doi 10.1515/ijnes-2012-0005

International Journal of Nursing Education Scholarship 2013; 10(1): 237–244

Elizabeth R. Moore* and Richard Watters

Educating DNP Students about Critical Appraisal and Knowledge Translation Abstract: Consumers expect that health care providers will use the best evidence when assisting them in making decisions about treatment options. Nurses at all educational levels report that they lack knowledge to critically appraise research studies and the skills to effectively implement evidence-based practice (EBP) in their clinical settings. Organizational culture and management support of innovation are critical factors in the adoption of EBP. Doctor of Nursing Practice (DNP) graduates can have a pivotal role in the transfer of knowledge to practice, yet critical appraisal and EBP competencies for DNP and Master of Science in Nursing (MSN) students have not been well differentiated in nursing curricula. Also students’ attitudes toward EBP, self-efficacy beliefs, utilization, and knowledge gaps are rarely evaluated before courses are designed. This article reports on the development of a DNP-level EBP course to help students evaluate and apply research findings to clinical practice.

Keywords: evidence-based practice, critical appraisal, knowledge translation

*Corresponding author: Elizabeth R. Moore, Vanderbilt University, Nashville, TN, USA, E-mail: [email protected] Richard Watters, Vanderbilt University, Nashville, TN, USA, E-mail: [email protected]

Introduction Nurses are challenged to provide safe, quality patient care within the context of a dynamic and complex health care environment. Consumers expect health care providers to use best evidence in their clinical practice, but studies have indicated that patients may not consistently receive safe and high-quality care (Agency for Healthcare Research and Quality [AHRQ], 2007; Mangione-Smith et al., 2007; McGlynn et al., 2003; Schuster, McGlynn, & Brook, 2005), thus affecting patient outcomes. Schools of nursing are incorporating evidence-based practice (EBP) models into their curricula, so that graduates will be able to apply the best available evidence in

clinical practice. Undetermined is how best to teach the attendant skills and content for application in the clinical setting and how to differentiate the objectives by Doctor of Nursing Practice (DNP) and master’s levels given the varied education and experiences of students in these programs. This article begins with a brief overview of how EBP is taught to Master of Science in Nursing (MSN)- and DNP-level students. As part of this overview, MSN- and DNP-level EBP competencies as well as strategies to support knowledge transfer by DNP graduates are also discussed. The main purpose of this article is to describe the development of a DNP-level EBP course based on this overview. This article concludes with recommendations for educators and educational researchers.

MSN and DNP evidence-based practice education Although there is a need to appraise the research evidence and utilize best evidence in clinical practice, a knowledge gap currently exists between best evidence and EBP (Lang, Wyer, & Haynes, 2007). Furthermore, the knowledge gap results in a delay in using research knowledge in the practice environment (Kontos & Poland, 2009; Lomas, 2000, 2007; Nicolini, Powell, Conville, & Martinez-Solano, 2008). In light of the most recent advances in research and innovation, this “knowledge gap” is of concern within the health care environment. Research evidence indicates that nurses’ knowledge and skills with respect to critically appraising research is limited and their utilization of best evidence in clinical practice is inconsistent. Nurses’ knowledge of, attitudes toward, and implementation of EBP are key factors that impact the utilization of EBP in the clinical setting. Nurses report that they lack the knowledge to access the evidence and understand the research process as well as critically appraise research methods and findings (Brown, Wickline, Ecoff, & Glaser, 2008; Fineout-Overholt, Levin, & Melnyk, 2004; Koehn & Lehman, 2008; Majid et al., 2011; Mills, Field, & Cant, 2011; Waters, Crisp, Rychetnik, & Barratt, 2009;

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Melnyk, Fineout-Overholt, Giggleman, & Cruz, 2010; Solomons & Spross, 2011). Nurses’ academic preparation influences their knowledge of EBP. Majid et al. (2011) reported nurses with bachelor’s or master’s degrees in nursing were more likely to have better self-efficacy in terms of performing EBP activities than certificate- or diploma-prepared nurses. A statistically significant difference was also found between nurses with varying levels of academic preparation and their knowledge of the research process (Bonner & Sando, 2008). Nurses with master’s degrees were more likely to understand research than baccalaureate-prepared nurses. Knowledge was significantly correlated with the level of education (Thiel & Ghosh, 2008). Overall, nurses have positive attitudes toward EBP (Brown et al., 2008; Koehn & Lehman, 2008; Majid et al., 2011; Thiel & Ghosh, 2008; Waters et al., 2009). Koehn and Lehman, however, found more positive attitudes among baccalaureate- and master’s-prepared nurses than those with diploma and associate degrees. Baccalaureate- and master’s-prepared nurses usually have received education in research and EBP. The baccalaureate- and master’s-prepared nurses’ positive attitudes were contingent on time to learn and implement EBP (Majid et al., 2011). Positive attitudes toward EBP also were associated with the level of position in which individuals in more senior positions were more positive (Bonner & Sando, 2008). Beyond the knowledge of EBP, translation into action is another issue for nurses. In an integrated review of 23 studies, Solomons and Spross (2011) found that time constraints caused by a heavy workload and other highpriority responsibilities were frequently cited as barriers (11 studies). The organizational culture also was cited as a barrier specifically related to staff resistance to new innovations (7 studies) and lack of authority to initiate change (5 studies). Frustration can occur when nurses are provided with the skills needed to evaluate and translate research evidence but are not given the authority to do so (Grant, Stuhlmacher, & Bonte-Eley, 2012; Santos, 2012; Solomons & Spross, 2011). In an integrative review of 10 studies, Santos found that staffing issues, lack of time, reimbursement, and social support from managers and peers were all barriers to staff participation in educational activities. A recent survey of 1,015 registered nurses (Melnyk, Fineout-Overholt, Gallagher-Ford, & Kaplan, 2012) found that lack of time, EBP skills, organizational support and mentors continue to be barriers to EBP. In contrast, Magnet hospitals provided more EBP experts, educational classes, and recognition of staff EBP projects. Education regarding how to approach these barriers is essential for nurses.

Accreditors of nursing programs have specified EBP competencies at each level of professional nursing education (National League for Nursing, 2010). At the master’s level, Essential IV in the Essentials of Master’s Education in Nursing (2001) document refers to translating and integrating scholarship into practice where graduates are prepared to “integrate theory, evidence, clinical judgment, research and interprofessional perspectives using translational processes” (American Association of Colleges of Nursing [AACN], 2011, p. 16). Employers expect that these nurses will possess the necessary knowledge and skills to do so and also be able to guide other nurses in implementing EBP. Reports on how to best convey this knowledge and teach these skills at the master’s level have been disseminated. For example, MSN-level EBP skill development has been promoted by the use of the PICO process (patient/population/problem, intervention/treatment, comparison intervention, and outcomes) (LoBiondoWood & Haber, 2010; Stiffler & Cullen, 2010) to formulate relevant clinical intervention questions. Students learn how to search the literature to locate the best evidence to answer clinical questions and identify the level of research evidence (Level I to Level VII) (Melnyk & Fineout-Overholt, 2005) of the identified studies. The importance of Level I evidence (e.g. systematic reviews, meta-analyses of randomized controlled trials (RCTs), and clinical practice guidelines (CPGs) based on these reviews (LoBiondo-Wood & Haber, 2010)) has also been emphasized. MSN students must be able to differentiate systematic reviews from other types of literature reviews and identify the resources for systematic reviews and CPGs in the literature. Students can then begin to develop critical appraisal skills by evaluating systematic reviews and RCTs using the Critical Appraisal Skills Program (CASP) guidelines (http://www.casp-uk.net/) and CPGs using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument (AGREE Next Steps Consortium, 2009; Krainovich-Miller, Haber, Yost, & Jacobs, 2007). Jones, Crookes, and Johnson (2011) developed a series of critical appraisal seminars for MSN-level students in Australia and Hong Kong, as part of a graduate certification program in health research. Rather than focusing primarily on Level I evidence, the seminars also included content on critical appraisal of quantitative research studies, such as cohort, case–control, and cross-sectional surveys, as well as qualitative research designs. The CASP guidelines were used to evaluate research articles using these study designs. The students also prepared a proposal for an integrated review of the literature on a health problem of interest and then

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E. R. Moore and R. Watters: Critical Appraisal and Knowledge Translation

reviewed six research articles related to their respective topics. The Essentials of Doctoral Education for Advanced Nursing Practice document indicates that analytic methods should be used to critically evaluate the research literature; however, it does not elaborate on standards at the DNP level for critical appraisal (AACN, 2006). A literature search was performed using keywords (DNP, EBP, and curriculum) in PubMed and CINAHL from inception until April 10, 2013. Few articles were found on the acquisition of EBP skills by nursing students at the DNP level. Stiffler and Cullen (2010) also note that few articles have been published on strategies for teaching EBP skills to nursing students. Burke et al. (2005) and Magyary et al. (2006) included the evaluation of CPGs or protocols as part of their DNP curriculum; however, it is important to develop DNP skills, especially in the evaluation of the evidence foundation of CPGs, at a more sophisticated level than that of the MSN nurse. DNP students also must know how to differentiate a systematic review from an integrated or narrative review and understand what makes these types of reviews systematic. Our review of the literature to determine differentiation of EBP learning objectives by graduate degree type (MSN and DNP) yielded only the National League for Nursing (2010) broadly stated graduate competencies under the program outcome “Spirit of Inquiry.”

Table 1

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Although the competencies refer to analyzing, evaluating impact of, and disseminating evidence, they do not address the process for critically appraising evidence.

Development and execution of DNP EBP education There were four steps taken by our school as the DNP program evolved: (1) differentiation of competencies between the MSN and DNP program, (2) identification of knowledge translation strategies, (3) identification of tools that evaluate research evidence, and (4) execution of the course that resulted from the first three steps.

Step 1: competency differentiation The development of the DNP program stimulated faculty discussions in work groups to differentiate the learning needs of the MSN and DNP students related to EBP. A search was also conducted in the medical literature to identify the competencies listed in evidence-based medicine curricula. As a result of this process, the competencies listed in Table 1 emerged.

MSN- and DNP-level EBP competencies

EBP abilities at the MSN level 1. Identify the components of the EBP model 2. Develop a PICO question for a clinical intervention 3. Conduct literature searches to find the best available evidence 4. Identify the level of evidence of studies retrieved from literature searches 5. Discuss the importance of Level I evidence 6. Describe the hierarchy of evidence 7. Differentiate systematic reviews/meta-analyses from literature reviews 8. Apply basic critical appraisal skills using checklists such as the CASP appraisal checklists 9. Synthesize results of the studies and making recommendations for clinical practice changes on their unit 10. Translate evidence-based knowledge from an individual perspective for clinical practice EBP abilities at the DNP level 1. Critically evaluate the EBP model and its applicability to clinical practice 2. Use national databases for identification of priority health issues 3. Apply advanced critical appraisal skills for Level I evidence using the Consolidated Standards of Reporting Trials (CONSORT) guidelines, Cochrane Risk of Bias tables, PRISMA, and the AGREE II instrument 4. Evaluate strength of evidence underlying CPGs 5. Utilize the consensus process for reaching a conclusion about the scientific merit of a research article 6. Identify the steps involved in conducting a systematic review of the literature 7. Interpret the results of a meta-analysis 8. Describe integration of evidence-based individual decision-making in the DNP role 9. Systematically locate, evaluate, and synthesize the best available evidence to answer a clinical question using the PICO format and disseminate; their findings in their work setting, professional conferences, and through publication 10. Translate evidence-based knowledge from a systems or organizational perspective for clinical practice

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Step 2: knowledge translation A number of interventions have been suggested to reduce barriers and facilitate KT in clinical practice; mentorship (Melnyk et al., 2012; 2010; Newhouse, Dearholt, Poe, Pugh, & White, 2004), multi-disciplinary teams (Kitson et al., 2011; Wiechula et al., 2009), EBP rounds (FineoutOverholt et al., 2004), EBP committees (Mohide & Coker, 2005; Mohide & King, 2003), EBP workshops and journal clubs (Solomons & Spross, 2011), and EBP internships and partnering with PhD-level researchers (Vincent, Johnson, & Velasquez, 2010). DNP graduates employed in nursing leadership positions can provide organizational commitment, strategies, and approaches to support the translation of evidence. Nurse leaders can build a culture (Thiel & Ghosh, 2008), create a learning environment (Estrada, 2009), and make evidence easier to understand (Brown et al., 2008). A positive attitude by nursing leadership toward research also will create a nursing research culture and promote EBP (Bonner & Sando, 2008). In addition, nursing leadership can provide resources such as education for clinicians and managers (Cadmus et al., 2008; Sherriff, Wallis, & Chaboyer, 2007). Pipe, Cisar, Caruso, and Wellik (2008) suggest incentives to facilitate EBP including reimbursement for professional memberships, journal subscriptions, books, and education that pertains to EBP. Other strategies include incorporating EBP in administrative and nursing policies and procedures (Stiffler & Cullen, 2010). Anderson et al. (2010) contend that the

Table 2

translation of knowledge into practice involves all levels of the organization; as opposed to the individual practice level, only. Researchers have yet to determine what intervention strategies are most effective (Armstrong et al., 2011; Solomons & Spross, 2011; Wallin, 2009) in implementing and sustaining change over time. A multi-dimensional approach, taking into account both individual and institutional barriers, may be needed to facilitate the adoption of EBP in the clinical setting. A comprehensive list of strategies is contained in Table 2. These formed the basis for translational strategies to be taught in the DNP program.

Step 3: evaluation of research evidence A number of tools that evaluate research evidence at a level consistent with the DNP competencies were identified and adopted for inclusion in the DNP program. They are described below and include the (1) Cochrane Risk of Bias tables, (2) CONSORT guidelines, (3) PRISMA guidelines, and (4) AGREE II instrument. DNP students need to be knowledgeable about the processes recently published in the medical literature to evaluate research evidence, especially in terms of bias. The Cochrane Collaboration has recently designed Risk of Bias tables to evaluate the internal validity of all RCTs included in Cochrane reviews (Higgins, Altman, & Sterne, 2011, Figure 8.6.a). Bias has been defined as, “the

Knowledge Translation Strategies

Knowledge translation strategies that can be utilized by the DNP graduate 1. Provide individualized mentoring on the unit for BSN- and MSN-level nurse practitioners in the EBP process 2. Serve as the leader on multi-disciplinary teams to introduce new evidence-based innovations 3. Conduct EBP rounds examining the best evidence supporting the treatment recommendations for patients with complex medical problems 4. Chair EBP committees to facilitate the use of best evidence in clinical practice 5. Facilitate the development of unit-based journal clubs 6. Develop a clinical scholars internship program where frontline nurses and managers can be mentored in the EBP process 7. Establish an online EBP resource website for their institution with EBP skills learning modules 8. Organize a local or regional annual EBP symposium at their facility 9. Serve as an expert guest lecturer at local, regional, or national conferences on the EBP process and evidence translation models and strategies 10. Partner with PhD-level researchers to design and obtain grant funding for research studies that provide answers to PICO questions not addressed adequately in the current literature 11. Work with the leadership team to incorporate EBP in organizational policies and procedures 12. Educate the executive team about the importance of utilizing KT to support best practice and improve patient outcomes

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systematic deviation of the results of a study from the truth because of the way it has been conducted, analyzed or reported” (Burls, 2009, p. 2). Bias is concerned with whether the results of an individual RCT over- or underestimate the true effects of a health care intervention. Studies with a high risk of bias are more likely to overestimate the effects of an intervention (Higgins et al., 2011). Research that is biased can cause clinicians to make false conclusions about the effectiveness of interventions. The CONSORT statement (Moher et al., 2010) was originally developed in 1996 by a group of journal editors and scientists to enhance the transparency and reliability of reporting of RCTs. This statement was updated in 2001 and again in 2010. The CONSORT statement and checklist focuses on the quality of reporting of the background, methods, results and discussion sections of RCTs, whereas the Risk of Bias tables in Cochrane reviews focus on the methodological rigor used in conducting the trials. Cochrane reviews are considered the “gold standard” for systematic reviews and meta-analyses. Cochrane reviewers are taught RCT appraisal skills as part of Reviewer Training Workshops, and they are included in the Cochrane Reviewer’s Manual. Some of these skills can also be learned by DNP students to assess the methodological quality of RCTs. In 1999, a group of experienced review authors and methodologists developed the QUality Of Reporting Of Meta-analysis (QUOROM) Statement and checklist to enhance the clarity and transparency of reporting systematic reviews and meta-analyses. An expansion of the QUOROM statement Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) has been recently developed in response to methodological and conceptual advances in the performance of these reviews (Liberati et al., 2009). In 2003, a group of researchers and guideline developers published the AGREE Instrument, a 23-item checklist that evaluates the internal and external validity of CPGs. This instrument has recently been revised and updated to AGREE II (AGREE Next Steps Consortium, 2009). The Enhancing the QUality And Transparency Of health Research (EQUATOR) Network has published a comprehensive catalog of reporting guidelines (Simera, Moher, Hoey, Schulz, & Altman, 2010) that is available on their website (http://www.equator-network.org/). These instruments and the Cochrane Risk of Bias tables are utilized in our DNP-level EBP course to enhance student understanding of critical appraisal.

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Step 4: DNP learning experiences Our course, EBP II: Evaluating and Applying Evidence, is a 3-credit-hour course offered during the second semester of the first year of the DNP program. Pre-requisites include Statistics in Health Sciences and EBP I: The Nature of the Evidence. This first course helps students develop a concept map and paper describing the relationships between the major concepts they have identified in their topic for their scholarly project (Christenbery, 2011). The number of students enrolled in the EBP II course has increased steadily from 32 in 2009, the first time the course was offered, to 64 in 2013. The first week classes are in a block format (three sessions, 2 hours each) at the school of nursing at the beginning of the semester and subsequent once weekly classes use online technologies and are asynchronous. The three major assignments for the course include (1) evaluation of a RCT using the CONSORT guidelines, (2) systematic review and meta-analysis using PRISMA, and (3) CPG using the AGREE II instrument. The lecture topics, delivery method, and student assessment and course evaluation methods are contained in Table 3. Students use the consensus process recommended by the Cochrane Collaboration. They are divided into small groups of 3–4 students each and select an RCT, metaanalysis, and CPG for a health care intervention related to one of their group members’ focus area. Each student completes the CONSORT and PRISMA checklists as well as the AGREE II instrument and domain scores independently. Their assigned faculty member also completes the evaluation checklists. The students then e-mail their checklists and instrument to other group members in addition to their faculty member. Students are asked to discuss their areas of disagreement on the scientific merit of the article or CPG and come to a group consensus about how the items should be scored. Students also calculate an average domain score for their CPG and reach a conclusion about whether or not it should be adopted in clinical practice. They, then, write a brief memo stating where they were in disagreement on the merits of the article or CPG, how they resolved their differences and their final conclusions. Afterward, their faculty member leads a group discussion about the articles and the consensus process. Additional assignments include a qualitative critique of an RCT using the Cochrane Risk of Bias tables,

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Table 3

E. R. Moore and R. Watters: Critical Appraisal and Knowledge Translation

DNP-level EBP and critical appraisal course content

Course content

Delivery method

1. EBP models and medical center initiatives 2. Evaluation of non-experimental quantitative research designs 3. Description and critical appraisal of RCTs using CONSORT and the Cochrane Risk of Bias tables; systematic reviews and meta-analyses using PRISMA 4. Critical appraisal of qualitative research 5. Continuous quality improvement 6. Using AGREE II to appraise CPGs 7. Oral and poster presentations 8. Knowledge translation in complex health care environments 9. Evidence-based global health

1. Student course evaluations 1. Critical appraisal of a 1. Three hours of lecture 2. Pre- and post-course assessments RCT, systematic review content delivered during a of the students’ attitudes toward, and meta-analysis, and week-long intensive at the perceived support from their a CPG beginning of the semester professional network, self-efficacy 2. Discussion board 2. Weekly voice over beliefs, knowledge, and prior postings on the PowerPoint or videotaped utilization of EBP following topics presentations and readings a. Checklists to evaluate available on Blackboard the quality of reporting 3. Group discussion board in non-experimental forums available on research articles Blackboard b. Meta-synthesis 4. Synchronous small group c. Patient safety discussions of research d. Comparison of several article critiques with faculty hospitals’ quality of leaders using Scopia care for high-impact conditions e. Translation of CPG recommendations to clinical practice

answering structured questions in an assigned paper and Blackboard discussions related to various aspects of EBP.

Results Student’s ratings of the statement, “overall this was an excellent class,” were an average of 4.2 out of a possible 5 points. Students identified a number of strengths including well-organized class, excellent lectures with strong course content, clear steps to complete assignments, exposure to various research article critique instruments, learning the ability to critique research and guidelines, and the opportunities for group interaction with classmates. Areas identified for improvement were issues with coordination of group assignments (different work schedules and time zones) and student time management issues based on the number of assignments for the course, especially postings on Blackboard. Some students also felt overwhelmed with the amount of material presented during the intensive sessions at the beginning of the course.

Conclusions Designing EBP-related courses to meet the needs of DNP students can be a challenge, especially because their

Student assessments

Course evaluation

clinical backgrounds and prior academic preparation can be diverse. An assessment of students’ attitudes toward, knowledge and implementation of EBP may help faculty develop EBP courses to better meet students’ learning needs. We are currently developing such an instrument. A post-course evaluation of the knowledge and skills acquired by students, using the same tool, would also be helpful in identifying any information gaps that still exist and refining these courses to help students achieve their learning goals. Another need is to identify how recent DNP graduates have utilized the skills they have acquired as part of their EBP curriculum to facilitate clinical practice changes in their work setting. Without such application information, the need for improvements in this area of the DNP curriculum will be handicapped. Right now the role of the DNP in this process appears to be underutilized and/or underreported. Articles on KT often cite the importance of the master’s-prepared clinical nurse specialist or nurse educator, with guidance from a faculty member at the school of nursing if available, as the facilitator of EBP rather than the DNP-prepared APN (Advanced Practice Nurse). The importance of an expert practitioner, with specialized EBP training, serving as a mentor in this process is emphasized (Fineout-Overholt et al., 2004; Kitson et al., 2011; Mohide & Coker, 2005; Mohide & King, 2003). Nurses often rely on their peers for EBP information. Having a DNP-prepared nurse strategically placed within the organization in a position of

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authority to facilitate the uptake of research evidence may help close the knowledge to practice gap. Equipping DNP students with an EBP roadmap and translational skills may help them become more effective

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leaders and innovators in the clinical setting. Students’ use of the best available evidence in practice to improve patient outcomes is a goal worthy of our utmost effort in curriculum development.

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E. R. Moore and R. Watters: Critical Appraisal and Knowledge Translation

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Educating DNP students about critical appraisal and knowledge translation.

Consumers expect that health care providers will use the best evidence when assisting them in making decisions about treatment options. Nurses at all ...
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