Journal of Nursing Education

Major Article Open Access

Evidence-Based Practice in Clinical Nursing Education: A Scoping Review

Valerie J. Fiset, MScN, RN; Ian D. Graham, PhD; Barbara L. Davies, PhD, RN

  • Journal of Nursing Education. 2017;56(9):534-541
  • https://doi.org/10.3928/01484834-20170817-04
  • Posted September 6, 2017

Abstract

Background:

Nursing students require education that integrates evidence-based practice (EBP) knowledge across classroom and clinical settings. This study was conducted to identify and examine the literature related to nursing students' use of evidence in clinical education and to identify associated research gaps.

Method:

A scoping review describing the extent, range, and nature of the research activity focused on students' use of evidence in clinical education.

Results:

Included studies (N = 37) describe the barriers and facilitators to nursing students' EBP and describe the evaluation of strategies that support nursing students' engagement in EBP. Most commonly identified barriers include a lack of knowledge and skills for EBP; negative attitudes toward EBP in students, faculty, and nurses; and lack of support in the clinical setting. Evaluated strategies included educational sessions and EBP projects, either alone or in combination, as well as other stand-alone interventions. All but two of the intervention studies reported positive subjective or objective outcomes.

Conclusion:

On the basis of these results, educators can engage in combined educational strategies that focus on addressing described barriers. [J Nurs Educ. 2017;56(9):534–541.]

Abstract

Background:

Nursing students require education that integrates evidence-based practice (EBP) knowledge across classroom and clinical settings. This study was conducted to identify and examine the literature related to nursing students' use of evidence in clinical education and to identify associated research gaps.

Method:

A scoping review describing the extent, range, and nature of the research activity focused on students' use of evidence in clinical education.

Results:

Included studies (N = 37) describe the barriers and facilitators to nursing students' EBP and describe the evaluation of strategies that support nursing students' engagement in EBP. Most commonly identified barriers include a lack of knowledge and skills for EBP; negative attitudes toward EBP in students, faculty, and nurses; and lack of support in the clinical setting. Evaluated strategies included educational sessions and EBP projects, either alone or in combination, as well as other stand-alone interventions. All but two of the intervention studies reported positive subjective or objective outcomes.

Conclusion:

On the basis of these results, educators can engage in combined educational strategies that focus on addressing described barriers. [J Nurs Educ. 2017;56(9):534–541.]

Using the best available evidence is a crucial competency for baccalaureate nursing students (Institute of Medicine [IOM], 2010). Most commonly, nursing programs have attempted to develop evidence-based practice (EBP) competencies through classroom learning, and not as part of clinical placements (Ciliska, 2005). However, in an appeal for radical transformation in nursing education, Benner, Sutphen, Leonard, and Day (2010) have recommended important changes to that model, notably moving “from a focus on covering decontextualized knowledge to an emphasis on teaching for a sense of salience…and action in particular clinical situations” and “from a sharp separation of classroom and clinical teaching to integrative teaching in all settings” (p. 89). Currently, as Ciliska suggested, EBP is taught as decontextualized knowledge, and the relevance of this knowledge must be supported through its integration in clinical practice.

This call is further supported by Aglen's (2016) recent systematic review that examined pedagogical strategies to teach EBP to undergraduate nursing students. The author concluded that the traditional focus in nursing education on information literacy is not sufficient, and that “knowledge about how evidence relates to practice is the important pre-requisite for EBP” (Aglen, 2016, p. 260). Another systematic review suggests that focusing on improving health professional students' attitudes toward EBP may result in greater improvements in EBP practices (Wong, McEvoy, Wiles, & Lewis, 2013). Strategies described in both articles include real-time teaching of formulation of clinical questions and subsequent literature search based on actual care issues, EBP teaching rounds and workshops, case presentations, problem-based learning, and journal clubs (Aglen, 2016; Wong et al., 2013). In a third integrative review, Ryan (2016) described undergraduate nursing students' attitudes and use of research and EBP. Key findings included the importance of students' capability beliefs and attitudes for EBP and the ability of clinical units and preceptors to support EBP. None of the three reviews has focused specifically on undergraduate nursing students' engagement in EBP as part of their clinical practice education. Clinical practice education refers to learning activities conducted outside the classroom or laboratory settings, and it takes place in a variety of health care environments.

The authors of the current study would suggest that ideally, students, through both curricular and teaching–learning strategies, would be challenged and supported to inform their practice with the best available evidence, whether that be in the form of research articles, systematic reviews, or practice guidelines. As a beginning point for understanding approaches to integrate EBP competencies in undergraduate clinical nursing education, the research evidence related to this topic was explored. To the authors' knowledge, this is the first scoping review to focus on this area.

Method

This review was conducted using the Arksey and O'Malley (2005) framework for scoping studies, taking into consideration recommendations by Levac, Colquhoun, and O'Brien (2010). In a review of the nursing literature related to scoping studies by Davis, Drey, and Gould (2009), the authors indicate:

The main strengths of a scoping study lie in its ability to extract the essence of a diverse body of evidence and give meaning and significance to a topic that is both developmental and intellectually creative.

Arskey and O'Malley (2005) distinguished scoping reviews from systematic reviews in that the latter tend to focus on a well-defined question and research design, whereas a scoping review addresses a broader question and includes studies reflecting wider designs. Another key difference between systematic reviews and scoping reviews is that the scoping review generally does not include quality assessment of included studies.

The steps of the scoping review outlined by Arskey and O'Malley (2010) include “1) identifying the research question; 2) identifying relevant studies; 3) study selection; 4) charting the data; 5) collating summarizing and reporting results; and 6) consultation” (p. 22). The specific research questions were:

  • What are the barriers, facilitators, and other factors that affect nursing students' EBP in clinical education?
  • What are the educational strategies described to promote EBP by nursing students in clinical education?

The next stage of the process was to identify relevant studies. As recommended by Levac et al. (2010), a team with content and methodological expertise was assembled, including researchers with expertise in nursing education and EBP, as well as nursing students and recent graduates. The purpose of this team was to provide guidance related to the search terms, as well as the article screening and data extraction process. A research librarian and library technician were also involved in developing and implementing the search strategy.

The databases searched included CINAHL®, Cochrane Database of Systematic Reviews, ERIC™, PubMed®, PsychINFO®, ProQuest®Nursing and Allied Health, Proquest Dissertations and Theses, Sage, and MEDLINE®, using a combination of keywords, ERIC thesaurus terms, and mapped subject headings. Search terms used were related to the concepts of nursing students (i.e., undergraduate nursing students), EBP (i.e., any educational strategy to support students using evidence in clinical education), and clinical nursing education (i.e., inpatient or community settings). The reference lists of retrieved articles were hand-searched. Tables of contents of key journals related to nursing education were also hand searched. The literature was searched from January 1998 to July 2015 in English and French. This time frame was chosen to reflect the 1998 launch of the journal Evidence-Based Nursing, the 1998 initiation of the National Guideline Clearinghouse, and 1 year prior to the initiation of the Best Practice Guideline program at the Registered Nurses Association of Ontario. English and French articles were included, as the primary investigator (V.J.F.) is fluent in both languages.

Following development and implementation of the search strategy, reviewers selected relevant studies for abstraction. Screening of potentially relevant studies for inclusion in the review was conducted by the first author (V.J.F.) and two trained research assistants. The inclusion and exclusion criteria were adapted by the authors from the PIPOH (Population, Intervention, Professionals and patients, Outcomes, Health care setting) framework (Fervers et al., 2006). More specifically, the population included undergraduate nursing students, the intervention included any educational strategy to support students' use of evidence in clinical education, the professionals involved were nursing faculty in clinical and academic settings, the outcomes included students' use of research evidence in clinical placements or factors that influenced their engagement in EBP, and the setting included any clinical setting, excluding all in-class settings.

Included studies were research studies of any methodology focused on undergraduate nursing students' use of research evidence during their clinical placements. Following the removal of duplicate references, three reviewers independently reviewed each title. Interrater reliability on a sample of studies was conducted until 90% agreement was achieved. In cases of uncertainty for inclusion based on title, the abstract of the article was considered. If the reviewers were still uncertain, or disagreed regarding the inclusion of the reference based on title and abstract screening, then the full-text of the article was reviewed. The reviewers met to discuss any uncertainties regarding study selection, which occurred in less than 10% of studies. When disagreements or uncertainties remained, a fourth and fifth reviewer were consulted to determine the eventual inclusion of the article (B.L.D. & I.D.G.).

The research team (V.J.F., B.L.D., I.D.G.) developed a data extraction form and determined which variables were to be extracted from the included studies. The form was piloted by three reviewers (V.J.F. and two research assistants) and modified until agreement was achieved on key elements to extract from included studies. As recommended by Levac et al. (2010), the team members independently extracted data from seven studies and met to compare findings to ensure consistency. Where inconsistencies existed, discussion took place until consensus was achieved.

Following data extraction, the study results were collated and summarized. Analysis of the included studies involved numeric summaries, as well as qualitative thematic analysis. The final stage was to engage in a consultation exercise with stakeholders to discuss the results of the scoping study and to discuss the implications for education, practice, and research (Arksey & O'Malley, 2005). Participants in the consultation were nursing faculty members and nursing students. They were provided with data tables and an abbreviated version of the results and discussion sections. They were asked to reflect on the completeness of the review, the key results and their relevance, and the discussion, particularly the implications for education and future research.

Results

Reference Retrieval

The search of electronic databases initially retrieved 3,114 references. Following deduplication, the remaining 3,076 titles were screened (Figure 1). The most common reasons for excluding articles at the full-text screening stage were (a) they were not related to EBP (n = 19), (b) they were nonresearch articles (n = 18), and (c)they were not related to clinical practice education (n = 10). Six articles were identified through the hand search of journal tables of contents and the reference lists of included articles. In total, 37 studies were included: 14 descriptive studies and 23 intervention studies. Two of the studies (Higuchi, Cragg, Diem, Molnar, & O'Donohue, 2006; Smith-Strøm, Oterhals, Rustad, & Larsen, 2012) included descriptive and evaluation components and were categorized numerically as evaluations studies, although the descriptive results are included in the relevant sections.

Flow diagram of study selection.EBP = evidence-based practice;PDA = personal digital assistant.

Figure 1.

Flow diagram of study selection.EBP = evidence-based practice;PDA = personal digital assistant.

Barriers, Facilitators, and Other Factors That Affect Nursing Students' EBP in Clinical Education

Descriptive studies focused on reporting the extent to which participants engaged in EBP, as well as barriers, facilitators, and other factors affecting EBP in clinical education. Table A (available in the online version of this article) provides a summary of these studies. Four of the 14 studies were published between 1998 to 2004, and the remainder were published between 2010 to 2015. Studies originated from a wide range of countries, with four from Sweden, the United Kingdom, and the United States. All but one of the studies were written in English (one was written in French). The studies were cross-sectional with a mix of both quantitative, qualitative, and mixed approaches to data collection. Although researchers in several studies developed their own questionnaires, several tools were also used, including Johnston's Knowledge Attitudes and Behaviors questionnaire (Johnston, Leung, Fielding, Tin, & Ho, 2003), which measures attitudinal, perceptual, and behavioral factors contributing to EBP (Brown, Kim, Stichler, & Fields, 2010); the Funk Barriers Scale (Funk, Champagne, Wiese, & Tornquist, 1991), which measure barriers to implementation of EBP from the perspective of the nurse, the setting, and the research (Kajermo, Nordstrom, Krusebrant, & Bjorvell, 2000; Stichler, Fields, Kim, & Brown, 2011; Walti-Bolliger, Needham, Halfens, 2007); and the EBP Questionnaire, created by Upton and Upton in 2006 to measure attitudes toward and knowledge and skills for EBP (Stichler et al. 2011; Upton, Scurlock-Evans, Williamson, Rouse, & Upton, 2015). Llasus, Angosta, and Clark (2014) used two previously validated tools, Stevens'Academic Center for EBP-EBP Readiness Inventory (2005), reflecting confidence in EBP competencies, and the EBP Implementation Scale, which measures of the extent that EBP is implemented, developed by Melnyk, Fineout-Overholt, and Mays (2008).

Summary of Studies Describing Barriers, Facilitators, and Other Factors Influencing EBP in Clinical Education (n = 15)aSummary of Studies Describing Barriers, Facilitators, and Other Factors Influencing EBP in Clinical Education (n = 15)aSummary of Studies Describing Barriers, Facilitators, and Other Factors Influencing EBP in Clinical Education (n = 15)aSummary of Studies Describing Barriers, Facilitators, and Other Factors Influencing EBP in Clinical Education (n = 15)aSummary of Studies Describing Barriers, Facilitators, and Other Factors Influencing EBP in Clinical Education (n = 15)aSummary of Studies Describing Barriers, Facilitators, and Other Factors Influencing EBP in Clinical Education (n = 15)a

Table A:

Summary of Studies Describing Barriers, Facilitators, and Other Factors Influencing EBP in Clinical Education (n = 15)

Barriers and Facilitators From the Student Perspective. Of the 14 studies that described barriers to EBP or research use in clinical education, four (29%) investigated barriers from the perspective of nursing faculty members, and the remaining 10 focused on nursing students (71%). The categories from the Funk Barriers to Research Utilization Scale (Funk et al., 1991) (characteristics of the nurse [student or faculty in this review], setting, research, and presentation) were used to categorize the barriers described in the included studies. From the student perspective, the most commonly cited barriers were negative attitudes toward EBP and lack of knowledge and skills related to EBP (Ax & Kincade, 2001; Brooke, Hvalic-Touzery, & Skela-Savic, 2015; Brown et al., 2010; Smith-Strøm et al., 2012). Nursing students perceived barriers related to the setting; notably, clinical staff and managers' resistance to the use of research findings and a lack of time for EBP (Ax & Kincade, 2001; Brooke et al., 2015; Brown et al., 2010; Jonsen, Melender, & Hilli, 2013; MacVicar, 1998; Smith-Strøm et al., 2012). The only characteristic of the research that nursing students described was identified by Brown et al. (2010); notably, that too much information existed when searching for evidence on the Internet. From the perspective of presentation, difficulty understanding and ascertaining the relevance of research findings was identified in two studies (Ax & Kincade, 2001; Kajermo et al., 2000), and challenges with accessing research reports were also described (Kajermo et al., 2000; Smith-Strøm et al., 2012).

Nursing students identified a number of facilitators, including taking a course or participating in education related to EBP (Arslan & Celen, 2014; Kajermo et al., 2000), having increased knowledge related to EBP (Florin, Ehrenberg, Wallin & Gustavsson, 2012; Smith-Strøm et al., 2012), having a positive attitude toward EBP (Florin et al. 2012, Kajermo et al., 2000), having an interest in a particular area of research (Bjorkstrom, Johansson, Hamrin, & Athlin, 2003; Florin et al. 2012), or participating in scientific activities (Arslan & Celen, 2014; Kajermo et al., 2000). Related to the setting, students perceived support from managers, other professionals, and students as key facilitators (Kajermo et al., 2000; Smith-Strøm et al., 2012). Kajermo et al. (2000) described facilitators of having accessible, high-quality, relevant research that is presented in a user-friendly format in the students' language of choice.

Barriers and Facilitators From the Faculty Perspective. Four studies related to the faculty perspective on barriers and facilitators. The most common barriers that related to characteristics of the nurse (in this case, faculty members and students) were centered on lack of knowledge and skills for EBP (Higuchi et al., 2006; Hussein & Hussein, 2013; Stichler et al., 2011; Upton et al., 2015; Walti-Bolliger et al., 2007). The most commonly described barrier relating to the characteristics of the clinical setting was the lack of power that students had in the clinical setting to influence practice (Stichler et al., 2011; Upton et al., 2015). In the academic setting, barriers included curricular issues, lack of resources for faculty training, and infrastructure for EBP (Higuchi et al., 2006; Hussein & Hussein, 2013; Upton et al., 2015). Facilitators of EBP, from the perspective of faculty members, included mainly characteristics of the nursing faculty, including the confidence and skills to engage in EBP and positive attitudes toward EBP (Hussein & Hussein, 2013; Stichler et al., 2011; Upton et al., 2015).

A summary of the barriers and facilitators described in all of the studies is provided in Figure 2. Taken together, the largest number of barriers from the perspective of students and faculty relate to the characteristics of the nurse and focus mostly on lack of knowledge and negative attitudes. Of the characteristics of the setting, overall lack of support was the most commonly identified barrier. Fewer barriers were identified overall relating to the characteristics of the research and the presentation of the research; students and faculty described the lack of availability and questionable relevance of research evidence as barriers.

Number of studies in which barriers and facilitators to the use of evidence in clinical education have been identified.

Figure 2.

Number of studies in which barriers and facilitators to the use of evidence in clinical education have been identified.

Educational Strategies Described to Promote EBP by Nursing Students in Clinical Education

Twenty-three of the included studies represented evaluations of educational strategies to encourage EBP in clinical placements. One of these studies was published between 1998 and 2004, 12 were published between 2005 and 2009, and 10 between 2010 and 2015. Descriptive evaluation designs were most commonly used (n = 10 of 23, 44%). Ten studies originated in the United States, followed by four studies in Finland. The remaining studies originated in a wide variety of countries. Six studies (26%) used a posttest only design, and the remainder used one-group pretest–posttest designs (n = 6 of 23, 26%) or quasi-experimental pretest–posttest design (n = 3 of 23, 13%). Structured questionnaires were the main method of data collection, but this data collection method was supplemented with other methods, such as open-ended questions, examination of student assignments and journals, practice and role-play observations, diaries, and focus groups.

Twenty (87%) of the 23 studies relied on researcher-designed questionnaires, with limited documentation of psychometric properties of the instruments. Kim, Brown, Fields, and Stichler (2009) used the Knowledge, Attitudes, and Behaviors questionnaire, developed and evaluated by Johnston et al. (2003), to assess undergraduate EBP teaching and learning. Morris and Maynard (2010) used an adapted version of the Fresno test of competence in evidence-based medicine (Ramos, Schafer, & Tracz, 2003) to test knowledge and skills in EBP. Oh et al. (2010) used eight items from Funk's Barriers to Research Utilization Scale (Funk et al., 1991).

A summary of the types of educational strategies that were evaluated in the intervention studies (n = 23) is provided in Table B (available in the online version of this article). Most of these studies (n =16 of 23, 70%) evaluated the implementation of EBP projects. EBP projects involved students addressing a relevant clinical question through the identification of evidence support practices in the clinical setting. EBP projects were used alone or in combination with workshops or journal clubs. The second most commonly described intervention was educational workshops and information sessions (n = 8 of 23, 35%), followed by student-led journal clubs (n = 4 of 23, 17%) (totals equal more than 100%, as some combination of educational strategies existed).

Characteristics of Evaluation Studies (n = 24)aCharacteristics of Evaluation Studies (n = 24)aCharacteristics of Evaluation Studies (n = 24)a

Table B:

Characteristics of Evaluation Studies (n = 24)

As evident in Table C (available in the online version of this article), all but two of the intervention studies reported positive subjective or objective outcomes. Four of the 23 evaluation studies demonstrated statistically significant improvements in measured outcomes. MacLaren, Cohen, Larkin, and Shelton (2008) evaluated a training program designed to improve nursing students' attitudes toward pain management. The intervention group had significant improvements in knowledge and use of evidence-based pain management strategies. Kim et al. (2009) evaluated the effectiveness of an “EBP-focused interactive teaching intervention” (p. 1220). Their quasi-experimental, controlled, pretest–posttest study demonstrated significant improvements in EBP knowledge and use in the experimental group versus the controls group. Oh et al. (2010) evaluated an EBP project in combination with education and support for students and clinical preceptors. They evaluated the intervention through a one-group pretest–posttest design with 74 third-year bachelor of science in nursing students and found that scores on all scales of the EBP Efficacy Scale improved significantly (Oh et al., 2010), and that overall barriers to research utilization decreased. Finally, Zhang, Zeng, Chen, and Li (2012) found significant improvements in EBP knowledge, attitudes, and behaviors (i.e., measured using a research-developed questionnaire) after an educational intervention that included self-directed learning, EBP workshops, and a critical appraisal exercise.

Summary of Results of Evaluation Studies (N = 24)Summary of Results of Evaluation Studies (N = 24)Summary of Results of Evaluation Studies (N = 24)Summary of Results of Evaluation Studies (N = 24)Summary of Results of Evaluation Studies (N = 24)Summary of Results of Evaluation Studies (N = 24)

Table C:

Summary of Results of Evaluation Studies (N = 24)

Scoping Review Stakeholder Consultation

Participants in the stakeholder consultation included three senior nursing students, one in-class and laboratory professor, and two clinical and laboratory instructors. Participants could relate to the findings in the published literature focusing on barriers and facilitators, especially the challenges encountered in the clinical setting (e.g., negative attitudes of staff nurses and lack of human resources on clinical units to support EBP), the issue of trying to identify when to consult evidence to inform practice, and once evidence is found, determining what is relevant for practice. In terms of the educational strategies discussed in included studies, stakeholders thought the approaches that promoted linkages between students and staff on the clinical units (EBP projects and journal clubs) would be relevant and helpful for clinical nursing education. Agreement was expressed related to the next steps for research in this area. In addition, participants believed that research focusing on strategies that better linked classroom and clinical learning is needed.

Linking Barriers and Educational Strategies

Figure 2 illustrates the most common barriers identified in the included studies. The presence of the setting-related barriers was also supported by the stakeholders. Table C provides a description of the barriers that each of the evaluated educational strategies is attempting to address. Evidence exists that some identified barriers are addressed, that others have been somewhat addressed, and that still others have received minimal attention. When examining strategies that focus on nursing students, faculty, and nursing staff, educational strategies most commonly addressed the barrier of lack of knowledge and skills (n = 22 of 23, 96%), followed by negative attitudes (n = 10 of 23, 44%). No studies looked at the barrier of educational preparation. In terms of characteristics of the setting, the evaluated educational strategies looked at addressing support for EBP in nine of 23 studies (39%). The curriculum is a barrier that was frequently addressed in 19 (83%) of 23 of studies. Resources to support EBP in the clinical setting was a barrier addressed in only two (9%) of 23 of studies. One (4%) of the 23 studies examined the barrier of quality and relevance of the evidence, and three (13%) of 23 of studies focused on the availability of evidence as a barrier. Education alone, and interventions combined with education, had the most studies with statistically significant positive outcomes in terms of improvements in participants' knowledge, skills, and attitudes toward EBP.

Discussion

Using the Arksey and O'Malley (2005) approach to scoping reviews, several studies were identified that reflected barriers and facilitators to nursing students' use of EBP, along with studies that reflected the evaluation of educational strategies to promote nursing students' use of evidence as part of their clinical placements. The most common barriers identified in the included studies were those related to support in the clinical setting, as well as knowledge, skills, and attitudes on the part of nursing students, faculty, and nursing staff. Many of the evaluated educational strategies represent approaches that address these barriers; however, several do not. Combining strategies appears to be the best approach to address multiple barriers. Limitations of the reviewed literature include a lack of description of barriers and facilitators from the perspective of staff nurses that support nursing students in clinical placements and interventions that engage the multiple stakeholders (e.g., clinical nurses, interprofessional team members, and faculty) that influence nursing students' EBP in clinical settings.

Implications for Education

This scoping review demonstrates that a number of educational strategies have been evaluated to address the barriers to nursing students' use of evidence in clinical education. Many ways exist to improve the situation; it is important as educators that we do something, and that our action must represent an integrated approach that crosses classroom and clinical settings. In a recent study, Blackman and Giles (2017) demonstrated that EBP knowledge and skills have the largest positive influence on participants' ability to apply clinical practice improvement strategies. As shown in the studies included this review, education related to EBP processes would help to address the barrier of lack of knowledge and skills. The barriers of negative attitudes to using research findings, and the lack of time available to implement findings in practice, would be addressed through EBP projects. In addition, if students engage in the EBP process in clinical units, they will be able to better comprehend the relevance of research findings. Similar to the literature regarding strategies to promote EBP by nurses in clinical practice settings (Yost et al., 2014), it is likely that using multiple approaches to nursing student education will improve students' knowledge, attitudes, and skills related to EBP. Doubtless, many educators may still question how they may be able to make these changes.

One model that may provide guidance in making changes in the current authors' approach to education is that of Khan and Coomarasamy (2006). They have proposed a hierarchy of teaching methods for the effective education of health care professionals related to EBP. Khan and Coomarasamy (2006) advocated for “clinically-integrated-interactive” (p. 6) approaches to teaching that are based on the learners' needs and the clinical context. Activities that fall under this include journal clubs, clinical rounds, and case discussions, as well as the previously mentioned EBP projects featured in several of the studies included in this review. Interventions such as EBP projects engage students; they take an active role in their learning and act not as mere recipients of knowledge, but also creators of that knowledge.

To make these changes in approaches to nursing student education, role development for clinical instructors and clinical nurses supporting students is necessary for these approaches to be used. This would address the barrier identified in the review regarding the educational preparation of faculty. Hussein and Hussein (2013) indicated that those faculty who taught in clinical settings actually had less positive attitudes toward EBP than classroom professors, perhaps because of a lack of training resources and less academic preparation. This reflects a recommendation in the recently published best practice guideline Practice Education in Nursing from the Registered Nurses' Association of Ontario (2016) that “clinical nursing instructors possess current theoretical and clinical expertise and support ongoing professional development opportunities to promote the transfer of theory to practice” (p. 9). Faculty workshops, such as those evaluated by Higuchi et al. (2006), hold promise to help address the issue of clinical instructor knowledge and skills regarding EBP.

Similar to the findings of studies included in this review that focused on the barriers inherent in the clinical settings and strategies to try to minimize them, Ryan (2016) identified that the focus on the more practical, skills-based aspects of nursing takes priority over EBP implementation, and that this characteristic of nursing, as well as unit culture, must be addressed. Henderson, Cooke, Creedy, and Walker (2012) indicated that practice areas should have nurse specialists or champions who are encouraged to support EBP in clinical areas, and that leadership in clinical areas should focus on changing unit cultures to be more open to practice improvements through EBP. In addition, improved partnerships between clinical and academic agencies may promote EBP by both students and nursing staff. Beal (2012) indicated that the benefits of academic– service partnership include the “maximization of resources, enhanced opportunity for educators to remain current in practice, cost effective quality care and education of students and staff, increased research productivity, and development of patterns of excellence” (Para. 7). Successful interventions described in Beal's review were those that emphasized collaboration between clinical staff and nursing students and nurse educators. Blackman and Giles (2017) identified the importance of nursing students observing EBP practices in the clinical setting—notably, that this influences their subsequent confidence in engaging with EBP. These approaches would help to address common barriers identified, such as lack of supports, negative attitudes toward EBP, and students' lack influence in the clinical setting.

Implications for Research

The majority of studies that focused on the identification of barriers and facilitators to the use of evidence in clinical education were from the perspective of students and, secondarily, from the perspective of faculty. It would be beneficial to expand the body of literature focusing on the perceptions of faculty, particularly the clinical instructors who are working with students in the clinical setting, and also to focus on the staff nurses who are working side-by-side with students as part of their placements. What do they see as the barriers and facilitators to nursing students' EBP? What do they see as their role in supporting students as part of their clinical education? How do the barriers and facilitators to clinical nurses' EBP link with those identified by nursing students and faculty?

Nursing students' use of evidence in clinical education does not occur in isolation. It is an inherently social process, affected by the faculty members (both in class and in clinical settings), nursing staff, and interprofessional team members. Although many of the evaluated educational strategies did attempt to affect more than one of the parties described above, none of them considered all. An important contribution to this area would be to evaluate strategies that have an effect on all relevant players influencing nursing students' use of evidence in clinical education, recognizing the potential methodological challenges that would be present.

Part of this review included documenting the methods used in this area of educational research. Overall, a lack of used experimental methods exists, with most studies using single sites with small convenience samples. In its position statement on nursing research, The American Association of Colleges of Nursing (2006) called for “the use of rigorous research strategies in the assessment of the teaching-learning process and outcomes at all levels of nursing education…” (Para. 14). The National League for Nursing (2016) echoed this call in its Research Priorities for 2016 to 2019, indicating that research efforts “build the science of nursing education through the discovery and translation of innovative evidence-based strategies” through the “creation of robust multi-site, multi-method research designs that address critical education issues” (p. 2). The American Association of Colleges of Nursing (2006) acknowledged that a lack of funding for nursing education research has hampered progress in this area. More rigorous studies in this area will help to raise the profile of educational research and result in better educational outcomes for nursing graduates and patient outcomes for those in their care.

An additional research limitation that arose from the scoping review is the apparent lack of evaluation tools that are specific to measuring EBP constructs in nursing student populations. The National League for Nursing's Research Priorities (2016) recommends “development and testing of instruments for nursing education research to measure learning outcomes and linkages to patient care” (p. 2). Eighty-three percent of included intervention studies and 50% of descriptive studies used researcher-developed tools, and for those studies that used validated tools, the majority were tools that have been validated in practicing clinicians (e.g., nurses and others). Ruzafa-Martinez, Lopez-Iborra, Moreno-Casbas, and Madrigal-Torres (2013) have described the development and initial validation of the Evidence-Based Practice Evaluation Competence Questionnaire, indicating that it is an appropriate tool to evaluate nursing students' competence in EBP. Upton, Scurlock-Evans, and Upton (2016) recently published a description of the Student(S)-EBPQ (Evidence-Based Practice Questionnaire), along with reporting results of the tool's reliability and validity. This tool measures frequency of EBP practices and attitudes toward EBP, as well as factors relating to sharing and applying EBP and retrieving and reviewing evidence. Having instruments that specifically measure the constructs regarding nursing students and EBP will facilitate the conduct of rigorous, relevant research in this area that can then inform educational practice.

Strengths and Limitations

Davis et al. (2009), as well as Pham et al. (2014), advocated for more standardized approaches to this type of synthesis. Currently, no reporting guidelines exist for scoping reviews as exists for systematic reviews (Equator Network, 2016). In their review of scoping studies, Davis et al. (2009) compared included studies against criteria described by Anderson, Allen, Peckham, and Goodwin (2008). The criteria met in this scoping review include:

  • Using a systematic approach to identification of studies.
  • Identifying strengths and weakness of the research base.
  • Identifying research gaps.
  • Providing recommendations for future research.
  • Indicating the value of further empirical research.
  • Acting as a resource for research findings.

Additional strengths of this review relate to the procedures that were undertaken to ensure the reliability and validity of the literature search process and the selection of articles for inclusion and the extraction of data. The protocol for the scoping review was created by a team with expertise in nursing education and knowledge synthesis, including library scientists. Two reviewers screened citations and abstracts, with involvement of a third reviewer in cases of disagreement and uncertainty.

One of the possible limitations of this scoping review is that it may have missed some relevant studies, as the grey literature was not searched and online search engines such as Google and Google Scholar were not used. This limitation was mitigated through hand searching reference lists of included articles, as well as the tables of contents of relevant journals, and through consultation. This scoping review was limited to English and French articles, and this may have limited results, as research in this area is taking place in several non-English–speaking countries. Limitations of the review also stem from limitations of the included studies. For example, many studies did not provide a fulsome description of the educational strategies evaluated. It is important to recognize that nursing education will vary from country to country and from program to program, so applicability to other settings outside that of the original country of study or study setting may be limited.

Conclusion

This scoping review has considered the unique context of clinical education and summarized the literature regarding the barriers and facilitators that influence students' use of EBP, as well as the educational strategies that have been evaluated. Some evidence suggests that approaches that engage students in EBP projects in clinical areas, along with the provision of education to students, nurses, and faculty to provide EBP knowledge and skills, can reduce barriers such as limited knowledge and poor attitudes to, and enhance facilitators, of EBP. The implications of this review are relevant at the level of individual schools of nursing and hospital units, at the level of academic and clinical partnerships, and at the level of health care research and national nursing accreditation associations. Schools of nursing must look at curriculum models that support the integration of EBP competencies beyond the classroom. To have credibility and capacity to support students in this important learning, clinical instructors and nurses must have the competencies to do so. In addition, academic and clinical agencies must engage in meaningful partnerships that will result in improvements in the student's learning, as well as clinical care processes.

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Summary of Studies Describing Barriers, Facilitators, and Other Factors Influencing EBP in Clinical Education (n = 15)a

AuthorsDateCountrySampleTheoretical FrameworkDesign Data CollectionKey Findings
Students
Arslan & Celen2014Turkey263None describedDescriptive cross-sectional correlational surveyPositive attitudes towards EBP associated with: Taking research course; reading journal articles; participating in scientific activities; desire to do research after graduation.
Ax & Kincade2001U.K.12None describedQualitative descriptive interviewsBarriers described:Students' resistance, clinical staff, and managers' resistance; difficulty understanding research and its relevance to nursing.
Bjorkstrom et al.2003Sweden155None describedDescriptive cross-sectional correlational surveyPositive attitude toward research related to: interest in research area; being female; older age; previous academic study. 77% knew of at least one researcher. 25% had never read one of the scholarly journals listed. 60% expected to use nursing research. 25% thought nursing education included too muchresearch. 17% felt education did not prepare them very well for the use of research.
Brooke et al.2015U.K. Slovenia70None describedInterpretive phenomenology focus groupsBarriers described: Lack of nurses' involvement in research; time limitations; difficulty accessing information; students' lack of awareness of EBP; maintaining research skills once a nurse. Students perceived that EBP/research: Provided confidence, knowledge and empowerment in clinical practice; is vital for improvements in patient care and safety; and part of students' responsibility to develop nursing as a profession.
Brown et al.2010U.S.436None describedCross-sectional quantitative descriptive survey52.9% reported too much information. 47.8% unable to judge quality of retrieved information. 46.8% too busy to get information. Longer length of time in program associated with: EBP knowledge; attitudes toward; and future use of EBP. Having confidence in clinical decision making associated with: EBP knowledge; EBP use; and future use of EBP. Being prepared for clinical associated with: EBP knowledge; EBP use; future use of EBP. Frequently used sources of evidence: Textbooks,84%;Internet, 77%; RNs/MDs, 51%.
Florin et al.2012Sweden1440None describedCross-sectionalquantitative descriptive andcorrelational surveyStudents experienced a higher degree of support for RU during campus education versus clinical education. Positive correlations from 0.140 to 0.316 found between students' experience of support for RU and capability beliefs regarding EBP skills. Support for RU during clinical education correlated with capability beliefs.
Higuchi et al.2006Canada20None describedQualitative descriptive focus groups and interviewsBarriers described: lack of knowledge about BPGs, lack of integration in clinical courses
Jonsen et al.2013Sweden Finland24None describedQualitative descriptive focus groupsBarriers described: disconnect between theoretical nursing and practice; little attention to EBP on the part of clinical preceptors; clinical preceptors had intolerant and condescending attitudes toward research. Facilitator described: getting support from some preceptors to search for articles that related to clinical problems.
Llasus et al.2014U.S.174None describedCross-sectional quantitative/qualitative correlational surveyBarrier described: relying on teaching EBP in the classroom. Facilitators described: using a problem-solving approach in the clinical setting; students' EBP readiness. EBP knowledge, M=7.62 (max score = 15); EBP readiness above average; EBP implementation low. EBP readiness and knowledge positively correlated. EBP readiness and implementation positively correlated. EBP implementation and EBP knowledge negatively correlated (decrease in EBP knowledge associated with an increase EBP implementation).
MacVicar1998Scotland10 midwifery students 9 nursing studentsNone describedQualitative Ethnography InterviewsBarriers described:Negative attitudes, fear of some staff; students' lack of influence/power in clinical setting and poor practice environments. Facilitators described:Students being imaginative, creative, perceived benefits of research; peer discussion/reflective sessions; having a research component in clinical course, with assignments and seminars on campus; and manager support.
Smith-Strømet al.2012Norway14None describedDescriptive evaluation, focus groupsBarriers described: lack of time; not a priority; searching for articles difficult; articles not written in Norwegian; lack of engagement/encouragement/knowledge of staff nurses. Facilitators described: Students' skills in EBP; leaders' and fellow students' commitment to EBP.
Faculty
Stichleret al.2011U.S.40Diffusion of innovation Adult learning theoryCross-sectional quantitative correlational SurveyBarriers described: unaware of relevant research; isolated from knowledgeable peers; lack of time; no authority to change focus to EBP; implications for education not clear. Multiple regression analysis indicate barriers to teaching EBP effect the “practice” of teaching EBP more than the “knowledge and skills” or “attitudes” toward EBP. Master's-level education associated with positive attitude toward EBP, PhD associated with negative attitude to EBP. EBP knowledge and skills positively correlated with EBP.
Upton et al.2015U.K. U.S. Australia81None describedCross-sectional quantitative/qualitative correlational surveyBarriers described: Not knowing where to find evidence; having relevant, accessible evidence; lack of time and power to change things in the clinical setting; lack of cohesion between academic and clinical teaching contexts; lack of concordance between nursing education and clinical reality; students feel it is boring and pointless. Facilitators described: access to the Internet in the workplace; post-graduate education; curriculum enhancements; confidence in EBP skills. Academic faculty reported greater knowledge/skill in EBP than clinical faculty
Walti-Bolliger et al.2007Switzerland222Diffusion of innovationCross-sectional quantitative/qualitative Correlational surveyBarriers described: Lack of time to bring new ideas up and to read research; lack of accessibility of research reports; lack of nursing science knowledge of colleagues; lack of collaboration of physicians; lack of support from administration and the team; lack of financial resources, material and expertise. Research experience and research education influence communication of research findings.
Faculty and students
Kajermo et al.2000Sweden37 faculty 166 studentsNone describedCross-sectional quantitative / qualitative descriptive surveyBarriers described: implications for practice not clear; research not readily available; nurse is isolated from knowledgeable peers. Facilitators described: education for nurses; opportunity to participate in research projects; change of nurses' attitudes toward research; time to read and discuss research; increased staffing; positions devoted to RU; cooperation between academic and clinical settings; support from managers; access to high quality, relevant research.

Characteristics of Evaluation Studies (n = 24)a

AuthorsDateCountrySample (N)Theoretical FrameworkDesign Data CollectionIntervention
Education only
Higuchi et al.2006Canada43None describedQuantitative descriptive surveyFaculty education
MacLaren et al.2008US50None describedQuasi-experimental, pretest, posttest survey and observationsEducation
Mohide & Matthew-Maich2007Canada9 dyadsNone describedPosttest only, survey and interviewsEducational workshop –students and preceptors
Zhang et al.2012China75None describedPretest-posttest designEducation
EBP practice projects
Brancato2006USNot reportedNone describedDescriptive evaluation surveys plusother data sourcesEBP project
Foss et al.2014Norway and Sweden68Collaborative model of best practicePosttest only pilot test, surveyEBP project
Helms & Pruitt-Walker2015USNot reportedNone describedDescriptive evaluation, data collection approach not specifiedEBP project “paint a picture of mental illness”
Kenty2001US29None describedPretest, posttest evaluation surveyEBP project
Kruszewski et al.2009US24None describedDescriptive evaluation survey and focus groupEBP project
Morris & Maynard2009UK3 students 2 mentorsNone describedPretest-posttest, surveyEBP project
Schoenfelder2007US13None describedDescriptive evaluation surveyEBP project
Smith-Strøm et al.2012Norway14Lave's and Wenger's situated learningDescriptive evaluation, focus groupsEBP project
Stone & Rowles2007US42None describedDescriptive evaluation, phone surveyEBP project
Tishelman et al.2007Sweden107None describedPosttest only, surveys and other sources of dataEBP project
Other single strategies
Aäri et al.2008Finland20None describedPretest, posttest surveyOne PBL cycle with two tutorials during 4-week clinical placement.
Harmer et al.2011US16 dyadsSituated learning theory Tanner's clinical judgement modelPosttest only, surveyClinical peer mentoring experience on a dedicated education unit
Mattila et al.2013Finland53None describedPosttest only, surveyJournal club
Combined educational strategies
Finotto et al.2013Italy300None describedQuantitative descriptive surveyEducation and EBP projects, across 3 years of curriculum.
Higuchi et al.2006CanadaFaculty n = 19 29 pre, 13 posttest Students 111 pre-workshop 85 end of placementNone describedPilot Pretest-posttest evaluation Survey and telephone interviewsFaculty education and Website
Kim et al.2009US208None describedQuasi experimental, controlled, pretest-posttest surveyEducation plus EBP project
Laaksonen et al.2013FinlandNurses 216 Students 235None describedDescriptive evaluation using semistructured surveyEBP project plus journal club
Mattila & Eriksson2007Finland50None describedDescriptive evaluation surveyEBP project plus journal club
Morris & Maynard2010UKNursing 8 Physio 10None describedPretest-posttest, surveyPersonal data assistant plus EBP activity (guideline appraisal)
Oh et al.2010Korea74None describedOne group pretest-posttest, surveyEducation plus EBP project

Summary of Results of Evaluation Studies (N = 24)

StudyDesign InstrumentBarrier(s) AddressedOutcomeResults
Education Only
Higuchi et al. 2006 (n = 34)Quantitative descriptive Researcher-developed questionnaireFaculty: Attitude regarding BPGs Knowledge re: BPGsAttitudes to BPGs: instructorsConfidence in implementing BPGs in teaching M=3.76/5–mean score
Knowledge of BPGs: instructorsAble to identify BPGs suitable for students M=4.14/5–mean score
MacLaren et al., 2008 (n = 50)Quasi-experimental, pre-test, posttest Researcher-developed questionnaireStudents: Knowledge regardingEBP pain strategies Attitudes toward pain management CurriculumKnowledge of pain conceptst test Control pre M=10.78; post M=11.00 Training pre M=11.26; post M=13.00* (p<.05)
Attitudes toward pain managementControl same pre and post Training pre M=3.72; post M=4.04
Mohide & Matthew-Maich, 2007 (n = 18)Posttest only Researcher-developed questionnaireStudents and preceptors: Attitudes Knowledge/skills Support Resources AvailabilityAttitudesNarrative summary: positive
Knowledge: preceptors and studentsNarrative summary: positive
Knowledge: studentsNarrative summary: positive
Support/resources/availabilityNarrative summary: positive
Zhang et al., 2012 (n = 75)Pretest-posttest design Researcher-developed questionnaireStudents: Attitudes/beliefs Knowledge CurriculumAttitudes and beliefst test Preintervention M = 35.67 Postintervention M =38.99a (p<.05)
KnowledgePreintervention M = 11.51 Postintervention M =17.11a (p<.05)
BehaviorPreintervention M = 10.99 Postintervention M =17.11a (p<.05)
EBP Project Only
Brancato, 2006 (nnot reported)Descriptive evaluation Researcher-developed questionnaireStudents: Knowledge/skills SupportAvailability CurriculumKnowledge/skillsNarrative summary: positive
SupportNarrative summary: positive
AvailabilityNarrative summary: positive
Foss et al., 2014 (n = 68)Posttest only Researcher-developed questionnaireStudents and nurses: Attitude Knowledge/skills Support Quality/relevance CurriculumAttitude74% 2nd year 95% 3rd year reported EBP important for care RNs narrative summary: positive
Knowledge/skillsRNs narrative summary: positive
Support100% 2nd year 95% 3rd year reported collaboration worked well RNs narrative summary: positive
Helms & Pruitt-Walker, 2015 (nnot reported)Descriptive evaluation Student's anecdotal notesStudents: Knowledge/skills CurriculumKnowledge/skillsNarrative summary: positive
Kenty, 2001 (n = 29)Pretest-posttest Evaluation Knowledge, Attitudes and Behaviors for EBP (Johnston et al., 2003)Students: Attitudes/beliefs Knowledge/skills CurriculumAttitudesScores not provided “increases in student attitude were not significant”
Knowledge/skillsScores not provided “increases in student knowledge were significant”
Kruszewsk et al., 2009 (n = 24)Descriptive evaluation Researcher-developed interview guide & Performance scale (12 criteria for EBP based on CURN model)Students: Attitudes Knowledge/skills CurriculumAttitudesStudents' scores above level of competency for belief in importance of EBP
Knowledge/skillsStudents' scores above level of competency for items related to knowledge of EBP
Morris & Maynard, 2009 (n = 3)Pretest-posttest Fresno questionnaire (Ramos et al., 2003; adapted by McCluskey and Lavoarini, 2005)) plus researcher-developed questionnaireStudents: Knowledge/skills Support CurriculumKnowledge/skillsFresno score by participant 1: pre = 50, post = 68 2: pre = 57, post = 88 3: pre = 78, post = 87
SupportNarrative summary-positive
Schoenfelder, 2007 (n = 13)Descriptive evaluation Researcher-developed questionnaireStudents: Attitudes toward EBP guidelines Knowledge regarding gerontology CurriculumAttitudes toward EBP guidelinesNarrative summary-positive
Knowledge regarding gerontologyNarrative summary-positive
Smith-Strømet al., 2012 (n = 14)Descriptive evaluation Researcher-developed interview guideStudents: Attitudes Knowledge/skills SupportAttitudesNarrative summary-mixed
KnowledgeNarrative summary-positive
SupportNarrative summary-positive
Stone & Rowles, 2007 (n=42)Descriptive evaluation Researcher-developed interview guideSetting: Support (lack of time) CurriculumEducation of nursing staff59% of nurses surveyed said project educated nursing staff.
Change of policy/practice on unit3 projects changed policy 5 projects changed practice
Tishelman et al., 2007 (n = 107)Posttest only Researcher-developed questionnaireStudents: Knowledge/skills Setting: Support CurriculumKnowledgeNarrative summary-positive
Collaborative partnerships academic/clinicalNarrative summary-negative
Other single strategies
Aäri et al., 2008 (n = 20)Pretest-posttest Researcher-developed questionnaireStudents: Attitude toward Information retrieval Knowledge/skills CurriculumAttitudeScores not provided “no significant difference in attitude”
Knowledge/skills (PBL)Scores not provided “increases in PBL skills significant”
Harmer et al., 2011 (n = 32)Descriptive evaluation Students anecdotal notesStudents: Knowledge/skills CurriculumKnowledge/skillsNarrative summary-positive
Mattila et al., 2013 (n = 53)Posttest only Researcher-developed questionnaireStudents: Knowledge/skills Setting: Support CurriculumKnowledge/skills40 of 53 learned to read research articles37 of 53 understood what evidence-based nursing is40 of 53 were able to search for knowledge from various sources40 of 53 learned about the research process
SupportNarrative summary-positive
Combined educational strategies
Finotto et al., 2013 (n = 300)Posttest only Researcher-developed questionnaireStudents: Knowledge/skills CurriculumKnowledge/skillsHighest rating = 10 M = 7- Skills useful M=5 - Difficulty forming clinical question M = 6 Used PICO M = 7 Use of PubMed® M = 5 Use of ClNAHL® M=7 Effective research on electronic database M=7 Found evidence for clinical problems
Higuchiet al., 2006 (n= faculty 29 pre-, 13 posttest Students 111 pre-workshop 85 end of placement)Researcher-developed questionnaireInstructors: Attitude knowledge/skills Students': AttitudeAttitude toward BPGs-instructorsOne-way ANOVA Preworkshop M = 3.93 Postworkshop M = 3.92
Knowledge of BPGs-instructorsPreworkshop M = 2.62 Postworkshop M = 3.35a p ≤ .01
Behaviors (use of BPGs) - instructorsPreworkshop M = 2.21 Postworkshop M = 3.08a p ≤ .05
Attitude toward BPGs-studentsBPGs useful for learning regarding nursing practice Pre-workshop M = 3.86 Post-workshop M=3.92 BPGs useful for learning about client care Pre-workshop M = 3.82 Post-workshop M=3.99 Easy to implement BPGs in mental health clinical Pre-workshop M = 1.59 Post-workshop M=2.29a p ≤ .01
Kim et al., 2009 (208)Quasi-experimental, controlled, pretest-posttestStudents: Attitudes Knowledge/skills CurriculumAttitudest test Experimental group 4.78, Control group 4.90
KnowledgeExperimental group 5.68, Control group 5.43*p=.001
BehaviorsExperimental group 2.62, Control group 2.36*p=.015
Future use of EBPExperimental group 5.17, Control group 5.04
Laaksonen et al., 2013 (n=216 nurses, 235 students)Descriptive evaluation Researcher-developed interview guideStudents: knowledge/skills Setting: Support CurriculumKnowledge/skills75% of students reported improved competence in EBP skills
SupportNarrative summary-positive
Mattila & Eriksson, 2007 (n = 50)Descriptive evaluation Researcher-developed interview guideStudents: Knowledge/skills CurriculumLearning of research skills28 of 132 mentioned familiarization with research article 48 of 132 mentioned understanding of research concepts 56 of 132 mentioned understanding of research in nursing practice
Learning of nursing care3 of 64 indicated that assignment did not advance their learning of nursing care.
Morris & Maynard, 2010 (n = 18)Posttest pilot studyResearcher-developed questionnaireStudents:Knowledge/skills Setting: Resources Presentation: AvailabilityEBP knowledge and skills14 of 19 reported development of EBP skills related to application 13 of 19 reported development of EBP skills related to critical appraisal 7 of 19 reported development of EBP skills related to search and retrieval
Resources/availability13 of 30 rarely used PDA 4 of 30 used PDA in clinical setting 11 of 30 felt no “added value” to use of PDA
Oh et al., 2010 (n = 74)One group pre-test/post-testStudents: Knowledge/skillsEBP efficacyt test Pretest M=2.30; Posttest M=3.05*p <.001
EBP Efficacy Scale developed by researchers; Barriers to RU (Funk et al., 1991)CurriculumStudents' perceptions of Barriers to research utilizationPretest M=2.02; Posttest M=1.67*p < .001
Authors

Ms. Fiset is a PhD candidate, and Dr. Davies is Professor, School of Nursing, and Dr. Graham is Professor, School of Epidemiology, Public Health and Preventive Medicine, University of Ottawa, Ottawa, Ontario, Canada.

© 2017 Fiset, Graham, Davies; licensee SLACK Incorporated. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International ( https://creativecommons.org/licenses/by-nc/4.0). This license allows users to copy and distribute, to remix, transform, and build upon the article non-commercially, provided the author is attributed and the new work is non-commercial.

The work contained in this review was supported by a doctoral research award from the Canadian Institutes of Health Research (CIHR) to Ms. Fiset, and by CIHR Foundation Grant #143237 to Dr. Graham.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors wish to thank Tarra Findlay, Jenny Lin, Candice McMullen, and Jessica Ross for their assistance.

Address correspondence to Valerie J. Fiset, MScN, RN, PhD candidate, University of Ottawa School of Nursing, 451 Smyth Road, Room RGN 1118, Ottawa, ON, Canada K1H 8M5; e-mail: vfise090@uottawa.ca.

Received: March 06, 2017
Accepted: April 06, 2017

10.3928/01484834-20170817-04

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