Full Length Research Paper
ABSTRACT
Evidence-Based Practice (EBP) in health is important for patient safety and quality care while Critical Thinking (CT) is a vital prerequisite to evidence based nursing. Despite their importance, in some settings neither EBP nor CT is taught assessed or implemented. This scoping review examined literature related to teaching, learning, assessment and implementation of EBP and application of CT by nursing students and graduates. Arksey and O’Malley framework was used to conduct the scoping review. PubMed, CINAHL, EMBASE and Joanna Briggs Institute for EBP data bases were searched for studies conducted between 2000 and 2020. Inclusion criteria were adapted from the -Population, Intervention, Professionals and Patients, Outcomes, Health Care settings (PIPOH) framework. Search terms included; evidence based practice, nursing education, nursing practice, critical thinking, methods, barriers, facilitators to teaching, learning, assessing and implementing EBP and CT. A total of 2,303 articles were retried, eventually 37 met the inclusion criteria. Use of non-traditional instructional methods for teaching EBP and CT were documented including Problem Based Learning, concept mapping, simulation, think aloud, critical incidence technique, debates and role-plays, reflective journaling, article analysis, nursing journal clubs and multidisciplinary clinical rounds. Validated tools for assessing EBP and CT Skills included; California Critical Thinking Skills Test, Upton and Upton 2006 EBP questionnaire and Yoon’s 2004 Critical Thinking Disposition Inventory. Teaching, assessing EBP and applying CT skills is challenging. Therefore innovative teaching methods are required to promote learning while successful implementation require strategies to minimize detractors and sustain enablers of the process.
Key words: Evidence-Based Practice nursing, critical thinking, teaching, learning, assessment and implementation.
INTRODUCTION
Evidence-Based Practice (EBP) in health is important for patient safety and quality care (Melnyk et al, 2012; Melnyk et al., 2014; Horntvedt et al., 2018). According to literature, there are better outcomes for patients who receive evidence based care compared to those who do not (Manjula et al., 2018). It is therefore important that EBP competencies be incorporated into all levels of training programs to establish EBP as foundation of practice (Melnyk et al., 2018). For Bachelors Nursing Students, using the available best evidence is important in patients’ care, while knowledge of the linkage between research evidence and practice is pre-requisite to implementing EBP (Institute of Medicine, 2010; Aglen, 2016; Fiset et al., 2017). Since the establishment of Evidence Based Medicine at McMasters University in the 1980s, several authors have defined and redefined EBP with most agreeing that it is “the conscientious, explicit and judicious use of current best evidence in conjunction with clinical expertise and patient values to facilitate clinical decision making” (Sackett et al., 1996, 2000; Titler et al., 2001, 2006; Hughes, 2008; Melnyk and Fineout-Overholt, 2011; Melnyk et al., 2014). On the other hand, Critical Thinking (CT) is a “mental process of active and skilful perception, analysis, synthesis and evaluation of information collected through observation, experience and communication that leads to a decision for action” (Papathanasiou et al., 2014).
Both EBP and CT are a component of one key domain of the International Council of Nurses (
Literature alerts us that teaching EBP can be challenging and that creative teaching methods are required in order to promote student learning (Liou et al., 2013; McCurry and Martins, 2010; Sin and Bliquez, 2017). Based on the 5As of the EBP process, Melnyk and Fineout-Overhold, (2005) and Sin and Bliquez (2017) proposed four steps that could be used to teaching EBP to undergraduate nursing students. These were asking a question, acquiring evidence, appraising evidence and applying evidence. The approach utilized small group teaching method and clinical scenarios as a way to enhance student knowledge and competency of EBP. Other authors (Larsen et al., 2019; Davidson and Candy, 2016; Whalen and Zentz, 2015; Reicherter et al., 2013; Dawley et al., 2011; Brown and McCrorie, 2015) have suggested interactive methods suitable for teaching both EBP and CT skills. These include research courses and workshops, concept mapping, journal clubs, clinical simulations, collaboration with clinical practice, use of dedicated education units and use of IT Technology.
Strategies and methods to develop and maintain CT include reflective journals and critiques (Craft, 2005), role modelling and questioning (Dickerson, 2005), Journal clubs (Seymour et al., 2003) and Problem Based Learning (PBL) with real life scenarios (Williams, 2004). Others reported in literature are concept mapping, clinical rounds, debates and simulation (Staib, 2003; Profetto-Mc Grath, 2005; Karabacak and Atay, 2011; Orique and McCarthy, 2015). Despite the established and documented methods for teaching, learning and assessing EBP and CT, at the University of Zambia School of Nursing Sciences (UNZA-SON) where the scoping review was conducted, the two concepts: EBP and CT are not taught in the undergraduate curricula, while in the MSc programmes EBP is taught using traditional lecture methods, while CT skills are not taught at all. Therefore the main objective of the scoping review was to identify methods for teaching, learning, assessment and factors influencing implementation of EBP and application CT Skills among Nursing Students and Graduates. The review was part of a major post-doctoral study whose aim was to building capacity for EBP and CT among nursing students and graduates of the University of Zambia. The other aspects and processes of the doctoral project are beyond the scope of this paper and are therefore reported elsewhere.
Rationale for the review
EBP transforms nursing from routine tasks and care decisions based on traditions to practices which have been subjected to critical appraisal and validated by research evidence (Gagan and Hewitt-Taylor, 2004; Sams et al., 2004). In addition, EBP allows for individualized, effective, streamlined and dynamic nursing care (Youngblut and Brooten, 2001). On the other hand, without EBP, care provision is prone to and is provided based on out-of-date procedures and guidelines. Nurses may be relying on concepts learned in nursing school several years prior as well as old clinical habits, or nursing traditions to guide care provision (Keller, 2018). Given the value attached to EBP and CT in addition to the gap in the teaching and application of the two at UNZA-SON, it was imperative that a scoping review of literature be conducted to obtain scientific evidence on the existing level of capacity of students and graduates of the School of Nursing. This was intended to set a benchmark or yardstick for developing mechanism for incorporating teaching, assessment and subsequently implementation of EBP and application of CT skills in Nursing and Midwifery education and practice in the Zambian context.
MATERIALS AND METHODS
Arksey and O’Malley framework was used to conduct a scoping review of literature (Arksey and O’Malley, 2005). Considering the broad nature of the question that was being addressed; what are the methods for teaching, learning, assessment and factors influencing implementation of EBP and application CT Skills among nursing students and graduates? A scoping review as opposed to a systematic review was more applicable. As asserted by Arksey and O’Malley (2005), systematic reviews are more suitable for well-defined questions and research designs while scoping reviews are appropriate for answering broader questions and allow for inclusion of studies of wide-ranging designs. In applying the Arksey and O’Malley Framework, the review was conducted through a five step approach: (1) identification of the research question; (2) identification of relevant studies; (3) selection of the studies; (4) charting of data; (5) collating, summarizing and reporting results. The sixth step of consultation was not undertaken as the reported scoping review was part of a large Post-Doctoral study, whose other results will be reported elsewhere.
A number of electronic data based were searched for the review. These included CINAHL, PubMed, EMBASE and Joanna Briggs Institute EBP Data Base. Determination of the inclusion criteria was adapted from the Population, Intervention, Professionals and Patients, Outcomes, Health Care settings (PIPOH) framework according to Fervers et al. (2006). The population considered in the scoping review was undergraduate nursing students and graduate nurses. Interventions were any teaching, learning and assessment methods, and barriers or facilitators to implementation of EBP or application of CT. Professionals were graduate nurses, outcomes were implementation of EBP and application of CT skills while the health care setting was any clinical area where nurses implement EBP and apply CT skills.
Search terms included evidence based practice, nursing education, nursing practice, critical thinking skills in nursing education and practice, methods, barriers, facilitators to teaching, learning, assessing and implementing EBP and CT. Others included nursing education and EBP and CT, EBP and CT in nursing practice. Data bases were searched for studies conducted between 2000 and 2020.
Only studies written in English were included. A librarian was involved in designing and implementation of the search strategy, while the researcher with one research assistant screened the articles and documented the review findings.
RESULTS
From the databases searched 2,303 articles were retried. Out of the 2,303, 97 were excluded as duplicates. For the remaining 2,206, 1,267 were excluded for not meeting the inclusion criteria. Records screened for full abstracts were 939, out of which 886 were excluded. Eventually 66 full articles were assessed and 29 were excluded for the following reasons; 9 not addressing nursing students or practicing nurses, 1 full English text not available, 12 none research article, and 7 not focusing on EBP or CT. Figure 1 gives a summary of the scoping review process.
DISCUSSION
The scoping review was designed to answer the question: what are the methods for teaching, learning, assessment and factors influencing implementation of EBP and application CT skills among nursing students and graduates? The review question was answered through the data from four databases: CINAHL, PubMed, EMBASE and Joanna Briggs Institute EBP Data Base, and desk search of some key articles identified through Google Scholar. Globally, there is a plethora of literature related to EBP and CT among nursing students and practicing nurses.
From global literature, several teaching and learning methodologies for EBP and CT have been documented in literature. These include Problem Based Learning (PBL), concept mapping, simulation, think aloud, critical incidence technique, videos, debates and role-plays, reflective journaling and article analysis, reflection and documentation, reading and writing assignments, group work and presentations (Simpson and Courtney, 2008, Karabacak and Atay, 2012; Goodstone et al., 2013; Ticha and Fakuda, 2015; Zori, 2016; Charania?et al., 2017). Others are use of clinical events (cases or case studies), nursing rounds, and interdisciplinary rounds, dedicated education units, experiential learning and clinical experience, writing answerable clinical questions and conducting literature searches (Chen and Lin, 2003; Vnenchak et al.,?2019; Weathers, 2019).
From the Zambian context where the current review was conducted, there is still scarcity of such literature as the search yielded only three articles. Two articles did not specifically focus on EBP but on use of research information by nurses in clinical practice and on challenges faced by nurses in searching for and accessing research information at a University Teaching Hospital in Zambia (Monde et al., 2017a, b). Although not specifically on EBP or CT, the two were considered and included in the scoping review as they provided contextual information related to the Zambia setting. The 3rd article which was directly related to the review and focused on the process, lessons and implication of implementing Evidence Based Practice Nursing at the University Teaching Hospitals-Adults Hospital in Lusaka, Zambia (Katowa-Mukwato et al., 2020). This review may therefore provide an impetus to nursing educators in Zambia to consider incorporation of EBP and CT in the nursing curriculum and provide for innovative teaching methods that have need for this document to promote learning.
The main curricula content to ensure students and graduates are competent in EBP and CT, include history of EBP and CT, role of EBP in clinical care, EBP models, formulating answerable clinical questions, searching relevant literature, appraising literature, evaluating qualitative and quantitative research, identifying best practices, implementing best practices, evaluating and re-starting the circle (Simpson and Courtney, 2008, Ramos-Morcillo et al., 2015; Kim et al., 2019) (Table 1). This is in addition to the generic research methodology competencies. While content for promoting CT skills include questioning skills, problem solving skills, intellectual eagerness/ curiosity, health scepticism which should be taught via simulation, debate, role play small group activity, interdisciplinary round participation, case studies and presentations during staff rounds, nursing journal clubs (Profetto-Mc Grath, 2005; Karabacak and Atay, 2011). In order to promote CT skills, scholars such as Goodstone (2013) and Orique and McCarthy (2015) support the utilization of non-traditional instructional including Concept Mapping, PBL and simulation methodologies in undergraduate nursing curricula. As stated earlier, other authors (Larsen et al., 2019; Davidson and Candy, 2016; Whalen and Zentz, 2015; Reicherter et al., 2013; Dawley et al., 2011; Brown and McCrorie, 2015) have suggested interactive methods suitable for teaching both EBP and CT skills. These include research courses and workshops, concept mapping, journal clubs, clinical simulations, collaboration with clinical practice, use of dedicated education units and use of IT Technology.
With regards to assessing EBP and CT skills, there are a number of validated tools; commonly the Upton and Upton 2006 EBP Questionnaire (Upton and Upton, 2006), the California Critical Thinking Skills Test (CCTST) of 1994. It is from these two tools that several scholars have modified notably the Yoon’s 2004 Critical Thinking Disposition Inventory YCTDI (Yoon, 2004). Whereas the CCTST is a general tool testing CT skills of Post-Secondary education candidates, YCTDI was originally developed specifically for Korean Nursing, but it is now validated and recommended for testing CT skills of nursing students.
Regarding implementation of EBP and application of CT skills by nurses, the reviewed literature, indicated varying levels of EBP and CT application from different clinical setting. Additionally, a number of challenges faced in implementing EBP were revealed. The challenges range from cost implication of funding EBP, organizational culture that do not support EBP, workplace resistance “That is the way we have always done it”, lack of knowledge and skills in EBP and CT by nurses, misunderstanding that EBP takes too much time, to inadequate mentors for EBP (Willis, 2012). Another major barrier is the over-emphasis on conduct of research by education institutions against none or limited emphasis on translation and utilization of research findings (Melnyk and Fineout-Overholt, 2015; Melnyk et al., 2012a, b, 2016).
Katowa-Mukwato et al. (2020) observed that there are both enablers and detractors to implementing EBP. The observed detractor included comfort with status quo. The comfort with status quo resulted in resistance to any justification and call to change, as some nurses remained doing what they have been doing which was described as being “encased” in the comfort zone. Such category of nurses was seen as detractors of the process. This observation corroborates with what others have reported that status quo is a barriers to EBP implementation (Wallis, 2012). Wallis (2012) affirmed that getting past workplace resistance and the phrase, “That is the way we have always done it” pauses as a major constraints to EBP implementation.
Limitation of the review
Considering the Zambia context within which the scoping review was conducted, EBP and CT as key elements in health care have not received their due value either in Nursing Education or Practice as such the desk review did not come across any policy documents or expert opinion regarding the two concept. This meant that as opposed to the general recommendation the policy documents and expert opinion may be part of a scoping review; it was not the case for this review. Consequently, only research papers were included.
CONCLUSION
Teaching and assessing EBP and applying CT skills have been reported to be challenging and therefore innovative teaching methods are required to promote learning while successful implementation require strategies to minimize detractors and sustain enablers of the process. Although there is a plethora of literature at global level on different methods for teaching, learning, assessment and implementation of EBP and CT in Nursing Education and Practice, from the Zambian context literature is very scarce. The two concepts are not taught in the undergraduate curricula, while in the MSc programmes EBP is taught using traditional lecture methods, while CT skills are not taught at all. This review may therefore provide an impetus to nursing educators in Zambia to consider incorporation of EBP and CT in the nursing curriculum and provide for innovative teaching methods that have need of this document to promote learning.
CONFLICT OF INTERESTS
The authors have not declared any conflict of interests.
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