitatorsofEBP 0.555 Communicatingbestevidencetoindividuals,groups,colleagues,themedia,andpolicymakers 0.772
factor, labeled “Skills for Cooperation with the Clinical Envi- ronment,” contained four items and assessed the ability to ask questions regarding patient care, to formulate clinical ques- tions in PICO (TS) format, to assess the clinical environment for readiness for EBP, and to communicate best evidence to individuals, groups, colleagues, media, and policymakers. The factor analysis showed suf?cient validity to justify using the instrument for evaluating the effectiveness of EBP courses. Faculty perceived themselves as most competent at the fol- lowingEBPskills:(a)askingquestionsregardingpatients’care (6.56), (b) considering patient preferences when implement- ing EBP (6.40), and (c) critically appraising the relevant body of evidence to address clinical questions (6.40). Participants from our sample felt least competent at (a) assessing the clini- calenvironmentforreadinessforEBPaswellasbarrierstoand facilitators of EBP (5.73); (b) communicating best evidence to individuals, groups, colleagues, the media, and policymakers (5.84); and (c) mentoring/teaching the EBP process to others (5.93) (see Table 5). All correlations between the total EBP competency score and the score for each item of the instrument were positive and statistically signi?cant at the .01 level. The total score for
perception of competency in EBP skills correlated most strongly with the following items: (a) communicating best ev- idence to individuals, groups, colleagues, the media, and pol- icymakers (.90); (b) applying synthesized evidence to initiate change (.87); (c) analyzing outcomes of evidence-based inter- ventions, practice changes, and clinical guidelines (.85); and (d) assessing the clinical environment for readiness for EBP as well as barriers to and facilitators of EBP (.83). This means thatparticipantswhoratedtheseitemsmorehighlyhadhigher total scores for perception of their competency in EBP skills. All the above-mentioned items with the strongest correlations were items rated lower in the sample. Even though the scores were lower, they were still quite high.
Perception of Students’ Competence in EBP Skills After Completing EBP Courses Perception of students’ competence in EBP skills was mea- sured using a 14-item instrument. A scale of 1 (not well at all) to 7 (extremely well) was employed (Table 6). The highest rated itemswere:(a)askingquestionsregardingpatients’care(mean 5.60);(b)formulatingsearchable,answerableclinicalquestions inPICO(TS)format(5.40);(c)searchingef?cientlyforevidence
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Table 5. Perception of Faculty Competence in EBP Skills (n=45)
Howcompetentdoyoufeelat: Mean* SD Range
Askingquestionsregardingpatients’care 6.56 .69 4–7 ConsideringpatientpreferenceswhenimplementingEBP 6.40 .78 4–7 Criticallyappraisingtherelevantbodyofevidencetoaddressclinicalquestions 6.40 .89 2–7 Searchingef?cientlyforevidencethatanswerstheclinicalquestions 6.36 .80 3–7 Synthesizingevidencetomakedecisionsaboutpatientcare 6.36 .96 2–7 Selectingthebestevidencefromwhatisfoundinthesearch 6.33 .91 2–7 Formulatingsearchable,answerableclinicalquestionsinPICO(TS)format 6.13 1.33 2–7 Analyzingoutcomesofevidence-basedinterventions,practicechanges,andclinicalguidelines 6.11 1.11 2–7 Challengingcurrentinstitutionalorunit-basedpractices 6.09 .97 3–7 Communicatingbestevidencetothepatient 6.07 1.19 2–7 Applyingsynthesizedevidencetoinitiatechange 5.98 1.22 2–7 Mentoring/teachingtheEBPprocesstoothers 5.93 1.18 2–7 Communicatingbestevidencetoindividuals,groups,colleagues,themedia,andpolicymakers 5.84 1.24 2–7 AssessingtheclinicalenvironmentforreadinessforEBPaswellasbarrierstoandfacilitatorsofEBP 5.73 1.30 2–7
*1( notatallcompetent )to7( extremelycompetent ).
that answers the clinical questions (5.40); and (d) considering patient preferences when implementing EBP (5.33). Accord- ing to the faculty surveyed, students who have completed EBP courses are least competent at “Mentoring/teaching the EBP process to others” (3.93).
DISCUSSION This paper focused on faculty perception of the effectiveness of EBP courses and on faculty perception of their own and graduate students’ competence in EBP skills. Although the sample size is small, it was designed to target the top graduate nursing schools where EBP is treated as a curricular priority. Theresultsofthestudyindicatethatfacultymembersperceive EBP courses as effective. The highest rated item on the scale measuring perception of the effectiveness of EBP courses was the one concerning a school’s access to different databases. Without technical sup- port,teachingEBPcourseswouldnotbeaseffective.However, thissupportisnottheonlyimportantfactor.Theincorporation of the teaching of EBP as an integral part of the mission of the school, teachers’ belief that EBP courses are very useful for graduate nursing students, as well as teachers’ high expecta- tions of what nursing students can achieve in EBP courses are also important elements in?uencing the effectiveness of EBP courses. All of these items were assigned the highest ratings. Another sign of the effectiveness of university courses is that
upon completing EBP courses, students are able to strengthen and apply their EBP skills, mostly in clinical courses. Imple- mentation of the EBP concept in clinical courses can help students work on skills necessary for EBP implementation in healthcare institutions. Though not viewing them as favorably as faculty, graduate students themselves perceived the useful- nessofEBPcoursesrelativetoothercourses,atleastaccording to the faculty in our study sample. The lowest rated item was, “I serve as an EBP mentor to other healthcare professionals” and the second lowest rated item was “I would like to serve as an EBP mentor to other healthcare professionals.” Both items were rated around the neutral position. “Mentoring/teaching the EBP process to oth- ers” was the third lowest rated competence. It seems that EBP mentoring is one of the weaknesses cited by our sample. The reasons why faculty do not serve and would not like to serve as EBP mentors were not examined. It may be hypothesized that lack of time is the main barrier. Nonetheless, mentoring continues to be an effective educational strategy that develops and enhances competence (Schroeter, 2009). Mentoring also hasbeenidenti?edascriticalintheARCCModeltosustaining EBP (Melnyk, 2007). Mentors who help guide nursing staff toward a greater understanding of professional dissemination andpublishingstandardscontributetotheprofessionalgrowth of the individual staff member and the discipline as a whole (Jeffers, Robinson, Luxner, & Redding, 2008).Nursing faculty
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Table 6. Perception of Students’ Competence after Completion of EBP Courses (n=45)
HowwellhavestudentsmasteredthefollowingEBPskillsuponcompletionofEBPcourses? Mean* SD
Askingquestionsregardingpatients’care 5.60 .84 Formulatingsearchable,answerableclinicalquestionsinPICO(TS)format 5.40 1.31 Searchingef?cientlyforevidencethatanswerstheclinicalquestions 5.40 .93 ConsideringpatientpreferenceswhenimplementingEBP 5.33 1.19 Selectingthebestevidencefromwhatisfoundinthesearch 5.28 1.03 Communicatingbestevidencetothepatient 5.14 1.19 Criticallyappraisingtherelevantbodyofevidencetoaddressclinicalquestions 5.07 1.03 Synthesizingevidencetomakedecisionsaboutpatientcare 5.02 1.10 Analyzingoutcomesofevidence-basedinterventions,practicechanges,andclinicalguidelines 4.93 1.24 Challengingcurrentinstitutionalorunit-basedpractices 4.81 1.33 Applyingsynthesizedevidencetoinitiatechange 4.72 1.35 AssessingtheclinicalenvironmentforreadinessforEBPaswellasbarrierstoandfacilitatorsofEBP 4.56 1.45 Communicatingbestevidencetoindividuals,groups,colleagues,themedia,andpolicymakers 4.51 1.06 Mentoring/teachingtheEBPprocesstoothers 3.93 1.35
*1( notatallwell )to7( extremelywell ).
mentors serve as important agents for facilitating EBP in com- plex healthcare environments (Jeffers et al., 2008). According to Roe and Whyte-Marshall (2012), development of partner- ships between academia and clinical practice is one way to promote EBP. The selection of instructors is critical to the success of an EBP course. Their quali?cations should include knowledge of the subject being taught, a desire to teach, the ability to communicate, and skill at getting people to participate (Kirk- patrick, 1998). They should also be “learner-oriented”—have a strong desire to meet learner need. Among the most en- couraging results of this research are the high expectations entertained by faculty of what students can achieve in EBP courses. This can be considered a sign of learner-oriented teaching. An interesting ?nding of this study is the slightly higher rating received by the item “I have adequate EBP skills” as compared to that received by the item “I have suf?cient EBP knowledge.” The teachers’ overall perception of the effectiveness of EBP courses for graduate nursing students is associated with items describing the students’ opportunities to strengthen and apply their EBP skills elsewhere in the curriculum after completing EBP courses, school support for teaching EBP courses (teach- ing EBP being a part of the philosophy and mission of the school, EBP concepts being integrated into the curriculum of
theschool),andadequacyofteachers’knowledgeofEBPandof their EBP skills. In contrast, knowing that a school has access to different databases does not signi?cantly predict the effec- tiveness of EBP courses. The effectiveness of EBP courses was associated with suf?cient motivation, support, and practice. The strongest correlation was found between the total score and the score for the item “Students completing EBP courses typically have opportunities elsewhere in the curriculum to strengthen and apply their EBP skills.” One of the research- based principles for effective teaching—“How students orga- nizeknowledgein?uenceshowtheylearnandapplywhatthey know” (Ambrose, Bridges, Lovett, DiPietro, & Norman, 2010, p. 44)—can help to explain this. Faculty perception of the effectiveness of EBP courses is also re?ected in their evaluation of the EBP skills students ac- quired during their courses. Faculty perception of students’ EBP skills was measured after these courses had been com- pleted. Even though faculty considered “Critically appraising the relevant body of evidence to address clinical questions” as the most important skill to focus on when teaching EBP, this skill was not among the top ?ve skills students mastered upon completion of EBP courses, as perceived by our faculty sample. Students were deemed most competent at (a) “Asking questions regarding patients’ care,” (b) “Formulating search- able, answerable clinical questions in PICO(TS) format,” and (c) “Searching ef?ciently for evidence that answers the clinical
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questions.” These three EBP skills are the skills that are most effectively developed by EBP courses. Another focus of the study was faculty members’ percep- tions of their own competence in EBP skills. Competence can be broadly de?ned as incorporating a variety of domains, in- cludingknowledge,skills,andattitudes.Assessingcompetence in EBP can be dif?cult due to the diverse cognitive skills and knowledge that must be tested (Ilic, 2009). Apart from knowl- edge, skills, and attitudes, EBP competence also incorporates the ability to work as a team member and to communicate effectively. The competence of nursing teachers is important for the quality of nursing education. There are few studies fo- cusing on the competence and evaluation of nursing teachers. The reasons are the lack of valid instruments for evaluation and the diversity of functions of nursing teachers (Schroeter, 2009). The results of this study indicate that faculty felt most competentattheseEBPskills:(a)“Askingquestionsregarding patient’s care,” (b) “Considering patient preferences when im- plementing EBP,” (c) “Critically appraising the relevant body of evidence to address clinical questions,” (d) “Searching ef?- cientlyforevidencethatanswerstheclinicalquestions,”and(e) “Synthesizing evidence to make decisions about patient care.” Faculty reported feeling less competent at communicating bestevidencetoinitiatechange;mentoringorteachingtheEBP processtoothers;communicatingbestevidencetoindividuals, groups,colleagues,themedia,andpolicymakers;andassessing theclinicalenvironmentforreadinessforEBP.Allitemsreceiv- ing lower ratings were connected with the EBP steps focusing on implementation of EBP in the clinical setting. Even though the lowest rated items were rated fairly high, there is room for facultydevelopmentandstrengtheningofskillsintheseareas. Even though faculty are able to attend some EBP workshops, most often these workshops are intended to develop skill in de?ning a clinical question, conducting an ef?cient search, and critically appraising studies (Ciliska, 2005). The ideal cur- riculum revision is to integrate EBP across courses. Curricula at graduate nursing schools can be restructured so that more hoursaredevotedtoteachingtheimplementationofEBPinthe clinicalsetting.ImplementationofEBPisin?uencedbyclinical and institutional factors, and it is dif?cult to teach this step of EBP because implementation takes years to realize. Nonethe- less, graduate nursing students can be required to outline an implementation plan as one of their assignments. There are a variety of instruments for evaluating the teach- ingofEBP.Mostoftheseinstrumentshavefocusedoncritically appraisingtheliteratureandsearchingef?cientlyforevidence. In their systematic review, Shaneyfelt and colleagues (2006) foundthatinstrumentsusedtoevaluateEBP,whichweremost commonlyadministeredtomedicalstudentsandpostgraduate trainees, evaluated skills in searching for and appraising ev- idence. Therefore, there is a need to evaluate competence in applying evidence to individual patient decision making, con- sidering the evidence (customized for the patient), clinical cir- cumstances, and patient preferences (Shaneyfelt et al., 2006).
It can be interpreted that most of the participants perceive themselves as competent in EBP skills. EBP skills are very comprehensive and dif?cult to measure. In addition, the in- strument evaluating the effectiveness of EBP teaching is fo- cused on asking questions regarding patient care, the critical appraisal of the relevant body of evidence to address clinical questions, and the ef?ciency of the search for evidence that answers clinical questions, rather than on skills such as com- municationofbestevidencetoindividuals,groups,colleagues, the media, and policymakers. The self-evaluation of faculty competency in EBP skills in our sample was very high (6.16 from 7). In comparison, the 40 faculty members in the study by Stichler, Fields, Kim, and Brown (2011) did not rate their knowledge and skills and prac- tice of EBP as positively, although they had a positive attitude towardEBP.Oneofthereasonswhyfacultyinoursamplemay have perceived themselves as highly competent was that all re- spondentswerefromthebestU.S.nursinguniversities,where teachingEBPispartofthephilosophyormissionoftheschool and where research is excellent. Even though two-thirds of the sample cited self-study as their primary training in teaching EBP,andonlyone-thirdcitedseveraldaysoftrainingoronline training,facultyfromtopU.S.universitiesperceivethemselves to be competent to teach EBP courses.
Study Limitations The main limitation is the small nonrandomized sample size offacultyfromthetop50nursingschools,whichpreemptsour generalizingthe?ndingstoU.S.graduatenursingschoolsout- sidethiscategorywhereteachingEBPisnotpartofthemission. Forthisreason,itwasdif?culttoreachtheminimumnecessary sample size for excellent agreement (Mundfrom et al., 2005). Of74attemptstoaccessthelinktothesurvey(allattemptswere counted), only 45 questionnaires were completed and had less than5%ofthedatamissing.Thereasonwhycertainitemswere not answered is unknown and unclear. Most of the question- naires not included in the sample contained only information pertaining to sample characteristics and answers to questions regarding teaching strategies. Questions that assessed percep- tion of the effectiveness of EBP courses and questions that assessed perceptions of faculty competence in EBP skills were not answered. All we can do is hypothesize that faculty began to answer these questions and then abandoned the attempt. One of the features of the survey that made this possible was the fact that respondents did not need to answer a question beforeadvancingtothenextoneorcompletingthesurvey.The voluntarilynatureofthesurvey,re?ectedatthismicrolevel,did not preempt nonresponses or the necessity to delete incorrect entries. Another reason for the failure to answer certain ques- tions may have had to do with the fact that respondents were contacted only once. Another limitation may be that the survey was taken by enthusiastic and motivated faculty willing to share their per- ceptions. The reliability of the survey data may be in?uenced
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bythefactthatrespondentsmaynothavefeltcomfortablepro- viding answers that presented them in an unfavorable light. It also would be helpful to have objective measurement of EBP teachinginadditiontofacultyperceptionsfromaself-reported survey. Finally, it is necessary to mention in relation to the devel- opment of the instrument that principal component analysis and factor analysis are distinct methods. Often, they produce similarresultsandprincipalcomponentanalysisisusedasthe defaultextractionmethodintheSPSSfactoranalysisroutines.
LINKING EVIDENCE TO ACTION
Evaluation of faculty perceptions of the effective- ness of EBP courses can help to guide the devel- opment of nursing school curricula that better in- tegrate EBP.
The teacher’s mastery of EBP plays an important role in successful learning.
ToenhancetheeffectivenessofEBPcourses,grad- uate nursing students completing EBP courses should have opportunities in the curriculum to implement their knowledge and skills.
Faculty involved in teaching EBP courses for graduate nursing students should cooperate with healthcare institutions and be involved in EBP mentoring of other healthcare professionals.
Graduate nursing schools should incorporate teaching EBP courses as an integral part of the mission of the school.
IMPLICATIONS FOR FUTURE RESEARCH Theeffectiveness of EBPcourses in nursingisnot oftena sub- ject of research. Future research should focus on testing the effectiveness of EBP courses for graduate nursing students. This paper provides useful information about teaching strate- gies from the 50 top graduate nursing schools in the United States. To improve response rates, these practices should be ap- plied: limit the number of items (reduce the items regarding teaching strategies, barriers to the teaching of EBP, the most importantEBPskillstofocuson),andreducethesurveylength. Another option is the use of paper-and-pencil surveys. Due to a lack of suf?cient participants in this study the testing of the validity of the instrument was limited. Future research should focus on further testing of the psychometric properties of the scale using a larger sample, one that includes faculty from nursing programs outside the top 50 graduate nursing schools.
CONCLUSIONS This is the ?rst study to evaluate U.S. nursing faculty percep- tions of the effectiveness of EBP courses for graduate nursing studentsandperceptionsoffacultyandstudentcompetencein EBP skills. The results determined that faculty from the best U.S.graduatenursingschoolsperceivedEBPcoursesforgrad- uate nursing students as effective. To strengthen the effective- nessofEBPcourses,studentsshouldhavemoreopportunities toimplementtheir EBPknowledge andskillsafter completing anEBPcourse.Besidesthis,theteacher’smasteryplaysanim- portantroleinsuccessfullearning.Facultyfromthe50topU.S. graduatenursingschoolsperceivethemselvesascompetentin EBP skills. Further evaluation of the psychometric properties oftheinstrumentformeasuringperceptionoftheeffectiveness of EBP courses is required. In addition, objective measures of facultycompetenceinEBPshouldbedevelopedandcompared to faculty perceptions of their own competence. WVN
Author information Ren´ata Zelen´ikov´a, Assistant Professor, Department of Nurs- ing and Midwifery, Faculty of Medicine, University of Ostrava, Czech Republic; Michael Beach, Assistant Professor, Acute Care Nurse Practitioner and Coordinator of the 2nd Degree Accelerated Program, Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA; Dianxu Ren, Associate Professor, Department of Health andCommunitySystemsandAssociate DirectorforStatistical Support Services, Center for Research and Evaluation (CRE), School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA; Emily Wolff, undergraduate nursing student, School of Nursing, University of Pittsburgh, PA, USA; Paula Sherwood, Professor and Vice-Chair of Research, Department of Acute and Tertiary Care, School of Nursing, and Professor in the DepartmentofNeurologicalSurgery,SchoolofMedicine,Uni- versity of Pittsburgh, Pittsburgh, PA, USA. ThisstudywassupportedbyaUniversityofPittsburghSchool ofNursing,DepartmentofAcuteandTertiaryCarefundingop- portunity for Translating Excellence into Practice. Address correspondence to Dr. Renata Zelenikova, Depart- ment of Nursing and Midwifery, Faculty of Medicine, Univer- sity of Ostrava, Syllabova 19, 703 00 Ostrava, Czech Republic; email@example.com
Accepted 13 July 2014 Copyright C 2014, Sigma Theta Tau International
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