The concept of using the best evidence to promote quality outcomes is not new. Florence Nightingale, nursing's pioneer in evidence-based practice (EBP), initiated the idea of improving patient outcomes through rigorous evidence as early as 1853 (Nightingale, 1946). Nightingale used evidence through observation and experimentation to demonstrate positive outcomes for patients at that time in history (Mackey & Bassendowski, 2017).
More recently, the Institute of Medicine (IOM, 2001) called for fundamental change in the health care delivery system in the United States to “cross the quality chasm” between research findings and clinical practice. Providers from many health-related professions believe implementation of EBP promotes safety, quality of care, and consistency, and improves patient outcomes while decreasing health care costs (Hyrkas & Rhudy, 2013). The IOM further recommended that 90% of clinical decisions be evidence-based by 2020 (IOM, 2010). Despite this recommendation, a persistent gap remains between what care providers do and what care providers should do based on best available evidence (IOM, 2010; Melnyk et al., 2018).
It is essential that EBP competencies be integrated into all levels of academic programs to establish and continuously emphasize EBP as the foundation of practice (Melnyk et al., 2018). Effective assessment of students' perception of competence in EBP processes is a critical step to ensuring the subsequent implementation of EBP competencies into professional practice. Therefore, this article proposes the use of an EBP model as a framework for course design, linked with self-assessment of national consensus-based EBP competencies as an effective approach to safeguard competency in EBP in students entering professional practice.
The purpose of this study was to evaluate the impact of the Star Model of Knowledge Transformation© as a specific framework for course design on Master of Science in Nursing (MSN) students' perceived EBP competencies. There were two specific aims of the study:
- To determine whether perceived EBP competency scores improved consistently following the course.
- To examine which stages of the Star Model showed the most and least change in EBP competency scores.
EBP Education and Achievement of EBP Competencies
There is a continued challenge to translate research results into evidence-based clinical nursing practice. Nurses who are educated in the EBP methodology believe the most effective decisions are based on scientific knowledge, practice expertise, and client preference in the context of the health care delivery setting (Stevens, 2009; Stokke, Olsen, Espehaug, & Nortvedt, 2014). The IOM calls for all health care professionals to be educated to deliver patient-centered care as members of an interprofessional team, emphasizing EBP and quality improvement. The IOM (2010), in the seminal report The Future of Nursing, recommended that faculty partner with health care organizations to develop and prioritize competencies, regularly updating curricula to ensure graduates meet future health care needs. Education-based competencies can translate into clinical practice, whereas continuing education of nurses within health care organizations or through professional development may sustain competency.
The American Association of Colleges of Nursing (AACN) and the IOM (2010) have identified EBP as a fundamental competency for nursing. The AACN specifically addresses EBP in The Essentials of Master's Education in Nursing (2011) as Essential IV: Translating and Integrating Scholarship into Practice. “Program graduates must possess the skills necessary to bring evidence-based practice to both individual patients for whom they directly care and to those patients for whom they are indirectly responsible” (AACN, 2011, p. 16).
Stevens (2009) developed and published essential EBP competencies based on the Star Model of Knowledge Transformation using an iterative process and refined the EBP competencies through a consensus process by an expert panel. These competencies were leveled across nursing education: associate, baccalaureate, master, and doctoral. This national consensus on essential competencies for EBP guides the inclusion of EBP skills and content in nursing education, and provides a basis for professional competencies in clinical practice. This work accomplished a national consensus on the definition of EBP competencies and provided the opportunity for faculty to design an EBP course based on a verified EBP model and to evaluate acquisition of the EBP competencies as perceived by students.
Linking the evaluation of acquired EBP competencies to course design using an EBP model as a framework contributes to the learning outcomes and demonstrates how this knowledge translates into practice (Birkmeier, Plack, Wentzell, & Maring, 2017; Singleton, 2017). In 2017, the Josiah Macy Jr. Foundation (JMF) convened health professions educators to make recommendations about competency-based health professions education. The JMF Conference recommended that leaders in competency-based health professions education programs use rigorous program evaluation models that track both individual and aggregate competency development and outcomes (JMF, 2017). JMF recommended that evaluation models include data on learner performance before and after critical phases of education to measure the effectiveness of a program's system of learning and assessment (JMF, 2017, p. 20).
Barriers to EBP Competencies Achievement
Reports in the literature indicate that EBP competencies are essential in educational processes; however, various barriers can hamper the achievement of EBP competencies. Nurses at the point of care (RNs and advanced practice nurses) may experience barriers to EBP and its implementation. More than a decade ago, Pravikoff, Pierce, and Tanner (2005) found that nurses lacked knowledge about and skills to implement EBP. Nurses revealed they were not ready to embrace and value EBP. More recently, the findings of Melnyk, Fineout-Overholt, Gallagher-Ford, and Kaplan (2012) revealed nurses were ready for EBP and indeed valued the process, but barriers to implementation remained.
Barriers to EBP implementation addressed in the literature included lack of time for and knowledge of the EBP process (Majid et al., 2011; Rojjanasrirat & Rice, 2017; Skela-Savič, Hvalič-Touzery, & Pesjak, 2017), difficulty reading and appraising literature (Majid et al., 2011; Rojjanasrirat & Rice, 2017), inadequate information-searching skills (Majid et al., 2011), limited support from organizations (Connor, Dwyer, & Oliveira, 2016; Melnyk et al., 2012), and resistance from colleagues (Melnyk et al., 2012). Stokke et al. (2014) questioned 185 nurses about their beliefs toward EBP and the implementation of EBP. Nurses not only valued the process of EBP, but they also believed critical appraisal of evidence was essential to quality practice and acknowledged that using current evidence resulted in the best patient care and positive outcomes. A key finding from this study showed that stronger beliefs and more knowledge about EBP impacted the translation into practice. Effectively teaching implementation phases of EBP in nursing programs, while attempting to overcome barriers to that learning, is important for students to gain competence and improve the odds of translating EBP knowledge into professional practice. Subsequently, professional development educators can frame offerings around the phases of EBP to help solidify translation.
Although barriers exist regarding the teaching and learning of the EBP process, there are means for nurse educators to facilitate EBP competence in students and professional nurses. Designing course materials based on a valid EBP model, with well-structured application activities performed by students, may improve EBP knowledge translation (Singleton, 2017).
Course Design Based on an EBP Model
The Star Model of Knowledge Transformation (Stevens, 2004) is a model for understanding the cycles, nature, and characteristics of knowledge that are used in various aspects of EBP. The Star Model organizes both old and new concepts of improving care and provides a framework to organize EBP concepts of processes and approaches. It is a simple depiction of the relationship between various stages of knowledge transformation as newly discovered knowledge is translated into practice. Configured as a simple five-point star, the Star Model illustrates five major stages of knowledge transformation: knowledge discovery, evidence summary, translation into practice recommendations, integration into practice, and evaluation (Stevens, 2004, 2009).
Several advantages exist to designing and teaching an EBP course using a valid EBP model. Models provide a visual and enhance understanding of the connectedness of the parts of the model. EBP models can frame the progression of course content, building one on another and linking the major stages of the EBP model. Course design using an EBP model can demonstrate progression of knowledge, skills, and abilities at each stage and demonstrate achievement of competencies.
Nurse educators bear the responsibility to prepare competent and knowledgeable clinicians who can translate EBP teachings into their clinical practice with patients (Orta et al., 2016); however, factors exist that influence evidence-based teaching practices (Kalb, O'Conner-Von, Brockway, Rierson, & Sendelbach, 2015). Empirical research evidence revealed nurse educators admit to having inadequate knowledge and feeling discomfort with EBP teaching practices (Kalb et al., 2015; Orta et al., 2016). The EBP course structure and content for this study was designed so that faculty members would have a road map to follow. Before-class preparatory activities and in-class application activities were provided to course faculty and students in the learning management system. These activities provided structure and congruence of content and also furnished less-confident faculty with resources. Despite the prescriptive nature of the course, academic freedom allowed course faculty to individualize lessons to facilitate student learning and achieve course outcomes. Placement of this EBP course within the program of study has remained relatively stable since its inception in 2012, with most students completing the course during their third semester of the program.
In summary, improved knowledge of EBP processes has been shown to increase the likelihood of translation into professional practice (Melnyk et al., 2012; 2018; Stokke et al., 2014). Developing EBP competencies for students and professional nurses is time and labor intensive. Course design that was framed around the Star Model (Stevens, 2004, 2009) guided this master's-level EBP course. The measurement of students' self-reported levels of competence with EBP processes corresponding with each Star Point in this study was a means to demonstrate readiness to translate knowledge into practice that is evidence based.
Design, Setting, and Sample
This study used a retrospective pre–post cohort design wherein data were collected during a 5-year period from MSN students (N = 544) admitted from 46 states. The study setting, although implemented in an online environment, was anchored at a large, private, not-for-profit university. Program tracks included family nurse practitioner, midwifery and women's health nurse practitioner, adult gerontology acute care nurse practitioner, and nurse educator. Distribution of students across tracks remained consistent except for nurse educator students. The women's health nurse practitioner track began in 2015, and the nurse educator track was phased out in 2015. Students who fully completed pre- and postcourse assessments related to their perceived ability to achieve master's-level EBP competencies were included in the study. The study was approved by the university's institutional review board and was deemed exempt from a formal consenting process. All data were deidentified. Participant identification numbers were assigned by the researchers and used to match pairs for data analysis.
Course Design and Assessment Tool
The course was designed using Stevens's (2004) Star Model of Knowledge Transformation, an EBP model, and corresponding national consensus-based master's-level EBP competencies based on the Star Model's stages or Star Points (Stevens, 2004, 2009). Course outcomes and learning activities paralleled the Star Points of the Star Model. Course objectives, design, and delivery remained consistent during the study period. Course updates were limited to the introduction of a new edition of the textbook in 2015, and supplemental readings were updated regularly. Minor revisions to assigned activities occurred; however, the course requirements and evaluation criteria remained constant. Thoughtful decisions were made to incorporate application-level learning activities to promote student achievement of EBP competencies. The sequential Star Point structure of the model provided logical flow to undergird the course, its content, and its progression. Each learning activity was designed and focused on levels of Bloom's taxonomy (Krathwohl, 2002) to promote application, synthesis, and creation of learning using verbs such as critique, create, appraise, and synthesize. Table 1 outlines Star Model point descriptors and learning activity alignment. Faculty teaching the course had no knowledge of the actual content of the assessment tool.
Star Model Point Descriptors and Learning Activity Alignment
The specific national consensus-based EBP competencies (Stevens, 2009) were used to develop an assessment tool to measure students' perceptions of their ability to perform each competency before and after the 13-week course. Content validity for the EBP competencies was established through Delphi consensus technique (Stevens, 2009). Others have demonstrated psychometric success with developing competence assessments tools using preexisting competencies (Nilsson et al., 2014). Students ranked their responses on a Likert-type scale ranging from 1 (no competence) to 5 (expert competence). The highest possible composite score for the assessment tool was 140. The highest possible stage-specific Star Point scores were Discovery (20), Summary (30), Translation (40), Implementation (30), and Evaluation (20).
Data Collection and Analysis
Demographic information was obtained from university enrollment management personnel. Study data were collected online before and after each successive cohort was enrolled and completed the 13-week EBP course. Students were provided a link within the course and encouraged by e-mail reminders to complete the self-assessment; however, completion was voluntary. Descriptive statistics were used to tabulate sample demographics. The EBP competency data were converted from ordinal level of measurement to interval level to operationalize a composite score and use parametric statistics. Reliability coefficient was calculated with Cronbach's alpha for both pre- and postcourse assessments, and a power analysis indicated the study was more than amply powered (> .80) at an assumed low to medium effect size (0.15). Repeated-measures analyses were used for comparisons across the study time frame. The formula used for percent change calculations was (y2−y1)/y1×100.
Responses were obtained from 785 students, but only 544 students fully completed both pre- and postassessments; therefore, the total sample analyzed was 544 participants. The number of participants and annual response percentages were 169 (35%) in 2012, n = 89 (19%) in 2013, n = 80 (21%) in 2014, n = 88 (29%) in 2015, n = 55 (14%) in 2016, and n = 63 (20%) in 2017. The overall response rate of completed assessments was 23%. The majority of the students in this sample were White women, with a mean age of 37 years (Table 2).
The first aim of this study was to determine whether perceived EBP competency scores improved consistently following the course. Findings indicated cumulative Star Point scores for all of the study years improved significantly (p ≤ .014) at the postmeasurements (Figure 1). When considering cumulative scores, the total precourse mean score was 74.09 ± 18.35 compared with a total postcourse mean score of 104.04 ± 14.18 (F = 854.43, p ≤ .000).
Pre- and postcumulative Star Point scores.
The second aim of this study was to examine which stages of the Star Model demonstrated the most and least change in EBP competency scores. The greatest pre–post change was noted in the Translation Star Point scores, and the least percent of pre–post change was observed in the Discovery Star Point scores (Figure 2). Cronbach's alpha was .94 for both the pre- and postassessment.
Change in pre- and postcumulative Star Point scores.
This study evaluated the effects of an EBP course based on a recognized EBP model on the perceived EBP competencies of MSN students. This study expands current knowledge by linking assessment and achievement of EBP competencies to the implementation of an EBP model as a framework for course design. It has been proposed that such courses may prepare students to practice EBP as new graduates (Birkmeier et al., 2017) and to improve the EBP knowledge translation of nurses in practice (Singleton, 2017). It also has been proposed that increased EBP knowledge increases the likelihood of translating EBP into professional nursing practice (Melnyk et al., 2012; Melnyk et al., 2018; Stokke et al., 2014).
First Aim of the Study
Results indicated MSN students' perceived EBP competency scores consistently improved following this EBP course designed based on the Star Model. For each Star Point, mean scores increased by an average 30 points following the course. Lack of knowledge about the overall EBP process and specifically lack of knowledge about searching for, reading, and appraising literature has been described previously as barriers for EBP (Majid et al., 2011; Rojjanasrirat & Rice, 2017). Majid et al. (2011) found that nurses felt the factor most key to helping them adopt EBP was having adequate training in this area. In the current study, the mean postcourse scores rose significantly, indicating that having more knowledge did, in fact, increase perceived EBP competence. It is acknowledged that pre- and poststudy designs typically show improvement in scores. However, the average increase of 30 points in this sample is compelling to indicate students' perception of improved competence. Continued learning and reinforcement of EBP processes is vital for professional nurses to maintain this sense of competence.
The findings also are consistent with those reported by Rojjanasrirat and Rice (2017), whose online graduate-level EBP and introductory research course increased overall EBP questionnaire scores. Interestingly, the course in this study included synchronous sessions each week, whereas the course evaluated by Rojjanasrirat and Rice (2017) was taught completely asynchronously. When included as a curriculum thread instead of a specific course, Singleton (2017) found that using an EBP model to teach Doctor of Nursing Practice (DNP) students EBP resulted in an increase in overall EBP beliefs and implementation. Despite differences in delivery format, the findings are similar, adding to the consistency of the evidence.
Second Aim of the Study
The findings of this study indicated the translation stage of the Star Model demonstrated the greatest change in EBP competency scores from pre- to postcourse, whereas the discovery stage demonstrated the least change. All of the students enrolled in this course had completed undergraduate nursing education, which may explain why the discovery stage demonstrated the least change. Undergraduate nursing coursework in the United States typically includes research and EBP; consequently, graduate nursing students likely have already amassed knowledge regarding research and gathering a body of evidence to address specific clinical questions. Majid et al. (2011) indicated having either previous bachelor-level nursing training or other EBP training enhanced the EBP abilities to identify clinical problems, form clinical questions, search for research, evaluate and critically appraise research, and relate research to clinical practice. However, Rojjanasrirat and Rice (2017) reported divergent findings and noted significant increases in scores related to formulating clinical questions and locating and appraising evidence following their online graduate nursing course.
Implementation of EBP has been reported to be low in both U.S. hospitals (Melnyk et al., 2017) and hospitals abroad (Skela-Savič et al., 2017). Beliefs related to knowledge of EBP have the greatest impact on implementation of EBP (Skela-Savič et al., 2017; Stokke et al., 2014), suggesting increased knowledge resulting from repeated exposure to education and continued professional development about EBP results in enhanced translation of EBP into clinical practice. Following this EBP course that used the Star Model as a framework, MSN students showed the greatest increase in EBP competency scores for the translation stage of the Star Model. Similarly, Singleton (2017) noted a large effect size for EBP implementation (analogous to the Star Model, translation stage) following completion of EBP content in a DNP curriculum framed around an established EBP model. Our EBP course designed around an EBP model demonstrated the greatest improvement in students' perceived ability to translate EBP knowledge into clinical practice. It is acknowledged that assessment of perceived EBP competence was completed prior to the graduates' entry into professional advanced nursing practice, and therefore sustainability of perceived competence has not been established.
Several limitations exist in the study. Retrospective design of the study precludes any assignment of causality. Further, this course was designed around a selected EBP model and no data are available to compare students' perceived EBP competence change following courses with other designs. Students self-selected their voluntary participation; therefore, selection bias may have occurred and influenced the findings. Completion of the tool was not mandated and the response rate was relatively low. Thus, those who chose to participate may have been inherently different than those who chose nonparticipation. A decrease in the number of students who completed both the pre- and postassessments may be attributable to timing of availability and functionality of the linked survey. The assessment tool used in the study was a self-report; no direct observation of EBP competencies was done. Like any self-report research instrument, social desirability bias may have occurred in our study.
Implications for Practice
Considering the limitations of this study and not wanting to overinterpret the results, several important implications remain for both academic nursing education and for continuing education of professional nurses. There is a pressing need to develop and improve nurses' competence in EBP to ensure the highest quality of health care and optimal patient outcomes. It is anticipated that health care systems of the future will expect EBP competency as a standard of all practitioners. Therefore, it is the responsibility of academic programs at all levels to prepare and assess students in the acquisition of EBP competencies to meet the IOM goals and safeguard competent practice (IOM, 2001; Melnyk et al., 2018).
It also is the responsibility of practicing nurses to master the EBP competencies. Many health care organizations have adopted an EBP model to be used to translate evidence into practice. Professional development educators providing continuing education are in position to use this EBP model as a framework to design program offerings to nurses in practice. Linking professional development learning activities to acquisition of EBP competencies may increase confidence and competence of practicing nurses. Nurses who believe in the value of EBP, have knowledge of EBP practices, and express confidence in applying EBP principles are more likely to translate these competencies into insightful professional nursing practice (Skela-Savič et al., 2017; Stokke et al., 2014).
Planned course design for students and continuing education for professional nurses, guided by a recognized EBP model and linked to an assessment of acquisition of EBP competencies, has important implications for achieving the goal of preparing nurses with EBP competence. Professional development nurses are situated strategically within health care organizations that incorporate an EBP model. In this position, they can foster sustainability of EBP knowledge, skills, and abilities in their nurses, who gained basic EBP competence in their academic programs. Future studies should evaluate interventions and assessments to determine successful achievement of EBP competencies in practicing nurses at all levels.
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Star Model Point Descriptors and Learning Activity Alignment
|Star Point (Stevens, 2004)||Stage of Knowledge Transformation||Associated Learning Activity|
|Discovery||Discovery addresses primary research or the knowledge generating stage.||Students search the primary research literature to gather a body of evidence pertinent to a specific clinical question; an exemplar learning activity is a critical appraisal of a primary research article.|
|Summary||Evidence summaries synthesize known research into a single meaningful statement; this Star Point is also a knowledge-generating stage while simultaneously summarizing the evidence into a systematic review.||Learning activities for this Star Point include finding a specific systematic review and appraising the methodology used to answer a specific clinical question.|
|Translation||The Translation Star Point starts the transformation of evidence summaries into practice via clinical practice guidelines to support clinical decisions.||Students find and appraise an example of clinical practice guidelines related to a specific clinical question using the AGREE II Instrument.|
|Integration||Integration completes the transformation of evidence summaries by changing individual and organizational practices at the point of care.||A learning activity associated with this Star Point is proposing an organizational or individual practice change and strategies for its implementation using an applicable change theory.|
|Evaluation||Evaluation is the final stage of knowledge transformation before the cycle begins anew; in this stage, a broad spectrum of outcomes and endpoints are evaluated.||Students continue the integration learning activity and propose how they would evaluate the recommended practice change theoretically implemented in the previous learning activity.|
|No. of students (2012 through 2017)||2,330||540a|
|No. of states from which students originated at time of admission||48||40|
| Female||2,158 (92.6%)||511 (94.6%)|
| Male||172 (7.4%)||29 (5.4%)|
| Family nurse practitioner||1,451 (62.3%)||366 (67.8%)|
| Midwifery/women's health nurse practitioner||480 (20.6%)||108 (20%)|
| Adult gerontology acute care nurse practitioner||324 (13.9%)||48 (8.9%)|
| Nurse educator||75 (3.2%)||18 (3.3%)|
| African American||135 (5.8%)||26 (4.8%)|
| Asian||216 (9.3%)||32 (5.9%)|
| Hispanic||83 (3.6%)||28 (5.2%)|
| White||1,711 (73.4%)||428 (79.2%)|
| Native American||15 (0.6%)||6 (1.1%)|
| Two or more||146 (6.3%)||16 (2.9%)|
| Unknown||24 (1%)||4 (0.7%)|