It is well-known that evidence-based practice (EBP) improves the quality and safety of health care, as well as patient outcomes. It also fosters the active engagement of nurses in their practices. Nurses should be able to handle vast amounts of information available and have access to the best evidence for clinical practice. The cultivation of the knowledge and skills of EBP, as well as positive attitudes toward EBP, are also required.
Although EBP education is required in all nursing programs, not many nurses are used to the EBP process nor has it permeated throughout nursing practice (Rojjanasrirat & Rice, 2017). In fact, many nurses were trained before the EBP paradigm was established, so it is not strange that they should lack the skills required for its application. Besides, it has been reported that nurses endured many difficulties in implementing EBP in their daily work. The nature of EBP and its related skills should be indispensably included in a bachelor's degree in education, and timely education is needed to ensure that the future nursing workforce meets the diverse needs of the rapidly changing clinical environment and is prepared for it.
Measures are required to facilitate quick and easy understanding of the EBP learning process by lowering the cognitive load, which is the total amount of intellectual efforts that learners use to solve the learning-related problems and promote the knowledge of practice. We have developed such a teaching method that allows learners to see the relevance of EBP in the real world. Effective teaching strategies ensure that the present and future workforces are able to resolve uncertain issues in clinical situations. They also help learners to accept uncertainty as an opportunity for changing the old habits. Stories are credited as being a strong learning tool, being understandable and memorable, and being able to trigger critical thinking and connect theory with practice. Digital story-based education (DSBE) is an indirect experiential learning that makes possible the teaching of both knowledge and values. DSBE can share living experiences through photographs, music, and animation, whereas general story-based education cannot. It is an effective method for capturing and sharing tacit knowledge and enhancing reflective learning. Furthermore, animated stories can make learning more attractive, and it promotes a higher level of understanding among learners through the use of visual and auditory forms of multimedia. It can be used to produce positive perceptions of problem solving. The educational contents of EBP were developed in the form of an animation based on a story that can easily be understood by the learner and increase their confidence in its practical application.
Digital Story-Based Education for EBP
Nursing faculty and clinical nurses participated in this educational development. They also engaged in collecting EBP cases, selecting clinically applicable cases, designing animation scenarios, and evaluating the validity of educational content. Animated character, background, and screen composition were designed to show the actual situations of clinical nursing.
The story that formed part of the training strategy was based on the following five stages of EBP (Melnyk, & Fineout-Overholt, 2018):
- Formulating questions that will induce the most suitable answers,
- Collecting the most highly related evidence by systematically searching the literature or clinical guidelines,
- Critically appraising the evidence,
- Integrating proven research evidence with clinical experience of the patients and their preferences and values, and
- Evaluating the outcome.
The characters included a new nurse with a lot of curiosity, an EBP coordinator, and a senior nurse who did not want to a change. The story was about finding appropriate tools for assessing the pain experienced by the patients with dementia (Table A; available in the online version of this article).
Stories According to Each Step of Evidence-Based Practice (EBP)
Story characters appeared in the quiz game to increase familiarity with the problem. Pop-up quizzes were inserted into the animations in the format of a game. Learners were given immediate feedback on their answers until they provided a correct one.
Thirty-one nurses and 91 students enrolled in the digital story-based EBP learning procedure. The participants were given the EBP Questionnaire (EBPQ) and were also asked about their cognitive load with DSBE after the exercise. A higher EBPQ score indicates a more positive attitude toward EBP, and better knowledge and implementation of EBP (Upton & Upton, 2006). A lower cognitive load score indicates a lesser amount of mental efforts of learners in performing the tasks related to learning (Ryu & Yim, 2009). Open-ended satisfaction questions were asked to query the learners about what they liked and disliked about their learning experience.
As a result of DSBE, significant improvements were observed between the pretest and posttest scores on the EBPQ for the nurse group and for the student group. The cognitive load with DSBE was relatively low in the nurse group and in the student group. The learners reported that one of the main positive features of the storytelling education was how interesting it was. They commented that the stories improved their immersion in the learning process: “I felt like a senior nurse in the story, I always felt fear before trying a new skill,” “It was easy to understand learning as it was structured based on clinical examples,” and “I didn't feel bored while learning because learning through games drove me to participate.”
The nurses and students stated that the content was easy to understand, fun, and informative. The quizzes that were inserted in the stories guided the main characters, which helped them to understand the main issues of each module. The learners expressed that they wanted to be trained by EBP with more storytelling scenarios. The DSBE that was our ordinary story and easy to understand produced the best results.
The application of DSBE allowed the learners to see the entire process of EBP from formulating clinical questions to their actual implementation. Setting the story character in a background similar to that of the learners promoted empathy and immersion. DSBE is an effective way to naturally learn and internalize knowledge with a low cognitive load. This teaching strategy could be an efficient method for strengthening the EBP competency of nurses and nursing students. A variety of stories based on real clinical settings can be collected and used as effective learning contents and to build experiences similar to those encountered in the work environment.
- Melnyk, B. M. & Fineout-Overholt, E. (2018). Evidence-based practice in nursing and healthcare: A guide to best practice. Lippincott, Williams & Wilkins.
- Rojjanasrirat, W. & Rice, J. (2017). Evidence-based practice knowledge, attitudes, and practice of online graduate nursing students. Nurse Education Today, 53, 48–53 doi:10.1016/j.nedt.2017.04.005 [CrossRef] PMID:28437780
- Ryu, J. H. & Yim, J. H. (2009). An exploratory validation for the constructs of cognitive load. The Journal of Educational Information and Media, 15(2), 1–27.
- Upton, D. & Upton, P. (2006). Development of an evidence-based practice questionnaire for nurses. Journal of Advanced Nursing, 53(4), 454–458 doi:10.1111/j.1365-2648.2006.03739.x [CrossRef] PMID:16448488
Stories According to Each Step of Evidence-Based Practice (EBP)
|1. Formulating a critical question||A senior nurse attempts to assess the pain with a numerical rating scale (NRS) for dementia patients who complain of pain. However, the patients do not express their pain in a clear way. The new nurse is concerned about the pain level experienced by a dementia patient who has trouble communicating. The new nurse consults with the EBP coordinator to develop clinical questions based on PICO (Patient or Population, Intervention, Comparison Intervention, Outcome).|
|2. Search for evidence||The EBP coordinator informs the new nurse of things to consider when searching the literature. She introduces a literature search site to the new nurse and describes its sensitivity and specificity. The new nurse is screened and checked for whether she had correctly searched, and thereafter she performs searches based on PICO.|
|3. Critical evaluation of the evidence||The EBP coordinator explains the definition and necessity of critical evaluation of the evidence. It is explained that three elements (quality of research, applicability, and influence on patients) should be considered in a critical evaluation of the evidence (shown with the picture). They discuss quality assessment tools.|
|4. Apply the evidence in practice||The new nurse is not sure how to apply the tool for measuring the pain of dementia patients derived from the evidence. The EBP coordinator informs her how to apply this to the clinical field and explains the definition and function of guidelines. The EBP coordinator and nurse together identify what steps to take to apply EBP. Finally, they devise a plan to apply the DS-DAT tool to the ward for dementia patients with pain.|
|5. Evaluation||The new nurse discusses the assessment after applying evidence in the hospital ward with the EBP coordinator. A self-evaluation, peer evaluation, and professional evaluation should be performed. They review and evaluate all the processes of EBP together, which results in the DS-DAT tool being considered suitable for assessing pain in dementia patients, and it is decided to apply it throughout the hospital. A senior nurse who has experienced a reduction in patient complaints due to the use of a new pain assessment tool becomes interested in EBP.|