evidence based practice capstone project

• Understanding the Basics of a DNP Project
• How to Develop a DNP Project Using an Evidence-Based Approach
• Stages and Components of a DNP Project
• DNP Project Ideas

Sponsored School(s)

The Doctor of Nursing Practice DNP project represents the culmination of your doctoral studies and an opportunity for you to translate your acquired knowledge into practice. It is also the epitome of the practice-focused DNP and an essential part of the integrative practice experience. Preparing your DNP project is an exciting time, as it allows you to lay the groundwork for future scholarship while at the same time giving you a chance to make a potentially meaningful contribution to improving nursing practice and patient outcomes.

In a whitepaper published in August 2015 entitled The Doctor of Nursing Practice: Current Issues and Clarifying Recommendations , the AACN recommended that the DNP Project be referred to simply as the “DNP Project” as a way to distinguish it from final projects in other types of graduate programs. While the term DNP Project is still commonly used, it’s worth noting that schools and professional organizations are in the process of uniformly adopting the term “DNP Project.”

Here’s what you’ll want to know:

What is a DNP Project?

A DNP project is the umbrella term used to describe a scholarly project with the express purpose of translating evidence into practice. You may also hear it referred to as a final or research DNP project. Your DNP project will reflect your specialization/area of interest, allowing you to delve deep and create a project focused on clinical practice . You will use your DNP project to demonstrate mastery of your advanced nursing specialty.

Fortunately, given the wide breadth of clinical nursing practice, your choices for a DNP project are nearly limitless.

For example, your DNP project may be a practice portfolio that explores the impact or outcomes of nursing practice, or it may be a practice change initiative represented by a program evaluation. It may be a quality improvement project, a consulting project, or the evaluation of a new practice model. It may be a practice topic dissemination, a systemic review, or a manuscript submitted for publication—and that’s just to start.

Although DNP projects may take on various forms, depending on your college/university’s requirements and your area of advanced nursing practice, all DNP projects have three things in common: They all include planning, implementation, and evaluation components.

These components reflect the American Association of Colleges of Nursing’s (AACN) DNP Essentials, which states that a DNP project should be able to successfully integrate some or all of the following into practice:

• Focus on a change that impacts healthcare outcomes through either direct or indirect care
• Have a systems (micro-, meso-, or macro-level) or population/aggregate focus
• Implement the appropriate area of practice
• Include a plan for sustainability (e.g., financial, systems, or political realities)
• Include an evaluation of processes and/or outcomes

All projects should be designed so that processes/outcomes can be evaluated to guide practice and policy, and all should provide a foundation for future practice scholarship.

What is the Purpose of the DNP Project?

The goal of the DNP project is to inform the methods you will use to deliver care and educate others in your chosen population/community. You will use the DNP project to demonstrate your ability to lead and practice at the highest level of clinical nursing practice.

You will be asked to integrate a number of skills into your final project:

• Expertise in reflective practice
• Expertise in your area of interest
• Independent practice inquiry (identifying existing problems/needs in nursing practice and/or healthcare systems)
• The ability to evaluate, translate, and use research and evidence to improve health and quality of care outcomes
• Organizational and systems leadership skills (developing, implementing, and evaluating interventions to improve outcomes for diverse populations and/or communities)
• Knowledge of advanced healthcare policy, ethics, and law to develop a population-based program based on the best available and current evidence

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This is your time to shine, so don’t let the task of choosing a DNP project stress you out.

Using your area of clinical expertise as a springboard, develop your project using an evidence-based process:

• Formulate a well-developed question: Describe an innovation or clinical inquiry; identify a problem/issue
• Review the literature to identify evidence-based resources that answer your question: Apply the best evidence from literature
• Assess the validity of your resources using evidence: Collect data using standard and acceptable methods/tools
• Apply that evidence: Define outcomes to be measured upon implementation
• Implement outcomes and/or analyze results: Re-evaluate the application and identify areas for improvement

An example of how one DNP student followed this 5-step evidence-based process to develop a change project with the goal of increasing vaccination among healthcare personnel working in a college:

Step 1. A change project was initiated to increase influenza vaccination among healthcare personnel at a college

Step 2. Barriers to vaccination as well as factors that would help facilitate vaccination were identified using a pre-intervention questionnaire survey

Step 3. Interventions were planned based on the findings of the pre-intervention questionnaire survey

Step 4. Interventions were implemented

Step 5. The effectiveness of the interventions was assessed through a post-intervention survey

An example of how one DNP student followed this 5-step evidence-based process to develop a quality improvement project with the goal of reducing delays in treatment for patients with hand trauma:

Step 1. A quality improvement project was initiated to avoid delays in care for patients with hand trauma

Step 2. Over 2,000 consultations and notes from emergency room and urgent care departments were reviewed to assess adherence to guidelines for treating hand trauma

Step 3. Factors associated with a lack of adherence to treatment guidelines were identified

Step 5. Outcomes were assessed

Questions to Ask

One of the best ways to ensure your DNP project accomplishes your objectives is to ask yourself questions to make sure the project meets the required standards:

• Does my project focus on individuals, communities, populations, and/or systems?
• What problems/issues will my project address?
• Is my DNP project grounded in clinical practice? Will it solve problems or directly inform my practice?
• Will my project demonstrate mastery of DNP competencies achieved through my doctoral education?
• Is my project supported by evidence provided through existing literature?
• Does my project address outcomes associated with patients and healthcare?
• Does my project provide a foundation for future scholarship in nursing?
• Executive summary of the project
• Introduction to the project
• Description of the problem, how it is defined, and the clinical setting/environment and target environment
• Data supporting the existence of the problem
• Description of the creative approach to resolving the problem

The steps required to complete a DNP project will also vary somewhat from one program to the next. Generally speaking, DNP projects include the following stages:

• Student identifies a focus area for the DNP project.
• A Capstone Chairperson is selected based on mutual agreement of the student and faculty member and the clinical/scholarly interests and area of expertise of the faculty member. Note: Careful selection of a capstone chairperson is important, as the student and chairperson will develop a plan of study and work closely throughout the process .
• Student selects a Capstone Committee (usually includes at least three faculty members, one of whom is the Capstone Chairperson).
• Student earns eligibility to defend the capstone proposal (the proposal must be formally approved by all Committee members).
• Student works with Capstone Chairperson to develop the proposal, using the Committee in an advisory capacity, as needed.
• Student prepares and distributes the proposal defense to the Committee members.
• Student arranges a meeting of the Committee to discuss the proposal and to rule on its acceptability (Committee members ensure the proposal’s feasibility, clinical relevance, and quality.).
• Upon acceptance of the proposal, the student begins the process of implementing the DNP project (must receive administrative approval for all steps of the project).
• Student schedules the final defense of the DNP project upon completing the written project and upon getting approval from the Capstone Chairperson.
• Student distributes the final copy to the Committee members and prepares for the oral defense of the DNP project.
• Committee members critique the project, identify any changes or additional work to be done, and determine the outcome of the DNP project defense.
• Smoking Cessation Program for Patients with Coronary Artery Disease
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• A Community Based Approach to Promoting Nutritional Awareness and Improving Dietary Habits
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• Evidence-Based Practice Update for Nurse Practitioners in Urgent Care
• Strategies to Improve Patient Flow in an Urgent Care Facility
• Empowering Community Health: A Faith-Based Approach
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• Integrated Model of Dementia Care in a Nursing Home
• An Evaluation of a School-Based Asthma Protocol
• A Strategy to Reduce Distress Among Isolated Blood and Marrow Transplant Patients Post-Transplantation
• An Evidence-Based Toolkit to Prevent Meningococcal Meningitis in College Students
• An Evidence-Based Ovarian Cancer Education Toolkit: A Pilot Study
• Consequences, Prevention, and Treatment of Childhood Overweight and Obesity
• Prevalence of Symptoms in Multiple Sclerosis Patients
• Obesity Prevention in Young Children
• Predictors of the First-Year Nursing Student at Risk for Early Departure
• The Predictive Value of Second Trimester Blood Pressures on the Development of Preeclampsia
• Nursing Informatics Certification and Competencies: A Report on the Current State and Recommendations for the Future
• Development of a Web-Based Health Information Database and Call Center
• Translation of Autism Screening Research into Practice
• Effectiveness of Chronic Disease Self-Management Programs for Mentally Ill Inmates with Diabetes
• Optimizing Inpatient Heart Failure Education to Support Self-Care After Discharge
• Strategic Plan for a Patient-Centered Medical Home Adaptation
• Development of a Virtual Nursing Learning Lounge to Bridge the Practice Gap
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• Media Influence on Nutritional Choices in School-Age Children
• Interdisciplinary Simulation Training for Evidence-Based Obstetric Crisis Management
• A Web-Based Group Intervention for Patients with Recurrent or Metastatic Pancreatic Cancer
• Evaluation of Pain Management Practices Among Laboring Women
• A Multi-Method Approach to Evaluating Online Distance Learning in Nursing Education
• Effects of Health Education on Nutrition and Physical Activity of School Children
• Clinical-Academic Partnership Education and Socialization into the Nursing Role
• Development of a Strategic Plan for a Dedicated Education Unit and Clinical Teaching Associate Role
• A Strategic Plan for Promoting Health in the Hispanic/Latino Population through Internet-Based Social Networks
• A Criterion-Based Job Description and Performance Assessment for the Advanced Practice Nurse
• A Strategic Plan for the Development of an Inpatient Hospice Program
• Deploying a Geriatric Nurse Practitioner in an Emergency Department to Improve Outcomes for Geriatric Patients
• Implementing Evidence-Based Practice in an Acute-Care Hospital
• A Strategic Plan for the Development of a Model of Care for HIV Co-Infected Diabetics in an Inner-City Clinic
• Implementation of Routine HIV Testing for the Hospitalized Patient
• Development of an Evidence-Based, In-Patient Alcohol Detoxification Guideline for Culturally Diverse Adults
• Conducting a Randomized Household Survey in an Underserved Urban Community
• Fall Prevention in the Medical Surgical Setting
• A Comprehensive Systematic Review of the Influence of Transformational Leadership Style on Nursing Staff in Acute Care Hospitals

Capstone Projects for Nursing Programs

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Are you ready to earn your online nursing degree?

Capstone courses function as a bridge between the end of school and the beginning of a career, allowing nursing students to put what they’ve learned into practice. As the name suggests, students complete capstones toward the end of their nursing training. Not every nursing program requires a capstone, but those that do generally culminate in a bachelor of science in nursing (BSN) or doctor of nursing practice (DNP) degree.

Each nursing program sets their own requirements. While capstone formats differ between programs, they typically consist of an evidence-based practice formal paper or presentation. Students might complete their capstone projects as team leaders, and BSN candidates may present their papers to a faculty panel. Projects could include case studies, program evaluations, and policy analyses.

The focus on evidence-based practice allows students to apply research and experiential evidence toward solving a healthcare problem. For example, candidates may develop intervention strategies that promote health, improve outcomes, enhance quality of life, and foster safe practices for patients.

Capstone goals center on the application of knowledge gained during nursing training programs, including topics related to leadership , management, research, theories, and evidence-based practice, along with the strategies needed to transition from students to baccalaureate-level nurses.

Choosing Your Nursing Capstone Topic

When selecting a capstone topic, students should evaluate their interests, strengths, and weaknesses, along with their chosen nursing specialty area. Luther College recommends that students with lower GPAs and weaker nursing skills consider a basic medical-surgical topic. Those with strong clinical skills and high GPAs might choose emergency or intensive care medicine, although some students might prefer outpatient topics, such as clinical services, long-term care, or public health. However, this is simply an example of one school’s approach, and readers should keep in mind that each school sets its own policies and recommendations.

Asking for guidance from faculty, supervisors, preceptors, and fellow students also helps narrow down capstone topics. Advisors can also provide assistance in choosing an appropriate capstone site, helping with questions of geographical location, facility size, patient population, and care delivery model.

Students develop and learn the skills needed to complete their capstones throughout their training. These include organization and time management, knowledge of evidence-based practice, writing, and critical thinking. They also learn to conduct literature searches, identify research designs, and evaluate evidence.

Completing Your Nursing Capstone

Capstone formats and completion times widely vary between programs. Students at Luther College and Purdue University Northwest complete their capstones in 4-5 weeks, while Ferris State University specifies a timeframe of 30 hours of online classes and 90 hours of applied project work. Case Western Reserve University’s capstone spans 10 weeks.

Regardless of the program, most students follow a PICO format for project proposal questions of inquiry: population, intervention, comparison or condition, and outcome.

Some universities allow capstone projects to be completed in teams, in which students develop and implement the project. Capstone components may include defining the project and the team leader’s role, selecting team members, and formulating the project plan.

In addition to the skills previously referenced, such as knowledge of evidence-based care, critical thinking, and effective writing, capstone courses hone leadership and management abilities These include mastering therapeutic communication, applying leadership and management concepts, and developing collaborative relationships and working on multidisciplinary teams.

Presenting Your Nursing Capstone

The capstone process culminates in a paper or presentation that measures students’ skills in communication, information dissemination, and application of evidence-based practice skills. Members of the public may attend.

Utilizing the poster format, students commonly use three panels to illustrate: (1) the background, problem, and purpose; (2) methodology; and (3) 2-3 key findings and implications. Students who present using PowerPoint on a laptop or other device should pay attention to time limits, planning for one slide per minute, and verify that equipment and internet connectivity are available.

Visuals like graphs, figures, and bullet points are more effective than large blocks of text . Students should practice presenting in front of others to ensure that they thoroughly know their content and can answer questions. Backing up a copy of a PowerPoint presentation and printing out copies or transparencies guards against last-minute glitches.

How is a Nursing Capstone Graded?

Capstone grading methods differ between programs, with some issuing letter grades and others using a pass/no pass system. Grades typically hinge on a percentage basis of the project’s written sections, the final proposal, and the presentation. Faculty evaluate how students execute the capstone course objectives, which may include the following:

Students’ presentation skill evaluation criteria include exhibiting thorough preparation and knowledge of the subject matter, clear and concise communication, adherence to any time limits, ability to answer questions and cite references, and persuasiveness.

What is the Difference Between a Nursing Capstone and a Thesis?

Students complete capstones individually or in groups, while thesis projects must be done alone. Capstone project time lengths span between four and 12 weeks, while graduate students work on their thesis projects throughout their 2- to 3-year programs. Graduate thesis courses generally take place over 1-2 semesters to keep students on track.

Finally, capstone topics evaluate current issues and theories; thesis students incorporate existing case studies and literature while exploring and arguing for their own original research. Some schools require students to publish their thesis papers in a healthcare journal.

Reviewed By:

Theresa Granger

Theresa Granger, Ph.D., MN, NP-C With over two decades of teaching and clinical practice as a family nurse practitioner, Dr. Granger is an expert in nursing education and clinical practice at all levels of education (associate, baccalaureate, and graduate). She has published and lectured extensively on nursing education and clinical practice-related content. Her expertise ranges from student advising and mentoring to curricular and content design (both on ground and online) to teaching and formal course delivery. Dr. Granger is one of the founding faculty members of the University of Southern California’s first ever fully online graduate family nurse practitioner program .

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IU School of Nursing Preceptor Online Training

• Evidence-based Practice

Example Student EBP Projects

Capstone preceptorship is an excellent opportunity to provide your unit with updated evidence-based knowledge and care practices. Examples of previous student projects include:

• Cardiac enzymes to rule out an MI in the ED
• Hypothermia in the OR and the use of warmed fluids and blankets
• Effects of glycemic control in critical care patients
• Correct technique for administering childhood immunizations
• Patient satisfaction: Why is it important and how nurses can affect outcomes
• Pain assessment, effectiveness of pain medications, route of administration
• Use of automatic external defibrillators in a school system
• Readability of patient teaching materials
• Breastfeeding for a woman who is smoking

Think about potential evidence-based practice topics for your Capstone student. Is there a new procedure or medication that you would like research information about? Do you need more current information regarding patient education for a certain population?

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Teaching evidence-based practice (EBP) is one of the core requirements of all graduate-level nursing education, including nurse practitioner (NP) programs. NP core competencies in EBP include translating research evidence into clinical practice to improve patient outcomes as well as leadership in generating knowledge and disseminating the evidence. 1 Translating evidence into practice involves 5 steps of EBP, known as the 5 As:

• • Asking a clinical question,
• • Acquiring the evidence,
• • Appraising the evidence,
• • Applying the best evidence to make an action plan, and
• • Assessing the outcomes of the action plan. 2

On one hand, for evidence-based clinical decision making, patients’ values and clinicians’ expertise also need to be integrated with the best evidence. On the other hand, generating evidence from clinical practice involves development and management of a project, collection and analysis of clinical data, and dissemination of the findings. 1,3

Graduates need to be proficient in EBP not only as evidence consumers but also as evidence generators. 4 Graduates also need to be competent to serve as EBP role models for clinical nurses and other health care professionals as they implement EBP in their clinical settings. 3 A recent study of 2,344 nurses, including 503 advanced practice nurses (APNs) with master’s or higher degrees, reported average scores of less than “competent” for all but 1 of the 24 EBP competencies among the APNs. 5 Thus, it is critical for educators to provide the most effective EBP education possible for NP students before they embark on the road to providing high-quality, evidence-based care.

To prepare NP students with EBP competencies, innovative and effective curricula that foster experiential learning are crucial. Students need to walk through the actual process of formulating an EBP action plan and then implementing the EBP approach at the point of care. 4,6 Thus, students will be better equipped not only with EBP knowledge and skills but also with EBP competence, attitude, and beliefs for lifelong application of EBP in patient care. 7 Interestingly, simply increasing EBP knowledge did not improve nurses’ confidence in EBP implementation, but believing in the value of EBP predicted EBP implementation. 8 Nevertheless, NP students tended to prioritize gaining clinical skills, including diagnosis and management of illnesses, while deprioritizing the...

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Capstone Project

Dpas students learn to become expert problem solvers, what is the dpas capstone project.

• Determine a problem that exists in your place of practice and learn how to solve it.
• Design your project built around applying evidence-based knowledge to enhance your place of practice.
• Work with your faculty mentor and stakeholders. Collaborate with colleagues and co-workers in larger group projects! 
• This includes a written defense.

Share your ideas with faculty prior to applying. Experience Pitt's collaborative Doctor of PA Studies environment now! Contact an enrollment specialist to schedule a 1-on-1 meeting with faculty to discuss problems you would like to see addressed in your area of practice (ie. your project idea!) before submitting your application!

See some examples of past student projects below.

Clinical PA Projects with a Clinical Focus: 

• Setting: Emergency Department/Urgent Care
• Setting: Long-Term Care Facilities
• Setting: Critical Care Medicine
• Setting: Pediatric Hematology and Pulmonary Clinics
• Setting: Pediatric Practice 
• Setting: VA Health System
• Read more about this alumnus' experience!

Clinical PA Projects with an Administrative or Process-oriented Focus: 

• Setting: Emergency Department
• Setting: Family Medicine Practice
• Setting: Pain Management
• Setting: Hospitalist Medicine
• Setting: Medical Oncology

Academic PA Projects:

• Setting: University PA Programs

Indiana Center for Evidence Based Nursing Practice

Capstone Project Repository

PNW baccalaureate nursing students complete an evidence-based quality improvement project on a variety of clinical problems. Students work with a faculty mentor and project director to scope and scale the problem, develop a searchable question, find the evidence, appraise the evidence, then synthesize the evidence to determine appropriate interventions or changes.

Since 2015, our students have completed over 375 EBQI projects and received over $10,000 in internal grant funding support. 

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DNP Final Project

DNP graduates remain in practice, leading cross-professional teams in the improvement and provision of informed quality healthcare.  Graduates apply disciplined processes and translate strong evidence into practice to achieve complex, innovative change. They rely on their ability to analyze intricate and rapidly changing practice problems; critically evaluate and synthesize evidence relevant to those problems; effectively communicate complex concepts across disciplines; engage teams in quality improvement; and evaluate outcomes in the face of significant flux, making use of unkempt data originally obtained for other purposes.  This work demands clear and compelling communication, strong analytic abilities, and flexible leadership at the systems level.

The knowledge, skills, and abilities to conduct such work is developed across the program and applied in the conduct of the DNP final project.  The DNP final project is the student’s original work that establishes them as a Hopkins Nursing clinical scholar.  Completion of the project demonstrates the student has achieved the program outcomes and provides evidence of:

Expertise in a particular practice arena

Critical evaluation of the evidence

Thorough, disciplined approach to problem solving

Innovative translation of strong evidence to improve quality of care

Attainment of significant outcomes

Judicious selection of evaluation methods

Deployment of reliable, valid, and specific instruments

Appropriate protection of human subjects

Effective communication with diverse stakeholder groups

Application of robust statistical methods

Ability to manage a complex project in the context of a dynamic healthcare delivery system

Upon completion of the DNP final project the student engages in thoughtful reflection focused on project execution in order to support ongoing professional development and identify institution-wide opportunities for ongoing performance improvement.

Evidence Based Capstone Project

The DScPAS program culminates in an Evidence-Based Healthcare capstone project. The capstone project offers students the opportunity to acquire skills and knowledge to advocate for best practices and promote the translation and utilization of the evidence. The Doctor of Science in Physician Assistant Studies prepares graduates to take on leadership roles in healthcare administration, education, public health, global health, research, and clinical practice.

The capstone project is designed to permit a student to explore a topic of personal or professional interest. Capstone projects have included:

• Implementing and assessing a ventilator-associated pneumonia prevention protocol. The project outcomes could result in enhanced practice for the entire facility, and by disseminating the outcomes and process, advances the delivery of care, and reductions in harm;
• Evaluating the best practices and leadership required in the implementation of an antibiotic stewardship program in an acute care hospital. Outcomes could include identifying the leadership approaches required to decrease the overall potential for infections by reducing indiscriminate use of antibiotics;
• Reducing central line infections in a surgical intensive care unit through the utilization of the Institute of Healthcare Improvement (IHI) Central Line Bundle. Outcomes could include reducing the potential harm to patients and the costs associated with an intensive care stay for surgical patients;
• Increasing high fidelity communication with emergency medical personnel transporting trauma victims to the emergency room. Outcomes could result in getting, translating, and effectively communicating actionable information to the entire care team faster facilitating the right care right away;
• Establishing and upholding family and person-centered care for adults with multiple comorbidities in a primary care practice. Outcomes could include recognizing and promoting the patient and care partners as the most valuable link in the delivery of safe and efficient care for chronic illnesses;
• Establishing the PA role in an orthopedic specialty clinic for children injured in sport. Outcomes could include improvements in future bone and joint health by helping young athletes to actively and safely engage in sport.

The student’s capstone project must be approved by the appropriate members of the DScPAS program faculty.

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• DOI: 10.1016/J.NURPRA.2018.12.011
• Corpus ID: 86634399

Capstone Projects As Experiential Evidence-Based Practice Education

• S. Kim , Barbara G. Covington , +1 author P. Willson
• Published in The Journal for Nurse… 1 March 2019
• Education, Medicine

2 Citations

Purpose, planning, and individualization of master of science in nursing capstone experiences: an integrative review., outcomes of inquiry-based learning in health professions education: a scoping review, 24 references, evidence-based practice for nurse practitioner students: a competency-based teaching framework., nurse practitioners and evidence-based nursing practice, staff practice, attitudes, and knowledge/skills regarding evidence-based practice before and after an educational intervention., regional evidence-based practice fellowship program, ebp design and translation: teaching how to begin a scholarly practice project., predictors of evidence-based practice implementation, job satisfaction, and group cohesion among regional fellowship program participants., advancing nurse practitioner preceptor and student engagement in evidence-based practice at the point of care, nurse practitioner educators' perceived knowledge, beliefs, and teaching strategies regarding evidence-based practice: implications for accelerating the integration of evidence-based practice into graduate programs., tactics for teaching evidence-based practice: improving self-efficacy in finding and appraising evidence in a master's evidence-based practice unit., graduate nursing students' evaluation of ebp courses: a cross-sectional study., related papers.

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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.

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