how does critical thinking relate to evidence based practice

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The Effectiveness of an Evidence-Based Practice (EBP) Educational Program on Undergraduate Nursing Students’ EBP Knowledge and Skills: A Cluster Randomized Control Trial

Daniela cardoso.

1 Health Sciences Research Unit: Nursing, Nursing School of Coimbra, Portugal Centre for Evidence-Based Practice: A Joanna Briggs Institute Centre of Excellence, 3004-011 Coimbra, Portugal; tp.cfnese@osodracf (A.F.C.); tp.cfnese@oiregor (R.R.); moc.liamg@7ramed (M.A.R.); tp.cfnese@olotsopa (J.A.)

2 FMUC—Faculty of Medicine, University of Coimbra, 3000-370 Coimbra, Portugal

Filipa Couto

3 Alfena Hospital—Trofa Health Group, Health Sciences Research Unit: Nursing, Nursing School of Coimbra, 3000-232 Coimbra, Portugal; moc.liamg@otuoccdapilif

Ana Filipa Cardoso

Elzbieta bobrowicz-campos.

4 Health Sciences Research Unit: Nursing, Nursing School of Coimbra, 3004-011 Coimbra, Portugal; [email protected] (E.B.-C.); tp.cfnese@stnasasiul (L.S.); tp.cfnese@ohnituocv (V.C.); tp.cfnese@otnipaleinad (D.P.)

Luísa Santos

Rogério rodrigues, verónica coutinho, daniela pinto, mary-anne ramis.

5 Mater Health, Evidence in Practice Unit & Queensland Centre for Evidence Based Nursing and Midwifery: A Joanna Briggs Institute Centre of Excellence, 4101 Brisbane, Australia; [email protected]

Manuel Alves Rodrigues

João apóstolo, associated data.

The data presented in this study are available on request from the corresponding author. The data are not publicly available because this issue was not considered within the informed consent signed by the participants of the study.

Evidence-based practice (EBP) prevents unsafe/inefficient practices and improves healthcare quality, but its implementation is challenging due to research and practice gaps. A focused educational program can assist future nurses to minimize these gaps. This study aims to assess the effectiveness of an EBP educational program on undergraduate nursing students’ EBP knowledge and skills. A cluster randomized controlled trial was undertaken. Six optional courses in the Bachelor of Nursing final year were randomly assigned to the experimental (EBP educational program) or control group. Nursing students’ EBP knowledge and skills were measured at baseline and post-intervention. A qualitative analysis of 18 students’ final written work was also performed. Results show a statistically significant interaction between the intervention and time on EBP knowledge and skills ( p = 0.002). From pre- to post-intervention, students’ knowledge and skills on EBP improved in both groups (intervention group: p < 0.001; control group: p < 0.001). At the post-intervention, there was a statistically significant difference in EBP knowledge and skills between intervention and control groups ( p = 0.011). Students in the intervention group presented monographs with clearer review questions, inclusion/exclusion criteria, and methodology compared to students in the control group. The EBP educational program showed a potential to promote the EBP knowledge and skills of future nurses.

1. Introduction

Evidence-based practice (EBP) is defined as “clinical decision-making that considers the best available evidence; the context in which the care is delivered; client preference; and the professional judgment of the health professional” [ 1 ] (p. 2). EBP implementation is recommended in clinical settings [ 2 , 3 , 4 , 5 ] as it has been attributed to promoting high-value health care, improving the patient experience and health outcomes, as well as reducing health care costs [ 6 ]. Nevertheless, EBP is not the standard of care globally [ 7 , 8 , 9 ], and some studies acknowledge education as an approach to promote EBP adoption, implementation, and sustainment [ 10 , 11 , 12 , 13 , 14 , 15 ].

It has been recommended that educational curricula for health students should be based on the five steps of EBP in order to support developing knowledge, skills, and positive attitudes toward EBP [ 16 ]. These steps are: translation of uncertainty into an answerable question; search for and retrieval of evidence; critical appraisal of evidence for validity and clinical importance; application of appraised evidence to practice; and evaluation of performance [ 16 ].

To respond to this recommendation, undergraduate nursing curricula should include courses, teaching strategies, and training that focus on the development of research and EBP skills for nurses to be able to incorporate valid and relevant research findings in practice. Nevertheless, teaching research and EBP to undergraduate nursing students is a challenging task. Some studies report that undergraduate students have negative attitudes/beliefs toward research and EBP, especially toward the statistical components of the research courses and the complex terminology used. Additionally, students may not understand the importance of the link between research and clinical practice [ 17 , 18 , 19 ]. In fact, a lack of EBP and research knowledge is commonly reported by nurses and nursing students as a barrier to EBP. It is imperative to provide the future nurses with research and EBP skills in order to overcome the barriers to EBP use in clinical settings.

At an international level, several studies have been performed with undergraduate nursing students to assess the effectiveness of EBP interventions on multiple outcomes, such as EBP knowledge and skills [ 20 , 21 , 22 , 23 ]. The Classification Rubric for EBP Assessment Tools in Education (CREATE) [ 24 ] suggests EBP knowledge should be assessed cognitively using paper and pencil tests, as EBP knowledge is defined as “learners’ retention of facts and concepts about EBP” [ 24 ] (p. 5). Additionally, the CREATE framework suggests EBP skills should be assessed using performance tests, as skills are defined as “the application of knowledge” [ 24 ] (p. 5). Despite these recommendations, few studies have assessed EBP knowledge and skills using both cognitive and performance instruments.

Therefore, this study aims to evaluate the effectiveness of an EBP educational program on undergraduate nursing students’ EBP knowledge and skills using a specific cognitive and performance instrument. The intervention used in this study was recently developed [ 25 ], and this is the first study designed to assess its effectiveness in undergraduate EBP.

2. Materials and Methods

2.1. design.

A cluster randomized controlled trial with two-armed parallel group design was undertaken (ClinicalTrials.gov Identifier: {"type":"clinical-trial","attrs":{"text":"NCT03411668","term_id":"NCT03411668"}} NCT03411668 ).

2.2. Sample Size Calculation

The sample size was calculated using the software G*Power 3.1.9.2. (Heinrich-Heine-Universität Dusseldorf, Düsseldorf, Germany) Recognizing that there were no studies performed a priori using a cognitive and performance instrument to assess the effectiveness of an EBP educational program on undergraduate nursing students’ EBP knowledge and skills, we used an effect size of 0.25, which is a small effect size as proposed by Cohen [ 26 ]. A power analysis based on a type I error of 0.05; power of 0.80; effect size f = 0.25; and ANOVA repeated measures between factors determined a sample size of 98 as total.

Taking into account that our study used clusters (optional courses) and that each one had an average of 25 students, we needed at least four clusters to cover the total sample size of 98. However, to cover potential losses to follow-up, we included a total of six optional courses.

2.3. Participants’ Recruitment and Randomization

We recruited participants from one Portuguese nursing school in 2018. From the 12 optional clinical nursing courses (such as Community Nursing Intervention in Vulnerable Groups; Ageing; Health and Citizenship; The Child with Special Needs: Diagnoses and Interventions in Pediatric Nursing; Liaison Psychiatry Nursing; Nursing in the Emergency Room; etc.) in the 8th semester of the nursing program (last year before graduation), students from three clinical nursing courses were randomly assigned to the experimental group (EBP educational program) and students from another three clinical nursing courses were randomly assigned to the control group (no intervention— education as usual ) before the baseline assessment. An independent researcher performed this assignment using a random number generator from the random.org website [ 27 ]. This assignment was performed based on a list of the 12 optional courses provided through the nursing school’s website.

2.4. Intervention Condition

The participants in the intervention group received education as usual plus the EBP educational program, which was developed by Cardoso, Rodrigues, and Apóstolo [ 25 ]. This intervention included EBP contents regarding models of thinking about EBP, systematic reviews types, review question development, searching for studies, study selection process, data extraction, and data synthesis.

This program was implemented in 6 sessions over 17 weeks:

• Sessions 1–3—total of 12 h (4 h per session) during the first 7 weeks using expository methods with practice tasks to groups of 20–30 students.
• Sessions 4–6—total of 6 h (2 h per session) during the last 10 weeks using active methods through mentoring to groups of 2–3 students.

Due to the nature of the intervention, it was not possible to blind participants regarding treatment assignment nor was it feasible to blind the individuals delivering treatment.

2.5. Control Condition

The participants in the control group received only education as usual; i.e., students allocated to this control condition received the standard educational contents (theoretical, theoretical–practical, practical) delivered by the nursing educators of the selected nursing school.

2.6. Assessment

All participants were assessed before (week 0) and after the intervention (week 18) using a self-report instrument. EBP knowledge and skills were assessed by the Adapted Fresno Test for undergraduate nursing students [ 28 ]. This instrument was adapted from the Fresno Test, which was originally developed in 2003 to measure knowledge and skills on EBP in family practice residents [ 29 ]. The Adapted Fresno Test for undergraduate nursing students has seven short answer questions and two fill-in-the-blank questions [ 28 ]. At the beginning of the instrument, two scenarios, which suggest clinical uncertainty, are presented. These two scenarios are used to guide the answers to questions 1 to 4: (1) write a clinical question; (2) identify and discuss the strengths and weaknesses of information sources as well as the advantages and disadvantages of information sources; (3) identify the type of study most suitable for answering the question of one of the clinical scenarios and justify the choice; and (4) describe a possible search strategy in Medline for one of the clinical scenarios, explaining the rationale. The next three short answer questions require that the students identify topics for determining the relevance and validity of a research study and address the magnitude and value of research findings. The last two questions are fill-in-the-blank questions. The answers are scored using a modified standardized grading system [ 28 ], which was adapted from the original [ 29 ]. The instrument has a total minimum score of 0 and a maximum score of 101. The inter-rater correlation for the total score of the Adapted Fresno Test was 0.826 [ 28 ]. The rater that graded the answers to the Adapted Fresno Test was blinded to treatment assignment.

Despite the fact that in the study proposal we did not consider any kind of qualitative analysis in order to assess EBP knowledge and skills in a more practical context, we decided during the development of the study to perform a qualitative analysis of monographs at the posttest. The monographs were developed by small groups of nursing students and were the final written work submitted by the students for their bachelor’s degree course. In this work, the students were asked to define a review question regarding the context of clinical practice where they were performing their clinical training. Students then proceeded to answer the review question through a systematic process of searching and selecting relevant studies and extracting and synthesizing the data. From the 58 submitted monographs (30 from the control group and 28 from the intervention group), 18 were randomized for evaluation (nine from the control group and nine from the intervention group) by an independent researcher using the random.org website [ 27 ] based on a list provided by the research team. Three independent experts (one psychologist with a doctoral qualification and two qualified nurses, one with a master’s degree) performed a qualitative analysis of the selected monographs. All experts had experience with the EBP approach and were blinded to treatment assignment. The experts independently used an evaluation form to guide the qualitative analysis of each monograph. This form presented 11 guiding criteria regarding review questions, inclusion/exclusion criteria, methodology (namely search strategy, study selection process, data extraction, and data synthesis), results presentation, and congruency between the review questions and the answers to them that were provided in the conclusion section. Thereafter, the experts met to discuss any discrepancies in their qualitative analysis until consensus was reached.

2.7. Statistical Analyses

The data were analyzed using Statistical Package for the Social Sciences (SPSS; version 24.0; SPSS Inc., Chicago, IL, USA). Differences in sociodemographic characteristics of study participants and outcome data at baseline were analyzed using Pearson’s chi-squared test for nominal data and independent the t -test for continuous data.

Taking into account the central limit theorem and that ANOVA tests are robust to violation of assumptions [ 30 ], we decided to perform two-way mixed ANOVA to compare the outcome between and within groups. The Wilcoxon signed-rank test was used to analyze how many participants had improved their EBP knowledge and skills item-by-item, how many remained the same, and how many had decreased performance within each group. Statistical significance was determined by p -values less than 0.05.

To minimize the noncompliance impact, an intention-to-treat (ITT) analysis was used to analyze participants in the groups that they were initially randomized to [ 31 ] by using the last observation carried forward imputation method.

2.8. Ethics

This study was approved by the Ethical Committee of the Faculty of Medicine of the University of Coimbra (Reference: CE-037/2017). The institution where the study was carried out provided written approval. All participants gave informed consent, and the data were managed in a confidential way.

Twelve potential clusters (optional courses in the 8th semester of the nursing program) were identified as eligible for this study. Of these, three were randomized for the intervention group and three for the control group. During the intervention, eight participants (two in the intervention group and six in the control group) were lost to follow-up because they did not fill-in the instrument in the post-intervention. Figure 1 shows the flow of participants through each stage of the trial.

Consolidated Standards of Reporting Trials (CONSORT) diagram showing the flow of participants through each stage of the trial. ITT: intention-to-treat.

3.1. Demographic Characteristics

As Table 1 displays, 148 undergraduate nursing students with an average age of 21.95 years (SD = 2.25; range: 21–41) participated in the study. A large majority of the sample were female ( n = 118, 79.7%), had a 12th grade educational level ( n = 144, 97.3%), and had participated in some form of EBP training ( n = 121, 81.8%).

Socio-demographic characterization of the sample—ITT analysis.

* Defined as any kind and duration of evidence-based practice (EBP) training, such as EBP contents in a course, a workshop, a seminar.

At baseline, the experimental and control groups were comparable regarding sex, age, education, EBP training, and performance on the Adapted Fresno Test ( Table 1 and Table 3). The baseline data were similar with dropouts excluded; therefore, only ITT analysis results are presented.

3.2. EBP Knowledge and Skills

3.2.1. adapted fresno test.

The two-way mixed ANOVA showed a statistically significant interaction between the intervention and time on EBP knowledge and skills, F (1, 146) = 9.550, p = 0.002, partial η 2 = 0.061 ( Table 2 ). Excluding the dropouts, the two-way mixed ANOVA analysis was similar. Thus, only the ITT analysis results are presented.

Main effects of time and group and interaction effects on EBP knowledge and skills—ITT analysis.

To determine the difference between groups at baseline and post-intervention, two separate between-subjects ANOVAs (i.e., two separate one-way ANOVAs) were performed. At the pre-intervention, there was no statistically significant difference in EBP knowledge and skills between groups: F (1,146) = 0.221, p = 0.639, partial η 2 = 0.002. At the post-intervention, there was a statistically significant difference in EBP knowledge and skills between groups: F (1,146) = 6.720, p = 0.011, partial η 2 = 0.044 ( Table 3 ).

Repeated measures ANOVA and between-subjects ANOVA—ITT analysis.

To determine the differences within groups from the baseline to post-intervention, two separate within-subjects ANOVAs (repeated measures ANOVAs) were performed. There was a statistically significant effect of time on EBP knowledge and skills for the intervention group: F (1,73) = 53.028, p < 0.001, partial η 2 = 0.421 and for the control group: F (1,73) = 13.832, p < 0.001, partial η 2 = 0.159 ( Table 3 ).

The results of repeated measures ANOVA and between-subjects ANOVA analysis are similar if we exclude the dropouts; therefore, only ITT analysis results are presented.

The results of the Wilcoxon signed-rank test for each item of the Adapted Fresno Test are presented in Table 4 . The results of this analysis revealed that students in both the intervention and control groups significantly improved their knowledge and skills in writing a focused clinical question (Item 1) (intervention group: Z = −4.572, p < 0.000; control group: Z = −2.338, p = 0.019), in building a search strategy (item 3) (intervention group: Z = −4.740, p < 0.000; control group: Z = −4.757, p < 0.000), in identifying and justifying the study design most suitable for answering the question of one of the clinical scenarios (item 4) (intervention group: Z = −4.508, p < 0.000; control group: Z = −3.738, p < 0.000), and in describing the characteristics of a study to determine its relevance (item 5) (intervention group: Z = −2.699, p = 0.007; control group: Z = −1.980, p = 0.048).

Within groups comparison with Wilcoxon signed-rank test for each item of the Adapted Fresno Test—ITT analysis.

The students in the control group significantly improved their knowledge and skills in describing the characteristics of a study to determine its validity (item 6) ( Z = −2.714, p = 0.007). The students in the intervention group significantly improved their knowledge and skills in describing the characteristics of a study to determine its magnitude and significance (item 7) ( Z = −2.543, p = 0.011). No other significant differences were detected.

The results of the within groups comparison with the Wilcoxon signed-rank test are similar if we exclude the dropouts; therefore, only ITT analysis results are presented.

3.2.2. Qualitative Analysis of Monographs

Based on the experts’ consensus report of each monograph, the analysis of the intervention group monographs showed that the students’ groups clearly defined their review questions and inclusion/exclusion criteria. These groups of students effectively searched for studies using appropriate databases, keywords, Boolean operators, and truncation. Additionally, we found thorough descriptions from students concerning the selection process, data extraction, and data synthesis. However, only three students’ groups provided a good description of the review findings with an appropriate data synthesis as well as a clear answer to the review question in the conclusion section of their monographs. It is noted that the criteria for the results and conclusion sections were more difficult to successfully achieve, even in the intervention group.

The monographs of the control groups showed weaknesses throughout. From the nine monographs of the control group, only two presented the review question in a way that was clearly defined. In all of the monographs, the inclusion/exclusion criteria were either not very informative, unclear, or did not match with the defined review questions. Additionally, the search strategies were not clear and demonstrated limited understanding, such as lack of use of appropriate synonyms, absent truncations, and no definition of the search field for each word or expression to be searched. None of the monographs from the control group reported information about the methods used to study the selection process, to extract data, or to synthesize data. In the conclusion section, students from the control group also demonstrated difficulties in synthesizing the data and limitations by providing a clear answer to the review question.

4. Discussion

This study sought to evaluate the effectiveness of an EBP educational program on undergraduate nursing students’ EBP knowledge and skills. Even though both groups improved after the intervention in EBP knowledge and skills, the study results showed that the improvement was greater in the intervention group. This result was reinforced by the results of the qualitative analysis of monographs.

To the best of our knowledge, this is the first study to use a cognitive and performance assessment instrument (Adapted Fresno Test) with undergraduate nursing students, as suggested by CREATE [ 24 ]. Additionally, it is the first study conducted using the EBP education program [ 25 ]. Therefore, comparison of our findings with similar studies in terms of the type of assessment instrument and intervention is limited.

However, comparing our study with other previous research using other types of instruments and interventions demonstrates similar results [ 20 , 21 , 22 , 23 ]. In a quasi-experimental study [ 20 ], it was found that an EBP educational teaching strategy showed positive results in improving EBP knowledge in undergraduate nursing students. A study showed that undergraduate nursing students who received an EBP-focused interactive teaching intervention improved their EBP knowledge [ 21 ]. Another study indicated that a 15-week educational intervention in undergraduate nursing students (second- and third-year) significantly improved their EBP knowledge and skills [ 22 ]. In addition, a study by Zhang, Zeng, Chen, and Li revealed a significant improvement in undergraduate nursing students’ EBP knowledge after participating in a two-phase intervention: a self-directed learning process and a workshop for critical appraisal of literature [ 23 ].

Despite the effectiveness of the program in improving EBP knowledge and skills, the students included in the present study had low levels of EBP knowledge and skills as assessed by the Adapted Fresno Test at the pretest and posttest. These low levels of EBP knowledge and skills, especially at the pretest, might have influenced our study results. As a matter of fact, the Adapted Fresno Test is a demanding test since it requires that students retrieve and apply knowledge while doing a task associated with EBP based on scenarios involving clinical uncertainty. Consequently, this kind of test is very useful to truly assess EBP knowledge retention and abilities in clinical scenarios that do not allow guessing the answers. Notwithstanding, due to these characteristics, the Adapted Fresno Test may possibly be less sensitive when small changes occur or when students have low levels of EBP knowledge and skills. Nevertheless, even using instruments with Likert scales, other studies also showed that students have low levels of EBP knowledge and skills [ 21 , 22 , 23 ].

The low levels of EBP knowledge and skills of the undergraduate nursing students may be a reflection of a persistent, traditional education with regard to research. By this we mean that the focus of training remains on primary research—preparing students to be “research generators” instead of preparing them to be “evidence users” [ 32 ]. Furthermore, the designed and tested intervention used in this study was limited in time (only 17 weeks), was provided by only two instructors, and was delivered to fourth-year undergraduate nursing students, which are limitations for curriculum-wide integration of EBP.

Indeed, a curriculum that promotes EBP should facilitate students’ acquisition of EBP knowledge and skills over time and with levels of increasing complexity through their participation in EBP courses and during their clinical practice experiences [ 32 , 33 , 34 , 35 ]. As Moch, Cronje, and Branson suggest, “It is only in such practical settings that students can experience the challenges intrinsic to applying scientific evidence to the care of real patients. In these clinical settings, students can experience both the frustrations and the triumphs inevitable to integrating scientific knowledge into patient care.” [ 35 ] (p. 11). Therefore, in future studies, other broad approaches for curriculum-wide integration of EBP as well as its long-term effects should be evaluated.

Previously in the Discussion, we highlighted the limitations of the proposed intervention in terms of time constraints (only 17 weeks), instructors’ constraints (only two instructors provided the intervention), and participants’ constraints (fourth-year undergraduate nursing students). In addition, the study was also restricted to one Portuguese nursing school, which can limit the generalization of the results. However, our study tried to address some of the fragilities identified in other studies [ 20 , 21 , 22 , 23 ] on the effectiveness of EBP educational interventions by including a control group and by measuring EBP knowledge and skills with an objective measure and not a self-reported measure.

Bearing this in mind, future studies in multiple sites should assess the long-term effects of the EBP educational intervention and the impact on EBP knowledge and skills of potential variations in contents and teaching methods. In addition, studies using more broad interventions for curriculum-wide integration of EBP should also be performed.

5. Conclusions

Our findings show that the EBP educational program was effective in improving the EBP knowledge and skills of undergraduate nursing students. Therefore, the use of an EBP approach as a complement to the research education of undergraduate nursing students should be promoted by nursing schools and educators. This will help to prepare the future nurses with the EBP knowledge and skills that are essential to overcome the barriers to EBP use in clinical settings, and consequently, to contribute to better health outcomes.

Acknowledgments

This paper contributed toward the D.C. PhD in Health Sciences—Nursing. The authors gratefully acknowledge the support of the Health Sciences Research Unit: Nursing (UICISA: E), hosted by the Nursing School of Coimbra (ESEnfC) and funded by the Foundation for Science and Technology (FCT). Moreover, the authors gratefully thank Catarina Oliveira for all the support as a Ph.D. supervisor and Isabel Fernandes, Maria da Nazaré Cerejo, and Irma Brito for help and facilitation of data collection.

Author Contributions

Conceptualization, D.C., M.A.R., and J.A.; methodology, D.C., M.A.R., and J.A.; validation, D.C., M.A.R., and J.A.; formal analysis, D.C., F.C., and A.F.C.; investigation, D.C., F.C., A.F.C., E.B.-C., L.S., R.R., V.C., D.P., M.-A.R., M.A.R., and J.A.; resources, D.C., M.A.R., and J.A.; data curation, D.C., F.C., and A.F.C.; writing—original draft preparation, D.C.; writing—review and editing, F.C., A.F.C., E.B.-C., L.S., R.R., V.C., D.P., M.-A.R., M.A.R., and J.A.; supervision, M.A.R. and J.A.; project administration, D.C. All authors have read and agreed to the published version of the manuscript.

This work was funded by National Funds through the FCT—Foundation for Science and Technology, I.P., within the scope of the project Ref. UIDP/00742/2020.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by Ethical Committee of Faculty of Medicine of the University of Coimbra (protocol code: CE-037/2017 and date of approval: 22 May 2017).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Conflicts of interest.

The authors declare no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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What is Evidence-Based Practice in Nursing?

5 min read • June, 01 2023

Evidence-based practice in nursing involves providing holistic, quality care based on the most up-to-date research and knowledge rather than traditional methods, advice from colleagues, or personal beliefs. 

Nurses can expand their knowledge and improve their clinical practice experience by collecting, processing, and implementing research findings. Evidence-based practice focuses on what's at the heart of nursing — your patient. Learn what evidence-based practice in nursing is, why it's essential, and how to incorporate it into your daily patient care.

How to Use Evidence-Based Practice in Nursing

Evidence-based practice requires you to review and assess the latest research. The knowledge gained from evidence-based research in nursing may indicate changing a standard nursing care policy in your practice Discuss your findings with your nurse manager and team before implementation. Once you've gained their support and ensured compliance with your facility's policies and procedures, merge nursing implementations based on this information with your patient's values to provide the most effective care. 

You may already be using evidence-based nursing practices without knowing it. Research findings support a significant percentage of nursing practices, and ongoing studies anticipate this will continue to increase.

Evidence-Based Practice in Nursing Examples

There are various examples of evidence-based practice in nursing, such as:

• Use of oxygen to help with hypoxia and organ failure in patients with COPD 
• Management of angina
• Protocols regarding alarm fatigue
• Recognition of a family member's influence on a patient's presentation of symptoms
• Noninvasive measurement of blood pressure in children 

Improving patient care begins by asking how you can make it a safer, more compassionate, and personal experience. 

Learn about pertinent evidence-based practice information on our  Clinical Practice Material page .

Five Steps to Implement Evidence-Based Practice in Nursing

Evidence-based nursing draws upon critical reasoning and judgment skills developed through experience and training. You can practice evidence-based nursing interventions by  following five crucial steps  that serve as guidelines for making patient care decisions. This process includes incorporating the best external evidence, your clinical expertise, and the patient's values and expectations.

• Ask a clear question about the patient's issue and determine an ultimate goal, such as improving a procedure to help their specific condition. 
• Acquire the best evidence by searching relevant clinical articles from legitimate sources.
• Appraise the resources gathered to determine if the information is valid, of optimal quality compared to the evidence levels, and relevant for the patient.
• Apply the evidence to clinical practice by making decisions based on your nursing expertise and the new information.
• Assess outcomes to determine if the treatment was effective and should be considered for other patients.

Analyzing Evidence-Based Research Levels

You can compare current professional and clinical practices with new research outcomes when evaluating evidence-based research. But how do you know what's considered the best information?

Use critical thinking skills and consider  levels of evidence  to establish the reliability of the information when you analyze evidence-based research. These levels can help you determine how much emphasis to place on a study, report, or clinical practice guideline when making decisions about patient care.

The Levels of Evidence-Based Practice

Four primary levels of evidence come into play when you're making clinical decisions.

• Level A acquires evidence from randomized, controlled trials and is considered the most reliable.
• Level B evidence is obtained from quality-designed control trials without randomization.
• Level C typically gets implemented when there is limited information about a condition and acquires evidence from a consensus viewpoint or expert opinion.
• Level ML (multi-level) is usually applied to complex cases and gets its evidence from more than one of the other levels.

Why Is Evidence-Based Practice in Nursing Essential?

Implementing evidence-based practice in nursing bridges the theory-to-practice gap and delivers innovative patient care using the most current health care findings. The topic of evidence-based practice will likely come up throughout your nursing career. Its origins trace back to Florence Nightingale. This iconic founder of modern nursing gathered data and conclusions regarding the relationship between unsanitary conditions and failing health. Its application remains essential today.

Other Benefits of Evidence-Based Practice in Nursing

Besides keeping health care practices relevant and current, evidence-based practice in nursing offers a range of other benefits to you and your patients:

• Promotes positive patient outcomes
• Reduces health care costs by preventing complications 
• Contributes to the growth of the science of nursing
• Allows for incorporation of new technologies into health care practice
• Increases nurse autonomy and confidence in decision-making
• Ensures relevancy of nursing practice with new interventions and care protocols 
• Provides scientifically supported research to help make well-informed decisions
• Fosters shared decision-making with patients in care planning
• Enhances critical thinking 
• Encourages lifelong learning

When you use the principles of evidence-based practice in nursing to make decisions about your patient's care, it results in better outcomes, higher satisfaction, and reduced costs. Implementing this method promotes lifelong learning and lets you strive for continuous quality improvement in your clinical care and nursing practice to achieve  nursing excellence .

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• Volume 24, Issue 3
• Evidence-based practice education for healthcare professions: an expert view
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• Elaine Lehane 1 ,
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• 1 Catherine McAuley School of Nursing and Midwifery , University College Cork , Cork , Ireland
• 2 School of Medicine , University College Cork , Cork , Ireland
• 3 Postgraduate Medical Training , Cork University Hospital/Royal College of Physicians , Cork , Ireland
• 4 Postgraduate Surgical Training, Breast Cancer Centre , Cork University Hospital/Royal College of Surgeons , Cork , Ireland
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• 8 Nursing and Midwifery Planning and Development Unit , Kerry Centre for Nurse and Midwifery Education , Cork , Ireland
• 9 Symptomatic Breast Imaging Unit , Cork University Hospital , Cork , Ireland
• 10 School of Public Health, Physiotherapy and Sports Science , University College Dublin , Dublin , Ireland
• 11 School of Physiotherapy , Royal College of Surgeons in Ireland , Dublin , Ireland
• Correspondence to Dr Elaine Lehane, Catherine McAuley School of Nursing and Midwifery, University College Cork, Cork T12 K8AF, Ireland; e.lehane{at}ucc.ie

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• qualitative research

Introduction

To highlight and advance clinical effectiveness and evidence-based practice (EBP) agendas, the Institute of Medicine set a goal that by 2020, 90% of clinical decisions will be supported by accurate, timely and up-to-date clinical information and will reflect the best available evidence to achieve the best patient outcomes. 1 To ensure that future healthcare users can be assured of receiving such care, healthcare professions must effectively incorporate the necessary knowledge, skills and attitudes required for EBP into education programmes.

The application of EBP continues to be observed irregularly at the point of patient contact. 2 5 7 The effective development and implementation of professional education to facilitate EBP remains a major and immediate challenge. 2 3 6 8 Momentum for continued improvement in EBP education in the form of investigations which can provide direction and structure to developments in this field is recommended. 6

As part of a larger national project looking at current practice and provision of EBP education across healthcare professions at undergraduate, postgraduate and continuing professional development programme levels, we sought key perspectives from international EBP education experts on the provision of EBP education for healthcare professionals. The two other components of this study, namely a rapid review synthesis of EBP literature and a descriptive, cross-sectional, national, online survey relating to the current provision and practice of EBP education to healthcare professionals at third-level institutions and professional training/regulatory bodies in Ireland, will be described in later publications.

EBP expert interviews were conducted to ascertain current and nuanced information on EBP education from an international perspective. Experts from the UK, Canada, New Zealand and Australia were invited by email to participate based on their contribution to peer-reviewed literature on the subject area and recognised innovation in EBP education. Over a 2-month period, individual ‘Skype’ interviews were conducted and recorded. The interview guide (online  supplementary appendix A ) focused on current practice and provision of EBP education with specific attention given to EBP curricula, core EBP competencies, assessment methods, teaching initiatives and key challenges to EBP education within respective countries. Qualitative content analysis techniques as advised by Bogner et al 9 for examination of expert interviews were used. Specifically, a six-step process was applied, namely transcription, reading through/paraphrasing, coding, thematic comparison, sociological conceptualisation and theoretical generalisation. To ensure trustworthiness, a number of practices were undertaken, including explicit description of the methods undertaken, participant profile, extensive use of interview transcripts by way of representative quotations, peer review (PL-W) of the data analysis process and invited interviewees to feedback in relation to the overall findings.

Supplementary file 1

Five EBP experts participated in the interviews ( table 1 ). All experts waived their right to anonymity.

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EBP education expert profile

Three main categories emerged, namely (1) ‘EBP curriculum considerations’, (2) ‘Teaching EBP’ and (3) ‘Stakeholder engagement in EBP education’. These categories informed the overarching theme of ‘Improving healthcare through enhanced teaching and application of EBP’ ( figure 1 ).

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Summary of data analysis findings from evidence-based practice (EBP) expert interviews—theme, categories and subcategories.

EBP curriculum considerations

Definitive advice in relation to curriculum considerations was provided with a clear emphasis on the need for EBP principles to be integrated throughout all elements of healthcare professions curricula. Educators, regardless of teaching setting, need to be able to ‘draw out evidence-based components’ from any and all aspects of curriculum content, including its incorporation into assessments and examinations. Integration of EBP into clinical curricula in particular was considered essential to successful learning and practice outcomes. If students perceive a dichotomy between EBP and actual clinical care, then “never the twain shall meet” (GG) requiring integration in such a way that it is “seen as part of the basics of optimal clinical care” (GG). Situating EBP as a core element within the professional curriculum and linking it to professional accreditation processes places further emphasis on the necessity of teaching EBP:

…it is also core in residency programmes. So every residency programme has a curriculum on evidence-based practice where again, the residency programmes are accredited…They have to show that they’re teaching evidence-based practice. (GG)

In terms of the focus of curriculum content, all experts emphasised the oft-cited steps of asking questions, acquiring, appraising and applying evidence to patient care decisions. With regard to identifying and retrieving information, the following in particular was noted:

…the key competencies would be to identify evidence-based sources of information, and one of the key things is there should be no expectation that clinicians are going to go to primary research and evaluate primary research. That is simply not a realistic expectation. In teaching it…they have to be able to identify the pre-processed sources and they have to be able to understand the evidence and they have to be able to use it… (GG)

In addition to attaining proficiency in the fundamental EBP steps, developing competence in communicating evidence to others, including the patient, and facilitating shared decision-making were also highlighted:

…So our ability to communicate risks, benefits, understand uncertainty is so poor…that’s a key area we could improve… (CH)

…and a big emphasis [is needed] on the applicability of that information on patient care, how do you use and share the decision making, which is becoming a bigger and bigger deal. (GG)

It was suggested that these EBP ‘basics’ can be taught “from the start in very similar ways” (GG), regardless of whether the student is at an undergraduate or postgraduate level. The concept of ‘ developmental milestones’ was raised by one expert. This related to different levels of expectations in learning and assessing EBP skills and knowledge throughout a programme of study with an incremental approach to teaching and learning advocated over a course of study:

…in terms of developmental milestones. So for the novice…it’s really trying to get them aware of what the structure of evidence-based practice is and knowing what the process of asking a question and the PICO process and learning about that…in their final year…they’re asked to do critically appraised topics and relate it to clinical cases…It’s a developmental process… (LT)

Teaching EBP

Adoption of effective strategies and practical methods to realise successful student learning and understanding was emphasised. Of particular note was the grounding of teaching strategy and associated methods from a clinically relevant perspective with student exposure to EBP facilitated in a dynamic and interesting manner. The use of patient examples and clinical scenarios was repeatedly expressed as one of the most effective instructional practices:

…ultimately trying to get people to teach in a way where they go, “Look, this is really relevant, dynamic and interesting"…so we teach them in loads of different ways…you’re teaching and feeding the ideas as opposed to “"Here’s a definitive course in this way”. (CH)

…It’s pretty obscure stuff, but then I get them to do three examples…when they have done that they have pretty well got their heads around it…I build them lots of practical examples…clinical examples otherwise they think it’s all didactic garbage… (BA)

EBP role models were emphasised as being integral to demonstrating the application of EBP in clinical decision-making and facilitating the contextualisation of EBP within a specific setting/organisation.

…where we’ve seen success is where organisations have said, “There’s going to be two or three people who are going to be the champions and lead where we’re going”…the issue about evidence, it’s complex, it needs to be contextualised and it’s different for each setting… (CH)

It was further suggested that these healthcare professionals have the ‘X-factor’ required of EBP. The acquisition of such expertise which enables a practitioner to integrate individual EBP components culminating in evidence-based decisions was proposed as a definitive target for all healthcare professionals.

And we call it the X factor…the idea is that the clinician who has the X factor is the good clinician. It’s actually integrating the evidence, the patient values, the patient’s pathophysiology, etc. It could be behavioural issues, systems issues…Those are the four quadrants and the clinical expertise is about integrating those together…You’re not actually adding clinical expertise. It seems to me that the clinical expertise is the ability to integrate those four quadrants. (RJ)

The provision of training for educators to aid the further development of skills and use of resources necessary for effective EBP teaching was recommended:

…so we choose the option to train people as really good teachers and give them really high level skills so that they can then seed it across their organisation… (CH)

Attaining a critical mass of people who are ‘trained’ was also deemed important in making a sustained change:

…and it requires getting the teachers trained and getting enough of them. You don’t need everybody to be doing it to make an impression, but you need enough of them really doing it. (GG)

Stakeholder engagement in EBP education

Engagement of national policy makers, healthcare professionals and patients with EBP was considered to have significant potential to advance its teaching and application in clinical care. The lack of a coherent government and national policy to EBP teaching was cited as a barrier to the implementation of the EBP agenda resulting in a somewhat ‘ad-hoc’ approach, dependent on individual educational or research institutions:

…there’s no cohesive or coherent policy that exists…It’s not been a consistent approach. What we’ve tended to see is that people have started going around particular initiatives…but there’s never been any coordinated approach even from a college perspective, to say we are about improving the uptake and use of evidence in practice and/or generating evidence in practice. And so largely, it’s been left to research institutions… (CH)

To further ingrain EBP within healthcare professional practice, it was suggested that EBP processes, whether related to developing, disseminating or implementing evidence, be embedded in a more structured way into everyday clinical care to promote active and consistent engagement with EBP on a continuous basis:

…we think it should be embedded into care…we’ve got to have people being active in developing, disseminating and implementing evidence…developing can come in a number of formats. It can be an audit. It can be about a practice improvement. It can be about doing some aspect like a systematic review, but it’s very clearly close to healthcare. (CH)

Enabling patients to engage with evidence with a view to informing healthcare professional/patient interactions and care decisions was also advocated:

…I think we really need to put some energy into…this whole idea of patient-driven care, patient-led care and putting some of these tools in the hands of the consumers so that they’re enabled to be able to ask the right questions and to go into an interaction with some background knowledge about what treatments they should be expecting. (LT)

If patients are considered as recipients of EBP rather than key stakeholders, the premise of shared decision-making for care cannot be achieved.

The implementation of a successful EBP education is necessary so that learners not only understand the importance of EBP and be competent in the fundamental steps, but it ultimately serves to influence behaviour in terms of decision-making, through application of EBP in their professional practice. In essence, it serves the function of developing practitioners who value EBP and have the knowledge and skills to implement such practice. The ultimate goal of this agenda is to enhance the delivery of healthcare for improved patient outcomes. The overarching theme of ‘Improving healthcare through enhanced teaching and application of EBP’ represents the focus and purpose of the effort required to optimally structure healthcare professional (HCP) curricula, promote effective EBP teaching and learning strategies, and engage with key stakeholders for the overall advancement of EBP education as noted:

…we think that everyone in training should be in the game of improving healthcare…It’s not just saying I want to do some evidence-based practice…it’s ultimately about…improving healthcare. (CH)

Discussion and recommendations

Education programmes and associated curricula act as a key medium for shaping healthcare professional knowledge, skills and attitudes, and therefore play an essential role in determining the quality of care provided. 10 Unequivocal recommendations were made in relation to the pervasive integration of EBP throughout the academic and clinical curricula. Such integration is facilitated by the explicit inclusion of EBP as a core competency within professional standards and requirements in addition to accreditation processes. 11

Further emphasis on communication skills was also noted as being key to enhancing EBP competency, particularly in relation to realising shared decision-making between patients and healthcare practitioners in making evidence-based decisions. A systematic review by Galbraith et al , 12 which examined a ‘real-world’ approach to evidence-based medicine in general practice, corroborates this recommendation by calling for further attention to be given to communication skills of healthcare practitioners within the context of being an evidence-based practitioner. This resonates with recommendations by Gorgon et al 13 for the need to expose students to the intricacies of ‘real world’ contexts in which EBP is applied.

Experts in EBP, together with trends throughout empirical research and recognised educational theory repeatedly, make a number of recommendations for enhancing EBP teaching and learning strategies. These include (1) clinical integration of EBP teaching and learning, (2) a conscious effort on behalf of educators to embed EBP throughout all elements of healthcare professional programmes, (3) the use of multifaceted, dynamic teaching and assessment strategies which are context-specific and relevant to the individual learner/professional cohort, and (4) ‘scaffolding’ of learning.

At a practical level this requires a more concerted effort to move away from a predominant reliance on stand-alone didactic teaching towards clinically integrative and interactive teaching. 10 14–17 An example provided by one of the EBP experts represents such integrated teaching and experiential learning through the performance of GATE/CATs (Graphic Appraisal Tool for Epidemiological studies/Critically Appraised Topics) while on clinical rotation, with assessment conducted by a clinician in practice. Such an activity fulfils the criteria of being reflective of practice, facilitating the identification of gaps between current and desired levels of competence, identifying solutions for clinical issues and allowing re-evaluation and opportunity for reflection of decisions made with a practitioner. This level of interactivity facilitates ‘deeper’ learning, which is essential for knowledge transfer. 8 Such practices are also essential to bridge the gap between academic and clinical worlds, enabling students to experience ‘real’ translation of EBP in the clinical context. 6 ‘Scaffolding’ of learning, whereby EBP concepts and their application increase in complexity and are reinforced throughout a programme, was also highlighted as an essential instructional approach which is in keeping with recent literature specific both to EBP education and from a broader curriculum development perspective. 3 6 18 19

In addition to addressing challenges such as curriculum organisation and programme content/structure, identifying salient barriers to implementing optimal EBP education is recommended as an expedient approach to effecting positive change. 20 Highlighted strategies to overcome such barriers included (1) ‘Training the trainers’, (2) development of and investment in a national coherent approach to EBP education, and (3) structural incorporation of EBP learning into workplace settings.

National surveys of EBP education delivery 21 22 found that a lack of academic and clinical staff knowledgeable in teaching EBP was a barrier to effective and efficient student learning. This was echoed by findings from EBP expert interviews, which correspond with assertions by Hitch and Nicola-Richmond 6 that while recommended educational practices and resources are available, their uptake is somewhat limited. Effective teacher/leader education is required to improve EBP teaching quality. 10 16 23 24 Such formal training should extend to academic and clinical educators. Supporting staff to have confidence and competence in teaching EBP and providing opportunities for learning throughout education programmes is necessary to facilitate tangible change in this area.

A national and coherent plan with associated investment in healthcare education specific to the integration of EBP was highlighted as having an important impact on educational outcomes. The lack of a coordinated and cohesive approach and perceived value of EBP in the midst of competing interests, particularly within the context of the healthcare agenda, was suggested to lead to an ‘ad-hoc’ approach to the implementation of and investment in EBP education and related core EBP resources. Findings from a systematic scoping review of recommendations for the implementation of EBP 16 draw attention to a number of interventions at a national level that have potential to further promote and facilitate EBP education. Such interventions include government-level policy direction in relation to EBP education requirements across health profession programmes and the instalment and financing of a national institute for the development of evidence-based guidelines.

Incorporating EBP activities into routine clinical practice has potential to promote the consistent participation and implementation of EBP. Such incorporation can be facilitated at various different levels and settings. At a health service level, the provision of computer and internet facilities at the point of care with associated content management/decision support systems allowing access to guidelines, protocols, critically appraised topics and condensed recommendations was endorsed. At a local workplace level, access to EBP mentors, implementation of consistent and regular journal clubs, grand rounds, audit and regular research meetings are important to embed EBP within the healthcare and education environments. This in turn can nurture a culture which practically supports the observation and actualisation of EBP in day-to-day practice 16 and could in theory allow the coherent development of cohorts of EBP leaders.

There are study limitations which must be acknowledged. Four of the five interviewees were medical professionals. Further inclusion of allied healthcare professionals may have increased the representativeness of the findings. However, the primary selection criteria for participants were extensive and recognised expertise in relation to EBP education, the fundamental premises of which traverse specific professional boundaries.

Despite positive attitudes towards EBP and a predominant recognition of its necessity for the delivery of quality and safe healthcare, its consistent translation at the point of care remains elusive. To this end, continued investigations which seek to provide further direction and structure to developments in EBP education are recommended. 6 Although the quality of evidence has remained variable regarding the efficacy of individual EBP teaching interventions, consistent trends in relation to valuable andragogically sound educational approaches, fundamental curricular content and preferential instructional practices are evident within the literature in the past decade. The adoption of such trends is far from prevalent, which brings into question the extent of awareness that exists in relation to such recommendations and accompanying resources. There is a need to translate EBP into an active clinical resolution, which will have a positive impact on the delivery of patient care. In particular, an examination of current discourse between academic and clinical educators across healthcare professions is required to progress a ‘real world’ pragmatic approach to the integration of EBP education which has meaningful relevance to students and engenders active engagement from educators, clinicians and policy makers alike. Further attention is needed on strategies that not only focus on issues such as curricula structure, content and programme delivery but which support educators, education institutions, health services and clinicians to have the capacity and competence to meet the challenge of providing such EBP education.

Summary Box

What is already known.

Evidence-based practice (EBP) is established as a fundamental element and key indicator of high-quality patient care.

Both achieving competency and delivering instruction in EBP are complex processes requiring a multimodal approach.

Currently there exists only a modest utilisation of existing resources available to further develop EBP education.

What are the new findings?

In addition to developing competence in the fundamental EBP steps of ‘Ask’, ‘Acquire’, ‘Appraise’, ‘Apply’ and ‘Assess’, developing competence in effectively communicating evidence to others, in particular patients/service users, is an area newly emphasised as requiring additional attention by healthcare educators.

The successful expansion of the assessment and evaluation of EBP requires a pragmatic amplification of the discourse between academic and clinical educators.

How might it impact on clinical practice in the foreseeable future?

Quality of care is improved through the integration of the best available evidence into decision-making as routine practice and not in the extemporised manner often currently practised.

Acknowledgments

Special thanks to Professor Leanne Togher, Professor Carl Heneghan, Professor Bruce Arroll, Professor Rodney Jackson and Professor Gordon Guyatt, who provided key insights on EBP education from an international perspective. Thank you to Dr Niamh O’Rourke, Dr Eve O’Toole, Dr Sarah Condell and Professor Dermot Malone for their helpful direction throughout the project.

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Contributors This project formed part of a national project on EBP education in Ireland of which all named authors are members. The authors named on this paper made substantial contributions to both the acquisition and analysis of data, in addition to reviewing the report and paper for submission.

Funding This research was funded by the Clinical Effectiveness Unit of the National Patient Safety Office (NPSO), Department of Health, Ireland.

Competing interests None declared.

Patient consent Not required.

Ethics approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional ethical committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Ethical approval was granted by the Social Research Ethics Committee, University College Cork (Log 2016–140).

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement The full report entitled ’Research on Teaching EBP in Ireland to healthcare professionals and healthcare students' is available on the National Clinical Effectiveness, Department of Health website.

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Promoting critical thinking through an evidence-based skills fair intervention

Journal of Research in Innovative Teaching & Learning

ISSN : 2397-7604

Article publication date: 23 November 2020

Issue publication date: 1 April 2022

The lack of critical thinking in new graduates has been a concern to the nursing profession. The purpose of this study was to investigate the effects of an innovative, evidence-based skills fair intervention on nursing students' achievements and perceptions of critical thinking skills development.

Design/methodology/approach

The explanatory sequential mixed-methods design was employed for this study.

The findings indicated participants perceived the intervention as a strategy for developing critical thinking.

Originality/value

The study provides educators helpful information in planning their own teaching practice in educating students.

Critical thinking

Evidence-based practice, skills fair intervention.

Gonzalez, H.C. , Hsiao, E.-L. , Dees, D.C. , Noviello, S.R. and Gerber, B.L. (2022), "Promoting critical thinking through an evidence-based skills fair intervention", Journal of Research in Innovative Teaching & Learning , Vol. 15 No. 1, pp. 41-54. https://doi.org/10.1108/JRIT-08-2020-0041

Emerald Publishing Limited

Copyright © 2020, Heidi C. Gonzalez, E-Ling Hsiao, Dianne C. Dees, Sherri R. Noviello and Brian L. Gerber

Published in Journal of Research in Innovative Teaching & Learning . Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at http://creativecommons.org/licences/by/4.0/legalcode

Introduction

Critical thinking (CT) was defined as “cognitive skills of analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge” ( Scheffer and Rubenfeld, 2000 , p. 357). Critical thinking is the basis for all professional decision-making ( Moore, 2007 ). The lack of critical thinking in student nurses and new graduates has been a concern to the nursing profession. It would negatively affect the quality of service and directly relate to the high error rates in novice nurses that influence patient safety ( Arli et al. , 2017 ; Saintsing et al. , 2011 ). It was reported that as many as 88% of novice nurses commit medication errors with 30% of these errors due to a lack of critical thinking ( Ebright et al. , 2004 ). Failure to rescue is another type of error common for novice nurses, reported as high as 37% ( Saintsing et al. , 2011 ). The failure to recognize trends or complications promptly or take action to stabilize the patient occurs when health-care providers do not recognize signs and symptoms of the early warnings of distress ( Garvey and CNE series, 2015 ). Internationally, this lack of preparedness and critical thinking attributes to the reported 35–60% attrition rate of new graduate nurses in their first two years of practice ( Goodare, 2015 ). The high attrition rate of new nurses has expensive professional and economic costs of $82,000 or more per nurse and negatively affects patient care ( Twibell et al. , 2012 ). Facione and Facione (2013) reported the failure to utilize critical thinking skills not only interferes with learning but also results in poor decision-making and unclear communication between health-care professionals, which ultimately leads to patient deaths.

Due to the importance of critical thinking, many nursing programs strive to infuse critical thinking into their curriculum to better prepare graduates for the realities of clinical practice that involves ever-changing, complex clinical situations and bridge the gap between education and practice in nursing ( Benner et al. , 2010 ; Kim et al. , 2019 ; Park et al. , 2016 ; Newton and Moore, 2013 ; Nibert, 2011 ). To help develop students' critical thinking skills, nurse educators must change the way they teach nursing, so they can prepare future nurses to be effective communicators, critical thinkers and creative problem solvers ( Rieger et al. , 2015 ). Nursing leaders also need to redefine teaching practice and educational guidelines that drive innovation in undergraduate nursing programs.

Evidence-based practice has been advocated to promote critical thinking and help reduce the research-practice gap ( Profetto-McGrath, 2005 ; Stanley and Dougherty, 2010 ). Evidence-based practice was defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of the individual patient” ( Sackett et al. , 1996 , p. 71). Skills fair intervention, one type of evidence-based practice, can be used to engage students, promote active learning and develop critical thinking ( McCausland and Meyers, 2013 ; Roberts et al. , 2009 ). Skills fair intervention helps promote a consistent teaching practice of the psychomotor skills to the novice nurse that decreased anxiety, gave clarity of expectations to the students in the clinical setting and increased students' critical thinking skills ( Roberts et al. , 2009 ). The researchers of this study had an opportunity to create an active, innovative skills fair intervention for a baccalaureate nursing program in one southeastern state. This intervention incorporated evidence-based practice rationale with critical thinking prompts using Socratic questioning, evidence-based practice videos to the psychomotor skill rubrics, group work, guided discussions, expert demonstration followed by guided practice and blended learning in an attempt to promote and develop critical thinking in nursing students ( Hsu and Hsieh, 2013 ; Oermann et al. , 2011 ; Roberts et al. , 2009 ). The effects of an innovative skills fair intervention on senior baccalaureate nursing students' achievements and their perceptions of critical thinking development were examined in the study.

Literature review

The ability to use reasoned opinion focusing equally on processes and outcomes over emotions is called critical thinking ( Paul and Elder, 2008 ). Critical thinking skills are desired in almost every discipline and play a major role in decision-making and daily judgments. The roots of critical thinking date back to Socrates 2,500 years ago and can be traced to the ancient philosopher Aristotle ( Paul and Elder, 2012 ). Socrates challenged others by asking inquisitive questions in an attempt to challenge their knowledge. In the 1980s, critical thinking gained nationwide recognition as a behavioral science concept in the educational system ( Robert and Petersen, 2013 ). Many researchers in both education and nursing have attempted to define, measure and teach critical thinking for decades. However, a theoretical definition has yet to be accepted and established by the nursing profession ( Romeo, 2010 ). The terms critical literacy, CT, reflective thinking, systems thinking, clinical judgment and clinical reasoning are used synonymously in the reviewed literature ( Clarke and Whitney, 2009 ; Dykstra, 2008 ; Jones, 2010 ; Swing, 2014 ; Turner, 2005 ).

Watson and Glaser (1980) viewed critical thinking not only as cognitive skills but also as a combination of skills, knowledge and attitudes. Paul (1993) , the founder of the Foundation for Critical Thinking, offered several definitions of critical thinking and identified three essential components of critical thinking: elements of thought, intellectual standards and affective traits. Brunt (2005) stated critical thinking is a process of being practical and considered it to be “the process of purposeful thinking and reflective reasoning where practitioners examine ideas, assumptions, principles, conclusions, beliefs, and actions in the contexts of nursing practice” (p. 61). In an updated definition, Ennis (2011) described critical thinking as, “reasonable reflective thinking focused on deciding what to believe or do” (para. 1).

The most comprehensive attempt to define critical thinking was under the direction of Facione and sponsored by the American Philosophical Association ( Scheffer and Rubenfeld, 2000 ). Facione (1990) surveyed 53 experts from the arts and sciences using the Delphi method to define critical thinking as a “purposeful, self-regulatory judgment which results in interpretation, analysis, evaluation, and inference, as well as an explanation of the evidential, conceptual, methodological, criteriological, or contextual considerations upon which judgment, is based” (p. 2).

To come to a consensus definition for critical thinking, Scheffer and Rubenfeld (2000) also conducted a Delphi study. Their study consisted of an international panel of nurses who completed five rounds of sequenced questions to arrive at a consensus definition. Critical thinking was defined as “habits of mind” and “cognitive skills.” The elements of habits of mind included “confidence, contextual perspective, creativity, flexibility, inquisitiveness, intellectual integrity, intuition, open-mindedness, perseverance, and reflection” ( Scheffer and Rubenfeld, 2000 , p. 352). The elements of cognitive skills were recognized as “analyzing, applying standards, discriminating, information seeking, logical reasoning, predicting, and transforming knowledge” ( Scheffer and Rubenfeld, 2000 , p. 352). In addition, Ignatavicius (2001) defined the development of critical thinking as a long-term process that must be practiced, nurtured and reinforced over time. Ignatavicius believed that a critical thinker required six cognitive skills: interpretation, analysis, evaluation, inference, explanation and self-regulation ( Chun-Chih et al. , 2015 ). According to Ignatavicius (2001) , the development of critical thinking is difficult to measure or describe because it is a formative rather than summative process.

Fero et al. (2009) noted that patient safety might be compromised if a nurse cannot provide clinically competent care due to a lack of critical thinking. The Institute of Medicine (2001) recommended five health care competencies: patient-centered care, interdisciplinary team care, evidence-based practice, informatics and quality improvement. Understanding the development and attainment of critical thinking is the key for gaining these future competencies ( Scheffer and Rubenfeld, 2000 ). The development of a strong scientific foundation for nursing practice depends on habits such as contextual perspective, inquisitiveness, creativity, analysis and reasoning skills. Therefore, the need to better understand how these critical thinking habits are developed in nursing students needs to be explored through additional research ( Fero et al. , 2009 ). Despite critical thinking being listed since the 1980s as an accreditation outcome criteria for baccalaureate programs by the National League for Nursing, very little improvement has been observed in practice ( McMullen and McMullen, 2009 ). James (2013) reported the number of patient harm incidents associated with hospital care is much higher than previously thought. James' study indicated that between 210,000 and 440,000 patients each year go to the hospital for care and end up suffering some preventable harm that contributes to their death. James' study of preventable errors is attributed to other sources besides nursing care, but having a nurse in place who can advocate and critically think for patients will make a positive impact on improving patient safety ( James, 2013 ; Robert and Peterson, 2013 ).

Adopting teaching practice to promote CT is a crucial component of nursing education. Research by Nadelson and Nadelson (2014) suggested evidence-based practice is best learned when integrated into multiple areas of the curriculum. Evidence-based practice developed its roots through evidence-based medicine, and the philosophical origins extend back to the mid-19th century ( Longton, 2014 ). Florence Nightingale, the pioneer of modern nursing, used evidence-based practice during the Crimean War when she recognized a connection between poor sanitary conditions and rising mortality rates of wounded soldiers ( Rahman and Applebaum, 2011 ). In professional nursing practice today, a commonly used definition of evidence-based practice is derived from Dr. David Sackett: the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient ( Sackett et al. , 1996 , p. 71). As professional nurses, it is imperative for patient safety to remain inquisitive and ask if the care provided is based on available evidence. One of the core beliefs of the American Nephrology Nurses' Association's (2019) 2019–2020 Strategic Plan is “Anna must support research to develop evidence-based practice, as well as to advance nursing science, and that as individual members, we must support, participate in, and apply evidence-based research that advances our own skills, as well as nursing science” (p. 1). Longton (2014) reported the lack of evidence-based practice in nursing resulted in negative outcomes for patients. In fact, when evidence-based practice was implemented, changes in policies and procedures occurred that resulted in decreased reports of patient harm and associated health-care costs. The Institute of Medicine (2011) recommendations included nurses being leaders in the transformation of the health-care system and achieving higher levels of education that will provide the ability to critically analyze data to improve the quality of care for patients. Student nurses must be taught to connect and integrate CT and evidence-based practice throughout their program of study and continue that practice throughout their careers.

One type of evidence-based practice that can be used to engage students, promote active learning and develop critical thinking is skills fair intervention ( McCausland and Meyers, 2013 ; Roberts et al. , 2009 ). Skills fair intervention promoted a consistent teaching approach of the psychomotor skills to the novice nurse that decreased anxiety, gave clarity of expectations to the students in the clinical setting and increased students' critical thinking skills ( Roberts et al. , 2009 ). The skills fair intervention used in this study is a teaching strategy that incorporated CT prompts, Socratic questioning, group work, guided discussions, return demonstrations and blended learning in an attempt to develop CT in nursing students ( Hsu and Hsieh, 2013 ; Roberts et al. , 2009 ). It melded evidence-based practice with simulated CT opportunities while students practiced essential psychomotor skills.

Research methodology

Context – skills fair intervention.

According to Roberts et al. (2009) , psychomotor skills decline over time even among licensed experienced professionals within as little as two weeks and may need to be relearned within two months without performing a skill. When applying this concept to student nurses for whom each skill is new, it is no wonder their competency result is diminished after having a summer break from nursing school. This skills fair intervention is a one-day event to assist baccalaureate students who had taken the summer off from their studies in nursing and all faculty participated in operating the stations. It incorporated evidence-based practice rationale with critical thinking prompts using Socratic questioning, evidence-based practice videos to the psychomotor skill rubrics, group work, guided discussions, expert demonstration followed by guided practice and blended learning in an attempt to promote and develop critical thinking in baccalaureate students.

Students were scheduled and placed randomly into eight teams based on attributes of critical thinking as described by Wittmann-Price (2013) : Team A – Perseverance, Team B – Flexibility, Team C – Confidence, Team D – Creativity, Team E – Inquisitiveness, Team F – Reflection, Team G – Analyzing and Team H – Intuition. The students rotated every 20 minutes through eight stations: Medication Administration: Intramuscular and Subcutaneous Injections, Initiating Intravenous Therapy, ten-minute Focused Physical Assessment, Foley Catheter Insertion, Nasogastric Intubation, Skin Assessment/Braden Score and Restraints, Vital Signs and a Safety Station. When the students completed all eight stations, they went to the “Check-Out” booth to complete a simple evaluation to determine their perceptions of the effectiveness of the innovative intervention. When the evaluations were complete, each of the eight critical thinking attribute teams placed their index cards into a hat, and a student won a small prize. All Junior 2, Senior 1 and Senior 2 students were required to attend the Skills Fair. The Skills Fair Team strove to make the event as festive as possible, engaging nursing students with balloons, candy, tri-boards, signs and fun pre and postactivities. The Skills Fair rubrics, scheduling and instructions were shared electronically with students and faculty before the skills fair intervention to ensure adequate preparation and continuous resource availability as students move forward into their future clinical settings.

Research design

Institutional review board (IRB) approval was obtained from XXX University to conduct this study and protect human subject rights. The explanatory sequential mixed-methods design was employed for this study. The design was chosen to identify what effects a skills fair intervention that had on senior baccalaureate nursing students' achievements on the Kaplan Critical Thinking Integrated Test (KCTIT) and then follow up with individual interviews to explore those test results in more depth. In total, 52 senior nursing students completed the KCTIT; 30 of them participated in the skills fair intervention and 22 of them did not participate. The KCTIT is a computerized 85-item exam in which 85 equates to 100%, making each question worth one point. It has high reliability and validity ( Kaplan Nursing, 2012 ; Swing, 2014 ). The reliability value of the KCTIT ranged from 0.72 to 0.89. A t -test was used to analyze the test results.

A total of 11 participants were purposefully selected based on a range of six high achievers and five low achievers on the KCTIT for open-ended one-on-one interviews. Each interview was conducted individually and lasted for about 60 minutes. An open-ended interview protocol was used to guide the flow of data collection. The interviewees' ages ranged from 21 to 30 years, with an average of 24 years. One of 11 interviewees was male. Among them, seven were White, three were Black and one was Indian American. The data collected were used to answer the following research questions: (1) What was the difference in achievements on the KCTIT among senior baccalaureate nursing students who participated in the skills fair intervention and students who did not participate? (2) What were the senior baccalaureate nursing students' perceptions of internal and external factors impacting the development of critical thinking skills during the skills fair intervention? and (3) What were the senior baccalaureate nursing students' perceptions of the skills fair intervention as a critical thinking developmental strategy?

Inductive content analysis was used to analyze interview data by starting with the close reading of the transcripts and writing memos for initial coding, followed by an analysis of patterns and relationships among the data for focused coding. The intercoder reliability was established for qualitative data analysis with a nursing expert. The lead researcher and the expert read the transcript several times and assigned a code to significant units of text that corresponded with answering the research questions. The codes were compared based on differences and similarities and sorted into subcategories and categories. Then, headings and subheadings were used based on similar comments to develop central themes and patterns. The process of establishing intercoder reliability helped to increase dependability, conformability and credibility of the findings ( Graneheim and Lundman, 2004 ). In addition, methods of credibility, confirmability, dependability and transferability were applied to increase the trustworthiness of this study ( Graneheim and Lundman, 2004 ). First, reflexivity was observed by keeping journals and memos. This practice allowed the lead researcher to reflect on personal views to minimize bias. Data saturation was reached through following the recommended number of participants as well as repeated immersion in the data during analysis until no new data surfaced. Member checking was accomplished through returning the transcript and the interpretation to the participants to check the accuracy and truthfulness of the findings. Finally, proper documentation was conducted to allow accurate crossreferencing throughout the study.

Quantitative results

Results for the quantitative portion showed there was no difference in scores on the KCTIT between senior nursing students who participated in the skills fair intervention and senior nursing students who did not participate, t (50) = −0.174, p  = 0.86 > 0.05. The test scores between the nonparticipant group ( M  = 67.59, SD = 5.81) and the participant group ( M  = 67.88, SD = 5.99) were almost equal.

Qualitative results

Initial coding.

The results from the initial coding and generated themes are listed in Table 1 . First, the participants perceived the skills fair intervention as “promoting experience” and “confidence” by practicing previously learned knowledge and reinforcing it with active learning strategies. Second, the participants perceived the skills fair intervention as a relaxed, nonthreatening learning environment due to the festive atmosphere, especially in comparison to other learning experiences in the nursing program. The nonthreatening environment of the skills fair intervention allowed students to learn without fear. Third, the majority of participants believed their critical thinking was strengthened after participating. Several participants believed their perception of critical thinking was “enhanced” or “reinforced” rather than significantly changed.

Focused coding results

The final themes were derived from the analysis of patterns and relationships among the content of the data using inductive content analysis ( Saldana, 2009 ). The following was examined across the focused coding process: (1) factors impacting critical thinking skills development during skills fair intervention and (2) skills fair intervention a critical thinking skills developmental strategy.

Factors impacting critical thinking skills development . The factors impacting the development of critical thinking during the skills fair intervention were divided into two themes: internal factors and external factors. The internal factors were characteristics innate to the students. The identified internal factors were (1) confidence and anxiety levels, (2) attitude and (3) age. The external factors were the outside influences that affected the students. The external factors were (1) experience and practice, (2) faculty involvement, (3) positive learning environment and (4) faculty prompts.

I think that confidence and anxiety definitely both have a huge impact on your ability to be able to really critically think. If you start getting anxious and panicking you cannot think through the process like you need too. I do not really think gender or age necessarily would have anything to do with critical thinking.

Definitely the confidence level, I think, the more advanced you get in the program, your confidence just keeps on growing. Level of anxiety, definitely… I think the people who were in the Skills Fair for the first time, had more anxiety because they did not really know to think, they did not know how strict it was going to be, or if they really had to know everything by the book. I think the Skills Fair helped everyone's confidence levels, but especially the Jr. 2's.

Attitude was an important factor in the development of critical thinking skills during the skills fair intervention as participants believed possessing a pleasant and positive attitude meant a student was eager to learn, participate, accept responsibility for completing duties and think seriously. Participant 6 believed attitude contributed to performance in the Skills Fair.

I feel like, certain things bring critical thinking out in you. And since I'm a little bit older than some of the other students, I have had more life experiences and am able to figure stuff out better. Older students have had more time to learn by trial and error, and this and that.

Like when I had clinical with you, you'd always tell us to know our patients' medications. To always know and be prepared to answer questions – because at first as a Junior 1 we did not do that in the clinical setting… and as a Junior 2, I did not really have to know my medications, but with you as a Senior 1, I started to realize that the patients do ask about their meds, so I was making sure that I knew everything before they asked it. And just having more practice with IVs – at first, I was really nervous, but when I got to my preceptorship – I had done so many IVs and with all of the practice, it just built up my confidence with that skill so when I performed that skill during the Fair, I was confident due to my clinical experiences and able to think and perform better.

I think teachers will always affect the ability to critically think just because you want [to] get the right answer because they are there and you want to seem smart to them [Laugh]. Also, if you are leading in the wrong direction of your thinking – they help steer you back to [in] the right direction so I think that was very helpful.

You could tell the faculty really tried to make it more laid back and fun, so everybody would have a good experience. The faculty had a good attitude. I think making it fun and active helped keep people positive. You know if people are negative and not motivated, nothing gets accomplished. The faculty did an amazing job at making the Skills Fair a positive atmosphere.

However, for some of the participants, a positive learning environment depended on their fellow students. The students were randomly assigned alphabetically to groups, and the groups were assigned to starting stations at the Skills Fair. The participants claimed some students did not want to participate and displayed cynicism toward the intervention. The participants believed their cynicism affected the positive learning environment making critical thinking more difficult during the Skills Fair.

Okay, when [instructor name] was demonstrating the Chevron technique right after we inserted the IV catheter and we were trying to secure the catheter, put on the extension set, and flush the line at what seemed to be all at the same time. I forgot about how you do not want to put the tape right over the hub of the catheter because when you go back in and try to assess the IV site – you're trying to assess whether or not it is patent or infiltrated – you have to visualize the insertion site. That was one of the things that I had been doing wrong because I was just so excited that I got the IV in the vein in the first place – that I did not think much about the tape or the tegaderm for sterility. So I think an important part of critical thinking is to be able to recognize when you've made a mistake and stop, stop yourself from doing it in the future (see Table 2 ).

Skills fair intervention as a developmental strategy for critical thinking . The participants identified the skills fair intervention was effective as a developmental strategy for critical thinking, as revealed in two themes: (1) develops alternative thinking and (2) thinking before doing (See Table 3 ).

Develops alternative thinking . The participants perceived the skills fair intervention helped enhance critical thinking and confidence by developing alternative thinking. Alternative thinking was described as quickly thinking of alternative solutions to problems based on the latest evidence and using that information to determine what actions were warranted to prevent complications and prevent injury. It helped make better connections through the learning of rationale between knowledge and skills and then applying that knowledge to prevent complications and errors to ensure the safety of patients. The participants stated the learning of rationale for certain procedures provided during the skills fair intervention such as the evidence and critical thinking prompts included in the rubrics helped reinforce this connection. The participants also shared they developed alternative thinking after participating in the skills fair intervention by noticing trends in data to prevent potential complications from the faculty prompts. Participant 1 stated her instructor prompted her alternative thinking through questioning about noticing trends to prevent potential complications. She said the following:

Another way critical thinking occurred during the skills fair was when [instructor name] was teaching and prompted us about what it would be like to care for a patient with a fractured hip – I think this was at the 10-minute focused assessment station, but I could be wrong. I remember her asking, “What do you need to be on the look-out for? What can go wrong?” I automatically did not think critically very well and was only thinking circulation in the leg, dah, dah, dah. But she was prompting us to think about mobility alterations and its effect on perfusion and oxygenation. She was trying to help us build those connections. And I think that's a lot of the aspects of critical thinking that gets overlooked with the nursing student – trouble making connections between our knowledge and applying it in practice.

Thinking before doing . The participants perceived thinking before doing, included thinking of how and why certain procedures, was necessary through self-examination prior to taking action. The hands-on situational learning allowed the participants in the skills fair intervention to better notice assessment data and think at a higher level as their previous learning of the skills was perceived as memorization of steps. This higher level of learning allowed participants to consider different future outcomes and analyze pertinent data before taking action.

I think what helped me the most is considering outcomes of my actions before I do anything. For instance, if you're thinking, “Okay. Well, I need to check their blood pressure before I administer this blood pressure medication – or the blood pressure could potentially bottom out.” I really do not want my patient to bottom out and get hypotensive because I administered a medication that was ordered, but not safe to give. I could prevent problems from happening if I know what to be on alert for and act accordingly. So ultimately knowing that in the clinical setting, I can prevent complications from happening and I save myself, my license, and promote patient safety. I think knowing that I've seen the importance of critical thinking already in practice has helped me value and understand why I should be critically thinking. Yes, we use the 5-rights of medication safety – but we also have to think. For instance, if I am going to administer insulin – what do I need to know or do to give this safely? What is the current blood sugar? Has the patient been eating? When is the next meal scheduled? Is the patient NPO for a procedure? Those are examples of questions to consider and the level of thinking that needs to take place prior to taking actions in the clinical setting.

Although the results of quantitative data showed no significant difference in scores on the KCTIT between the participant and nonparticipant groups, during the interviews some participants attributed this result to the test not being part of a course grade and believed students “did not try very hard to score well.” However, the participants who attended interviews did identify the skills fair intervention as a developmental strategy for critical thinking by helping them develop alternative thinking and thinking before doing. The findings are supported in the literature as (1) nurses must recognize signs of clinical deterioration and take action promptly to prevent potential complications ( Garvey and CNE series 2015 ) and (2) nurses must analyze pertinent data and consider all possible solutions before deciding on the most appropriate action for each patient ( Papathanasiou et al. , 2014 ).

The skills fair intervention also enhanced the development of self-confidence by participants practicing previously learned skills in a controlled, safe environment. The nonthreatening environment of the skills fair intervention allowed students to learn without fear and the majority of participants believed their critical thinking was strengthened after participating. The interview data also revealed a combination of internal and external factors that influenced the development of critical thinking during the skills fair intervention including confidence and anxiety levels, attitude, age, experience and practice, faculty involvement, positive learning environment and faculty prompts. These factors should be considered when addressing the promotion and development of critical thinking.

Conclusions, limitations and recommendations

A major concern in the nursing profession is the lack of critical thinking in student nurses and new graduates, which influences the decision-making of novice nurses and directly affects patient care and safety ( Saintsing et al. , 2011 ). Nurse educators must use evidence-based practice to prepare students to critically think with the complicated and constantly evolving environment of health care today ( Goodare, 2015 ; Newton and Moore, 2013 ). Evidence-based practice has been advocated to promote critical thinking ( Profetto-McGrath, 2005 ; Stanley and Dougherty, 2010 ). The skills fair intervention can be one type of evidence-based practice used to promote critical thinking ( McCausland and Meyers, 2013 ; Roberts et al. , 2009 ). The Intervention used in this study incorporated evidence-based practice rationale with critical thinking prompts using Socratic questioning, evidence-based practice videos to the psychomotor skill rubrics, group work, guided discussions, expert demonstration followed by guided practice and blended learning in an attempt to promote and develop critical thinking in nursing students.

The explanatory sequential mixed-methods design was employed to investigate the effects of the innovative skills fair intervention on senior baccalaureate nursing students' achievements and their perceptions of critical thinking skills development. Although the quantitative results showed no significant difference in scores on the KCTIT between students who participated in the skills fair intervention and those who did not, those who attended the interviews perceived their critical thinking was reinforced after the skills fair intervention and believed it was an effective developmental strategy for critical thinking, as it developed alternative thinking and thinking before doing. This information is useful for nurse educators who plan their own teaching practice to promote critical thinking and improve patient outcomes. The findings also provide schools and educators information that helps review their current approach in educating nursing students. As evidenced in the findings, the importance of developing critical thinking skills is crucial for becoming a safe, professional nurse. Internal and external factors impacting the development of critical thinking during the skills fair intervention were identified including confidence and anxiety levels, attitude, age, experience and practice, faculty involvement, positive learning environment and faculty prompts. These factors should be considered when addressing the promotion and development of critical thinking.

There were several limitations to this study. One of the major limitations of the study was the limited exposure of students' time of access to the skills fair intervention, as it was a one-day learning intervention. Another limitation was the sample selection and size. The skills fair intervention was limited to only one baccalaureate nursing program in one southeastern state. As such, the findings of the study cannot be generalized as it may not be representative of baccalaureate nursing programs in general. In addition, this study did not consider students' critical thinking achievements prior to the skills fair intervention. Therefore, no baseline measurement of critical thinking was available for a before and after comparison. Other factors in the nursing program could have affected the students' scores on the KCTIT, such as anxiety or motivation that was not taken into account in this study.

The recommendations for future research are to expand the topic by including other regions, larger samples and other baccalaureate nursing programs. In addition, future research should consider other participant perceptions, such as nurse educators, to better understand the development and growth of critical thinking skills among nursing students. Finally, based on participant perceptions, future research should include a more rigorous skills fair intervention to develop critical thinking and explore the link between confidence and critical thinking in nursing students.

Initial coding results

Factors impacting critical thinking skill development during skills fair intervention

Skills fair intervention as a developmental strategy for critical thinking

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Evidence Based Practice

What it is and how to implement it into your professional work?

This guide is designed to help you understand and implement Evidence Based Practice in your professional work. It provides resources, tools, and information to support your research and application of EBP principles.

• 1.) Introduction to Evidence Based Practice
• 2.) Formulating a Clinical Question
• 3.) Finding Evidence
• 4.) Appraising the Evidence
• 5.) Applying the Evidence
• 6.) Assessing the Outcome
• 7.) Additional Resources

Introduction to Evidence Based Practice

What is Evidence Based Practice?

Evidence Based Practice (EBP) is an approach to clinical decision-making that integrates the best available research evidence with clinical expertise and patient values. It aims to improve patient outcomes by applying the most current and relevant information to healthcare decisions.

The EBP Process

The EBP process involves five key steps:

• Ask : Formulate a clear, answerable clinical question.
• Acquire : Search for the best available evidence.
• Appraise : Critically appraise the evidence for its validity and relevance.
• Apply : Apply the evidence to clinical practice.
• Assess : Evaluate the effectiveness and efficiency of the practice.

Formulating a Clinical Question

PICO Framework

The PICO framework is a tool used to formulate clinical questions in a structured and focused way. It stands for:

• P atient/Problem
• I ntervention
• C omparison

Example : In patients with chronic low back pain (P), does yoga (I) compared to standard physical therapy (C) improve pain management (O)?

Finding Evidence

Databases and Journals

Key databases for EBP include:

• PubMed (link)
• CINAHL (link)
• Cochrane Library (link)
• PsycINFO (link)

Search Strategies

Effective search strategies include:

• Using specific keywords related to your PICO question
• Applying Boolean operators (AND, OR, NOT) to refine your search

Grey Literature

Grey literature refers to research that is not published in traditional journals. It includes reports, theses, conference papers, and more. Important sources of grey literature are:

• OpenGrey ( link )
• National Institutes of Health (NIH) ( link )
• World Health Organization (WHO) ( link )

Appraising the Evidence

Critical Appraisal Tools

Use tools like:

• CASP (Critical Appraisal Skills Programme) checklists (link)
• PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) (link)

Levels of Evidence

Understanding the hierarchy of evidence helps in determining the strength of recommendations:

• Systematic reviews and meta-analyses
• Randomized controlled trials (RCTs)
• Cohort studies
• Case-control studies
• Case series and case reports
• Expert opinion

Applying the Evidence

Integrating Evidence into Practice

Strategies for implementation include:

• Developing clinical guidelines and protocols
• Collaborating with interdisciplinary teams
• Engaging in continuous education and training

Case Studies and Examples

Explore real-world applications of EBP through case studies and examples from various healthcare settings.

Assessing the Outcome

Evaluating the Impact

Methods for assessing outcomes:

• Patient feedback and satisfaction surveys
• Clinical outcome measures
• Quality improvement metrics

Continuous improvement is vital to ensure that EBP is effectively enhancing patient care and outcomes.

Additional Resources

Websites and Online Resources

• Cochrane Collaboration ( link )
• Centre for Evidence-Based Medicine (CEBM) ( link )
• National Institute for Health and Care Excellence (NICE) ( link )

• A Framework for Enhancing the Value of Research for Dissemination and Implementation
• Learning how to undertake a systematic review: part 1
• Learning how to undertake a systematic review: part 2
• Systematic reviews of complex interventions: framing the review question

Video: What is Evidence Based Practice

Video: What are Systematic Reviews

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Evidence-based practice for effective decision-making

Effective HR decision-making is based on considering the best available evidence combined with critical thinking.

People professionals are faced with complex workplace decisions and need to understand ‘what works’ in order to influence organisational outcomes for the better. 

Evidence-based practice helps them make better, more effective decisions by choosing reliable, trustworthy solutions and being less reliant on outdated received wisdom, fads or superficial quick fixes. 

At the CIPD, we believe this is an important step for the people profession to take: our Profession Map describes a vision of a profession that is principles-led, evidence-based and outcomes-driven. Taking an evidence-based approach to decision-making can have a huge impact on the working lives of people in all sorts of organisations worldwide.

This factsheet outlines what evidence-based practice is and why it is so important, highlighting the four sources of evidence to draw on and combine to ensure the greatest chance of making effective decisions. It then looks to the steps we can take to move towards an evidence-based people profession. 

On this page

• What is evidence-based practice?
• Why is evidence-based practice important?
• What evidence should we use?
• How can we move towards an evidence-based people profession?
• Useful contacts and further reading

At the heart of evidence-based practice is the idea that good decision-making is achieved through critical appraisal of the best available evidence from multiple sources. When we say ‘evidence’, we mean information, facts or data supporting (or contradicting) a claim, assumption or hypothesis. This evidence may come from scientific research, the local organisation, experienced professionals or relevant stakeholders. We use the following definition from CEBMa :

“Evidence-based practice is about making decisions through the conscientious, explicit and judicious use of the best available evidence from multiple sources… to increase the likelihood of a favourable outcome.”

In search of best available evidence

The reasons why evidence-based practice is so important, the principles that underpin it, how it can be followed and how challenges in doing so can be overcome.

Information overload

In their report Evidence-based management: the basic principles , Eric Barends, Denise Rousseau and Rob Briner of CEBMa outline the challenge of biased and unreliable management decisions. 

People professionals face all sorts of contradictory insights and claims about what works and what doesn’t in the workplace. As Daniel Levitin puts it:

"We're assaulted with facts, pseudo facts, jibber-jabber, and rumor, all posing as information. Trying to figure out what you need to know and what you can ignore is exhausting."

While assessing the reliability of evidence becomes more important as the mass of opinion grows, with such a barrage of information, we inevitably use mental shortcuts to make decisions easier and to avoid our brains overloading.

Unfortunately, this means we are prone to biases. Our reports a head for hiring and our minds at work outline the most common of these:

• authority bias: the tendency to overvalue the opinion of a person or organisation that is seen as an authority
• conformity bias: the tendency to conform to others in a group, also referred to as 'group think' or 'herd behaviour'
• confirmation bias: looking to confirm existing beliefs when assessing new information
• patternicity or the illusion of causality: the tendency to see patterns and assume causal relations by connecting the dots even when there is just random 'noise'.

So-called ‘best practice’

Received wisdom and the notion of ‘best practice’ also creates bias. One organisation may look to another as an example of sound practice and decision-making, without critically evaluating the effectiveness of their actions. And while scientific literature on key issues in the field is vital, there’s a gap between this and the perceptions of practitioners, who are often unaware of the depth of research available.

Cherry-picking evidence

Even when looking at research, we can be naturally biased. We have a tendency to ‘cherry-pick’ research that backs up a perspective or opinion and ignores research that does not, even if it gives stronger evidence on cause-and-effect relationships. This bad habit is hard to avoid – it's even common among academic researchers. So we need approaches that help us determine which research evidence we should trust.

Our ‘insight’ article When the going gets tough, the tough get evidence explains the importance of taking an evidence-based approach to decision making in light of the COVID-19 pandemic. It emphasises and discusses how decision makers can and should become savvy consumers of research.

How can evidence-based practice help?

Our thought leadership article outlines the importance of evidence-based practice in more detail but, essentially, it has three main benefits:

• It ensures that decision-making is based on fact, rather than outdated insights, short-term fads and natural bias.
• It creates a stronger body of knowledge and as a result, a more trusted profession.
• It gives more gravitas to professionals, leads to increased influence on other business leaders and has a more positive impact in work.

The four sources of evidence

The issues above demonstrate the limitations of basing decisions on limited, unreliable evidence. Before making an important decision or introducing a new practice, an evidence-based people professional should start by asking: "What is the available evidence?" As a minimum, people professionals should consider four sources of evidence.

• Scientific literature on people management has become more readily available in recent years, particularly on topics such as the recruitment and selection of personnel, the effect of feedback on performance and the characteristics of effective teams. People professionals’ ability to search for and appraise research for its relevance and trustworthiness is essential.
• Organisational data must be examined as it highlights issues needing a manager’s attention. This data can come externally from customers or clients (customer satisfaction, repeated business), or internally from employees (levels of job satisfaction, retention rates). There’s also the comparison between ‘hard’ evidence, such as turnover rate and productivity levels, and ‘soft’ elements, like perceptions of culture and attitudes towards leadership. Gaining access to organisational data is key to determining causes of problems, solutions and implementing solutions.
• Expertise and judgement of practitioners, managers, consultants and business leaders is important to ensure effective decision-making. This professional knowledge differs from opinion as it’s accumulated over time through reflection on outcomes of similar actions taken in similar contexts. It reflects specialised knowledge acquired through repeated experience of specialised activities.
• Stakeholders, both internal (employees, managers, board members) and external (suppliers, investors, shareholders), may be affected by an organisation’s decisions and their consequences. Their values reflect what they deem important, which in turn affects how they respond to the organisation’s decisions. Acquiring knowledge of their concerns provides a frame of reference for analysing evidence.

Combining the evidence

One very important element of evidence-based practice is collating evidence from different sources. There are six ways – depicted in our infographic below – which will encourage this:

Evidence based practice infographic

• Asking – translating a practical issue or problem into an answerable question.
• Acquiring – systematically searching for and retrieving evidence.
• Appraising – critically judging the trustworthiness and relevance of the evidence.
• Aggregating – weighing and pulling together the evidence.
• Applying – incorporating the evidence into a decision-making process.
• Assessing – evaluating the outcome of the decision taken so as to increase the likelihood.

Through these six steps, practitioners can ensure the quality of evidence is not ignored. Appraisal varies depending on the source of evidence, but generally involves the same questions:

• Where and how is evidence gathered?
• Is it the best evidence available?
• Is it sufficient to reach a conclusion?
• Might it be biased in a particular direction? If so, why?

Evidence-based practice is about using the best available evidence from multiple sources to optimise decisions. Being evidence-based is not a question of looking for ‘proof’, as this is far too elusive. However, we can – and should – prioritise the most trustworthy evidence available. The gains in making better decisions on the ground, strengthening the body of knowledge and becoming a more influential profession are surely worthwhile.

To realise the vision of a people profession that’s genuinely evidence-based, we need to move forward on two fronts. 

First, we need to make sure that the body of professional knowledge is evidence-based – the CIPD’s Evidence review hub is one way in which we are doing this. 

Second, people professionals need to develop capacity in engaging with the best available evidence. Doing this as a non-researcher may feel daunting, but taking small steps to making more evidence-based decisions can make a huge difference. Our thought leadership article outlines a maturity model for being more evidence-based in more detail, but to summarise, we’d encourage people professionals to take the following steps:

• Read research : engage with high-quality research on areas of interest through reading core textbooks and journals that summarise research.
• Collect and analyse organisational data : in the long-term, developing analytical capability should be an aim for the people profession. More immediately, HR leaders should have some knowledge of data-analytics, enough to ask probing questions and make the case for the resources needed for robust measures.
• Review published evidence , including conducting or commissioning short evidence reviews of scientific literature to inform decisions.
• Pilot new practices : evaluate new interventions through applying the same principles used in rigorous cause-and-effect research.
• Share your knowledge : strengthen the body of knowledge by sharing research insights at events or in publications.
• Critical thinking : throughout this process, question assumptions and carefully consider where there are gaps in knowledge.

Developing this sort of capability is a long journey but one that people professionals should aspire to. As the professional body for HR and people development, the CIPD takes an evidence-based view on the future of work – and, importantly, what this means for our profession. By doing this, we can help prepare professionals and employers for what’s coming, while also equipping them to succeed and shape a changing world of work.

Our Profession Map has been developed to do this. It defines the knowledge, behaviours and values which should underpin today’s people profession. It has been developed as an international standard against which an organisation can benchmark its values. At its core are the concepts of being principles-led, evidence-based and outcomes driven. This recognises the importance of using the four forms of evidence in a principled manner to develop positive outcomes for stakeholders. As evidence is often of varying degrees of quality, it’s important that people professionals consider if and how they should incorporate the different types of evidence into their work.

Evidence-based practice is a useful concept for understanding whether practices in HR lead to the desired outcomes, and whether these practices are being used to the best effect. 

Both our guide and thought leadership article offer a detailed, step-by-step approach to using evidence-based practice in your decision making.

All our evidence reviews are featured on our Evidence Hub . For a learning and development perspective, listen to our Evidence-based L&D podcast. There's also Using evidence in HR decision-making: 10 lessons from the COVID-19 crisis , part of our coronavirus webinar series.

Center for Evidence-Based Management (CEBMa)  

ScienceForWork - Evidence-based management  

Books and reports

Barends, E. and Rousseau, D. (2018)  Evidence-based management: how to use evidence to make better organizational decisions . Kogan Page: London

Levitin, D. (2015) The Organized Mind: Thinking Straight in the Age of Information Overload . London: Penguin. 

Randell, G. and Toplis, J. (2014)  Towards organizational fitness: a guide to diagnosis and treatment . London: Gower.

Visit the  CIPD and Kogan Page Bookshop  to see all our priced publications currently in print.

Journal articles

Petticrew, M. and Roberts, H. (2003) Evidence, hierarchies, and typologies: horses for courses . Journal Of Epidemiology And Community Health . Vol 57(7): 527.

Rousseau, D. (2020) Making evidence based-decisions in an uncertain world.  Organizational Dynamics . Vol 49, Issue 1, January-March. Reviewed in Bitesize research.

Severson, E. (2019) Real-life EBM: what it feels like to lead evidence-based HR.  People + Strategy . Vol 42, No 1. pp22-27.

CIPD members can use our  online journals  to find articles from over 300 journal titles relevant to HR.

Members and  People Management  subscribers can see articles on the  People Management  website.

This factsheet was last updated by Jake Young: Research Associate, CIPD

Jake’s research interests cover a number of workplace topics, notably inclusion and diversity. Jake is heavily involved with CIPD’s evidence reviews, looking at a variety of topics including employee engagement, employee resilience and virtual teams.

Tackling barriers to work today whilst creating inclusive workplaces of tomorrow.

Related content

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A case study on using evidence-based practice to better understand how to support hybrid workforces

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Probing the Relationship Between Evidence-Based Practice Implementation Models and Critical Thinking in Applied Nursing Practice

• PMID: 27031030
• DOI: 10.3928/00220124-20160322-05

HOW TO OBTAIN CONTACT HOURS BY READING THIS ISSUE Instructions: 1.2 contact hours will be awarded by Villanova University College of Nursing upon successful completion of this activity. A contact hour is a unit of measurement that denotes 60 minutes of an organized learning activity. This is a learner-based activity. Villanova University College of Nursing does not require submission of your answers to the quiz. A contact hour certificate will be awarded after you register, pay the registration fee, and complete the evaluation form online at http://goo.gl/gMfXaf. In order to obtain contact hours you must: 1. Read the article, "Probing the Relationship Between Evidence-Based Practice Implementation Models and Critical Thinking in Applied Nursing Practice," found on pages 161-168, carefully noting any tables and other illustrative materials that are included to enhance your knowledge and understanding of the content. Be sure to keep track of the amount of time (number of minutes) you spend reading the article and completing the quiz. 2. Read and answer each question on the quiz. After completing all of the questions, compare your answers to those provided within this issue. If you have incorrect answers, return to the article for further study. 3. Go to the Villanova website to register for contact hour credit. You will be asked to provide your name, contact information, and a VISA, MasterCard, or Discover card number for payment of the $20.00 fee. Once you complete the online evaluation, a certificate will be automatically generated. This activity is valid for continuing education credit until March 31, 2019. CONTACT HOURS This activity is co-provided by Villanova University College of Nursing and SLACK Incorporated. Villanova University College of Nursing is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

Objectives: • Describe the key components and characteristics related to evidence-based practice and critical thinking. • Identify the relationship between evidence-based practice and critical thinking. DISCLOSURE STATEMENT Neither the planners nor the author have any conflicts of interest to disclose. Evidence-based practice is not a new concept to the profession of nursing, yet its application and sustainability is inconsistent in nursing practice. Despite the expansion of efforts to teach evidence-based practice and practically apply evidence at the bedside, a research-practice gap still exists. Several critical factors contribute to the successful application of evidence into practice, including critical thinking. The purpose of this article is to discuss the relationship between critical thinking and the current evidence-based practice implementation models. Understanding this relationship will help nurse educators and clinicians in cultivating critical thinking skills in nursing staff to most effectively apply evidence at the bedside. Critical thinking is a key element and is essential to the learning and implementation of evidence-based practice, as demonstrated by its integration into evidence-based practice implementation models.

Copyright 2016, SLACK Incorporated.

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What is Evidence-Based Practice in Nursing? (With Examples, Benefits, & Challenges)

Are you a nurse looking for ways to increase patient satisfaction, improve patient outcomes, and impact the profession? Have you found yourself caught between traditional nursing approaches and new patient care practices? Although evidence-based practices have been used for years, this concept is the focus of patient care today more than ever. Perhaps you are wondering, “What is evidence-based practice in nursing?” In this article, I will share information to help you begin understanding evidence-based practice in nursing + 10 examples about how to implement EBP.

What is Evidence-Based Practice in Nursing?

When was evidence-based practice first introduced in nursing, who introduced evidence-based practice in nursing, what is the difference between evidence-based practice in nursing and research in nursing, what are the benefits of evidence-based practice in nursing, top 5 benefits to the patient, top 5 benefits to the nurse, top 5 benefits to the healthcare organization, 10 strategies nursing schools employ to teach evidence-based practices, 1. assigning case studies:, 2. journal clubs:, 3. clinical presentations:, 4. quizzes:, 5. on-campus laboratory intensives:, 6. creating small work groups:, 7. interactive lectures:, 8. teaching research methods:, 9. requiring collaboration with a clinical preceptor:, 10. research papers:, what are the 5 main skills required for evidence-based practice in nursing, 1. critical thinking:, 2. scientific mindset:, 3. effective written and verbal communication:, 4. ability to identify knowledge gaps:, 5. ability to integrate findings into practice relevant to the patient’s problem:, what are 5 main components of evidence-based practice in nursing, 1. clinical expertise:, 2. management of patient values, circumstances, and wants when deciding to utilize evidence for patient care:, 3. practice management:, 4. decision-making:, 5. integration of best available evidence:, what are some examples of evidence-based practice in nursing, 1. elevating the head of a patient’s bed between 30 and 45 degrees, 2. implementing measures to reduce impaired skin integrity, 3. implementing techniques to improve infection control practices, 4. administering oxygen to a client with chronic obstructive pulmonary disease (copd), 5. avoiding frequently scheduled ventilator circuit changes, 6. updating methods for bathing inpatient bedbound clients, 7. performing appropriate patient assessments before and after administering medication, 8. restricting the use of urinary catheterizations, when possible, 9. encouraging well-balanced diets as soon as possible for children with gastrointestinal symptoms, 10. implementing and educating patients about safety measures at home and in healthcare facilities, how to use evidence-based knowledge in nursing practice, step #1: assessing the patient and developing clinical questions:, step #2: finding relevant evidence to answer the clinical question:, step #3: acquire evidence and validate its relevance to the patient’s specific situation:, step #4: appraise the quality of evidence and decide whether to apply the evidence:, step #5: apply the evidence to patient care:, step #6: evaluating effectiveness of the plan:, 10 major challenges nurses face in the implementation of evidence-based practice, 1. not understanding the importance of the impact of evidence-based practice in nursing:, 2. fear of not being accepted:, 3. negative attitudes about research and evidence-based practice in nursing and its impact on patient outcomes:, 4. lack of knowledge on how to carry out research:, 5. resource constraints within a healthcare organization:, 6. work overload:, 7. inaccurate or incomplete research findings:, 8. patient demands do not align with evidence-based practices in nursing:, 9. lack of internet access while in the clinical setting:, 10. some nursing supervisors/managers may not support the concept of evidence-based nursing practices:, 12 ways nurse leaders can promote evidence-based practice in nursing, 1. be open-minded when nurses on your teams make suggestions., 2. mentor other nurses., 3. support and promote opportunities for educational growth., 4. ask for increased resources., 5. be research-oriented., 6. think of ways to make your work environment research-friendly., 7. promote ebp competency by offering strategy sessions with staff., 8. stay up-to-date about healthcare issues and research., 9. actively use information to demonstrate ebp within your team., 10. create opportunities to reinforce skills., 11. develop templates or other written tools that support evidence-based decision-making., 12. review evidence for its relevance to your organization., bonus 8 top suggestions from a nurse to improve your evidence-based practices in nursing, 1. subscribe to nursing journals., 2. offer to be involved with research studies., 3. be intentional about learning., 4. find a mentor., 5. ask questions, 6. attend nursing workshops and conferences., 7. join professional nursing organizations., 8. be honest with yourself about your ability to independently implement evidence-based practice in nursing., useful resources to stay up to date with evidence-based practices in nursing, professional organizations & associations, blogs/websites, youtube videos, my final thoughts, frequently asked questions answered by our expert, 1. what did nurses do before evidence-based practice, 2. how did florence nightingale use evidence-based practice, 3. what is the main limitation of evidence-based practice in nursing, 4. what are the common misconceptions about evidence-based practice in nursing, 5. are all types of nurses required to use evidence-based knowledge in their nursing practice, 6. will lack of evidence-based knowledge impact my nursing career, 7. i do not have access to research databases, how do i improve my evidence-based practice in nursing, 7. are there different levels of evidence-based practices in nursing.

• Level One: Meta-analysis of random clinical trials and experimental studies • Level Two: Quasi-experimental studies- These are focused studies used to evaluate interventions. • Level Three: Non-experimental or qualitative studies. • Level Four: Opinions of nationally recognized experts based on research. • Level Five: Opinions of individual experts based on non-research evidence such as literature reviews, case studies, organizational experiences, and personal experiences.

8. How Can I Assess My Evidence-Based Knowledge In Nursing Practice?