Nurse Education Today 72 (2019) 1–5

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Nurse Education Today

journal homepage: www.elsevier.com/locate/nedt

Undergraduate student nurses' knowledge of evidence-based practice: A T

short online survey
Mohammad Al Qadire
Faculty of Nursing, Al Al-Bayt University, P.O. Box 130040, Mafraq 25113, Jordan

A R T I C LE I N FO A B S T R A C T

Keywords: Background: Various approaches and frameworks have been designed and tested to increase the uptake of re-
Nurses search findings into practice. One approach is to base healthcare providers' practices on the best available
Students research evidence rather than on expired policy or tradition. For which knowledge of evidence-based practice
Jordan (EBP) principles is a prerequisite.
Evidence
Objective: The purpose of the current inquiry is to evaluate Jordanian nursing students' knowledge of EBP.
Practice
Design: This study was an on-line cross-sectional survey.
Clinical
Education Settings: We targeted students in two universities in the north and one in the capital city of Amman.
Participants: The target population was Jordanian student nurses, and the sample consisted of 316 from the
nursing schools within three government universities.
Methods: The EBP knowledge test was used to collect data from students. It was adapted from the EBP
Knowledge, Attitudes, Access & Confidence Evaluation. Ethical approval was obtained from the principal in-
vestigator's university before the questionnaire was uploaded on to the free online survey website. The link to the
survey was established and shared on Facebook.
Results: Just over half of the participating students were male (51.9%) and the average age was 21.6 years (SD
2.7). The mean total knowledge score as measured by the EBP knowledge test was low at 1.9 (SD 1.4) out of 10.
Conclusions: An evaluation of EBP-related content in nursing schools' curricula is needed in order to design and
test the effectiveness of implementing an EBP course in improving knowledge and skills. Critical appraisal and
evidence synthesis skills should be honed as they are seen to be very weak, with much room for improvement.
Meanwhile, research courses could be the mainstay for a nursing faculty to introduce the EBP approach for
undergraduate nurses.

1. Background research evidence could improve patients' clinical outcomes, reduce

care cost and enhance the quality of care.
The quantity of scientific research is increasing at an ever-faster rate Previous studies have focused on working nurses' knowledge, atti-
(Hickman et al., 2018; Melnyk and Fineout-Overholt, 2015). However, tudes, skills and the barriers to EBP (AbuRuz et al., 2017; Al Khalaileh
the uptake of the current findings into practice does not parallel the et al., 2016; Almalki, 2017; Heydari et al., 2014; Hickman et al., 2018;
speed of publication (Al Khalaileh et al., 2016; Hickman et al., 2018; Sherriff et al., 2007). For example, one study evaluated nurses' and
Melnyk and Fineout-Overholt, 2015). So, the gap between research and midwives' (n = 240) knowledge, attitude, and practice of EBP in Iran
practice is obvious. Various approaches and frameworks have been (Heydari et al., 2014). The result showed that nurses and midwives had
designed and tested to increase the uptake of research findings into a low level of knowledge and practice of EBP, although they reported
practice. One approach is to base healthcare providers' practices on the positive attitudes toward EBP. Another study that explored the barriers
best available research evidence rather than on expired policy or tra- to utilization of research findings found that nurses reported a high
dition (Al Khalaileh et al., 2016; Melnyk and Fineout-Overholt, 2015). level of barriers, mostly related to the setting in which they worked (Al
Nurses have crucial role in developing and implementing research Khalaileh et al., 2016). For example, most nurses said that they lacked
evidence, for which knowledge of evidence-based practice (EBP) prin- the authority to implement new research results in their practice, as
ciples is a prerequisite (Al Khalaileh et al., 2016; Melnyk and Fineout- they had no access or time to read research reports. More than the half
Overholt, 2015). It is argued that underpinning clinical practice with of the nurses (56%) reported that published research reports were not

E-mail address: [email protected].

https://doi.org/10.1016/j.nedt.2018.10.004
Received 24 April 2018; Received in revised form 25 September 2018; Accepted 4 October 2018
0260-6917/ © 2018 Elsevier Ltd. All rights reserved.
M. Al Qadire Nurse Education Today 72 (2019) 1–5

easy to read and they found themselves unable to critically appraise the 2000 students, a sample size of 220 to 312 was sufficient. From http://
evidence (Al Khalaileh et al., 2016). A recent review confirmed that www.raosoft.com/samplesize.html, this would allow the percentage of
nurses tend to have low to moderate knowledge and practice of EBP, correct answers to be estimated with a 95% margin-of-error of at
admitting their inability to critically appraise and judge the quality of most ± 5%. The survey was available online during the first semester of
research articles (Patelarou et al., 2017). This has brought the issue of the academic year 2017/2018.
improving nurses' knowledge of EBP to the surface. Without knowledge
of the EBP approach, research uptake into practice will not be as it 2.3. Setting
should be. Knowledge could improve practice, skills and attitudes
(Allen et al., 2015; Hickman et al., 2018). Thus, many studies have been This study used an online method of questionnaire delivery. We
conducted to test different educational interventions to improve nurses' targeted students in two universities in the north and one in the capital
knowledge and willingness to use EBP in their clinical practice (Allen city of Amman. To avoid bias resulting from the inclusion of students
et al., 2015; Hickman et al., 2018; Means et al., 2009). Assessing un- not enrolled in the selected universities, we allowed participation on-
dergraduate nurses' knowledge might be a preliminary step to im- line from all the universities in Jordan. In the analysis, however, we
proving knowledge regarding EBP. included only the completed forms from students in the three uni-
This interest in assessing student nurses' knowledge of EBP has versities.
begun only recently, and Allen et al. (2015) reported that many factors
are involved. These factors include the ability to comprehend data 2.4. Instruments
analysis, results, critical appraisal, and dissemination of results within
the setting of their own practice. Without doubt, student nurses would The EBP knowledge test was adapted from the EBP Knowledge,
affect the future of EBP in nursing and have a crucial role in enhancing Attitudes, Access & Confidence Evaluation (Hendricson et al., 2011),
its adoption into clinical practice (Brown et al., 2010). Student nurses that was developed for dental students. Only the knowledge part of this
tended to retain more knowledge of EBP as they progressed from year tool was used. The internal consistency coefficient for the original
one to graduation year; and those with greater confidence in clinical knowledge scale was 0.78. The adapted knowledge scale consisted of
preparedness and decision making indicated better adoption of EBP ten multiple-choice questions, each with five choices. The fifth choice
(Brown et al., 2010). Few studies focused on undergraduate knowledge for each question was “I don't know” to avoid guessing. As the original
of EBP, most previous work having been on working nurses (Allen et al., tool was designed for students in dental schools, the word “dental” was
2015; Means et al., 2009) or postgraduate students (Brown et al., 2010; replaced by “nursing” wherever it occurred. In addition, questions
Hickman et al., 2018). In a recent review, the author was only able to number 6, 9 and 10 were replaced by three new questions more specific
identify nine articles that investigated the barriers to use of EBP among to nursing. The test remained in English since the language of nursing
student nurses (Ryan, 2016). Based on the results of this review, it was teaching and examination in Jordan is English. The tool was subjected
concluded that students held a positive attitude but lacked the experi- to review from three members of the nursing faculty to assess its con-
ence to us EBP, and further studies among student nurses were re- tent, the appropriateness of the questions, and its relevance to nursing.
commended (Ryan, 2016). Further, Al-Ghabeesh et al., 2013 reported It was then piloted with 20 students, who found it easy to understand
that the main source of knowledge used by Jordanian nurses in clinical and took only 5 min to complete. The internal consistency coefficient
practice was the information they gained during their undergraduate (Cronbach alpha) for the EBP knowledge test was 0.81. Each correct
study and then followed their accumulated expertise. The EBP approach answer was given a score of “1” while wrong and “I don't know” an-
to nursing care was not reported as source of gaining knowledge during swers were give “0”. The total knowledge score, that is the sum of all
practice (Al-Ghabeesh et al., 2013). Hence, undergraduate study pre- correct answers, was calculated. It could range from zero (lowest score)
sents a golden opportunity to occupy nurses with required knowledge to ten (highest possible score), a higher score reflecting a better
and skills of EBP approach. Student nurses must learn the principles and knowledge level, and a score of four or less meaning that the student
approaches to EBP. This can be achieved with more EBP content and failed the test. Data about students' age, gender, academic level, uni-
training within the nursing curriculum (Ruzafa-Martínez et al., 2016). versity, and whether or not they had completed the research methods
Including an EBP module within the nursing education programme has course, was collected.
been found to improve students' competencies in EBP (knowledge and
skills) (Ruzafa-Martínez et al., 2016). Further, in a study that in- 2.5. Procedure
vestigated the barriers to utilizing research findings into clinical nur-
sing practice, participated nurses deemed that their research knowledge Ethical approval was obtained from the principal investigator's
and skills were inadequate (Al Khalaileh et al., 2016). Thus, because of university before the questionnaire was uploaded on to the free online
the importance and scarcity of such studies at international and local survey website. The link to the survey was established and shared on
levels, the purpose of the current inquiry is to evaluate Jordanian Facebook. Messages to page administrators explaining the study pur-
nursing students' knowledge of EBP. pose and requesting to share the link were sent, after which the link was
sent to them. It was re-published weekly during the first semester.
2. Methods Finally, all completed questionnaires were printed out and entered into
the statistical package (SPSS) to avoid any mistakes that might occur
2.1. Design from the use of the export option provided on the survey website.

This study was an on-line cross-sectional survey. 2.6. Data Analysis

2.2. Sample Data was entered into SPSS, and descriptive and inferential statistics
were produced. Descriptive statistics such as means, standard deviation,
The target population was Jordanian student nurses, and the sample percentages and frequencies were used to describe the sample char-
consisted of 316 from the nursing schools within three government acteristics and their responses on the EBP knowledge test (Field, 2013).
universities. Students from different year of their degree were invited to The Mann-Whitney U test was used to compare the EBP knowledge test
participate. The required sample size depended on the expected per- score distribution between two-group variables: gender, and had com-
centage of correct answers on the EBP knowledge test. For a percentage pleted the research methods in nursing or not; and the Kruskal-Wallis
of 40–80%, given that these three nursing schools have an estimated test to compare the EBP knowledge test score distribution between

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M. Al Qadire Nurse Education Today 72 (2019) 1–5

Table 1 The mean of the total knowledge score was compared against stu-
Students characteristics (n = 316). dents' gender and whether they had completed the research methods
Characteristic Frequency (%) course, using the independent t-test. No significant difference was
found in the mean knowledge score between males (mean = 2.0, SD
Gender 1.4) and females (mean = 1.9, SD 1.3) (t = −0.169, p = .866, 95%
Male 164 (51.9)
CI = −0.33 to 0.28). However, students who had attended the research
Female 152 (48.1)
Student level
methods in nursing course (mean = 2.3, SD 1.2) did significantly better
First year 33 (10.4) on the EBP knowledge test than students who had not (mean = 1.8, SD
Second year 29 (9.2) 1.4) (t = −3.13, p = .001, 95% CI = −0.77 to −0.19). The Kruskal-
Third year 101 (32.0) Wallis test was used to compare the EBP knowledge test score dis-
Fourth year 153 (48.4)
tribution between variables with two or more groups (students' aca-
Have you enrolled in the research methods in nursing course?
Yes 135 (42.7) demic level and university). The ANOVA test was not used because of
No 181 (57.3) the violation of assumption of equal groups. The result showed no
University significant difference in the total score with regard to students' aca-
University A 190 (60.1)
demic level (H (2) = 2.61, p = .455) or university (H (3) = 0.913,
University B 77 (24.4)
University C 49 (15.5)
p = .634).

4. Discussion
variables from with more than two groups: students' academic level and
students' university (Field, 2013).
This study demonstrated that student nurses had a low level of
knowledge of EBP. The mean total knowledge score was low, and stu-
3. Results dents seemed to have no knowledge at all of the principles of critical
appraisal. This result was lower than previously reported results
At the end of the data collection, 328 questionnaires were found in (AbuRuz et al., 2017; Brown et al., 2010; Jalali-Nia et al., 2011). This
the survey website repository; 12 were discarded because of incomplete can be explained by the fact that the movement toward EBP in Jordan is
data. Just over half of the participating students were male (51.9%) and still at an early stage, and hence not all undergraduate nursing pro-
the average age was 21.6 years (SD 2.7), ranging from 18 to 44. Under grammes curricula yet have EBP content or training. Usually, the
half (42.7%) were in their fourth year and had enrolled in the research teaching of EPB and its related skills such as research critique are re-
course. See Table 1. served for postgraduate studies. Hence, nursing faculties are advised to
integrate EBP-related knowledge in the undergraduate nursing curri-
3.1. Knowledge of Evidence-based Practice cula. The EBP approach also needs to be used in teaching the theoretical
and clinical courses. Jalali-Nia et al. (2011) tested the use of this ap-
The mean total knowledge score as measured by the EBP knowledge proach in teaching selected nursing topics compared to the classical
test was low at 1.9 (SD 1.4) out of 10. It ranged from 0 to 6 with teaching method, using a quasi-experimental design. A significant im-
mode = 2. Question number 9, which asked about the correct defini- provement in students' attitudes toward EBP in the treatment group was
tion of EBP, was the highest correctly answered question (31.3%) (see noted (Jalali-Nia et al., 2011). However, the results of study are limited
Table 2). All other questions were answered correctly by 29.7% of by the design and very small sample size (n = 41). Different methods
students or fewer. The worst performance was on question number 1, can be used to improve knowledge among students, for instance one
about one aspect of critical appraisal; only 7.9% of students correctly study used a journal club for this purpose (Camilla, 2013). A total of
answered the question and 63 selected the “I don't know” option (see 216 qualified and 235 student nurses were subjected to multiple journal
Fig. 1). Only 51 (16.1%) knew what a meta-analysis means (question club sessions and their experience evaluated using a semi-structured
7). Overall, students performed badly on the knowledge test, with the interview. Student nurses found the sessions effective in improving
worst performance on questions related to critical appraisal (questions their skills in using the EBP approach, such as the ability to search for
2, 4 and 6). evidence, appraise its quality and implement it within clinical practice

Table 2
Students correct answers on the EBP knowledge test (n = 316).
Question Correct answers

Frequency (%)

1- Published reports on treatments can be ranked with respect to the strength of the evidence. Which one of the following is the most correct statement with 25 (7.9)
respect to ranking of evidence? (Expert opinion is the lowest level of evidence.)
2- In judging the quality of the Nursing literature, which one of the following is the highest level of evidence? (Cochrane Review of Nursing or health 46 (14.6)
topic.)
3- If you were conducting a PubMed search to answer a clinical question pertaining to a patient, which one of the following would be the least productive 60 (19.0)
search strategy? (Limit search to current year.)
4- Which statement is the most accurate with respect to the number of subjects in a clinical trial? (If data are obtained from a large sample, an 89 (28.2)
investigator can be confident that findings are clinically meaningful.)
5- Which of the following statements best describes a PICO? (Process for converting a clinical problem into questions that can be answered by 76 (24.1)
searching for evidence.)
6- The least clinically useful EBP resource on the internet is? (Journal article on a clinical topic.) 56 (17.7)
7- A statistical process that quantitatively pools the results of several research studies into one analysis is known as a: (Meta-analysis.) 51 (16.1)
8- Which of the following is the most appropriate study design to evaluate the efficacy of a new diagnostic device for assessment of a selected health 33 (10.4)
problems? (Blind comparison with a gold standard.)
9- Evidence-based practice (EBP) is defined as: Integrating… (best research evidence with clinical expertise and patient values into clinical practice.) 99 (31.3)
10- The stronger level of evidence indicates: (Greater confidence that the intervention is effective.) 94 (29.7)

Statements in bold and between brackets are the correct answers, see appendix for full version of the questionnaire.

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M. Al Qadire Nurse Education Today 72 (2019) 1–5

Fig. 1. Frequency of students answers on question number 1.

(Camilla, 2013), although they reported that the EBP approach was knowledge and skills of EBP. In this context, it was reported that stu-
challenging and needed to be taught as early as possible in their un- dents' ability to comprehend statistical analysis, evaluate the quality of
dergraduate study. This is because using the EBP approach in clinical research and disseminate research results predicted greater competency
practice needs not only knowledge but also practicing it, which has in EBP (Blackman and Giles, 2017). Hence, nursing curricula should
equal or more importance than knowledge alone (Camilla, 2013). either include more focused content about EBP or include a separate
Overall, improving students' knowledge and skills in the use of EBP EBP course. Previous studies have tested the effectiveness of separate
during their undergraduate study is paramount (Hickman et al., 2018). courses on EBP for postgraduate students, but not undergraduates
Further research to evaluate the suitability of the content of nursing (Hickman et al., 2018). These courses, although few, have been found
programme curricula for the movement toward evidence-based nursing to be effective in honing nurses' knowledge and skills in implementing
practice is urgently needed (Zeleníková et al., 2014). Such research EBP into clinical practice (Hickman et al., 2018). Further research using
might investigate the content of courses, faculty knowledge, attitudes a randomized clinical trial design on this issue is needed.
and competencies in EBP. This would form a baseline assessment to set Finally, the results of this short survey should be read and utilized in
a plan to enhance future nurses' knowledge and competencies related to the light of the following limitations. First, this was an online survey, so
EBP, in the hope of improving quality of care and patients' related students without Internet access were unable to participate; they may
clinical outcomes. have different levels of knowledge from students who participated.
As already stated, most of previous work on knowledge of EBP was Second, the knowledge measurement used in this study was presented
conducted among working nurses or masters students rather than un- as a test, which may put students under exam stress and affect their
dergraduates. This has restricted the comparison of the results of the response. Third, this tool was developed for the purpose of this study,
current study with the previous work. In addition, a considerable and further psychometric testing might be needed. Fourth, this study
number of EBP questionnaires is available, with varying content. These included students from first and second years who had not yet enrolled
questionnaires usually measure knowledge and attitudes on a Likert- in the research methods course, which might affect the results.
type scale rather than objective measures. Knowledge tests might be However, statistical analysis showed no significant differences in the
better in giving an objective indicator of EBP knowledge level. Also, mean of total knowledge score regarding students' academic level.
integration of the evaluation of competencies could compensate for the
bias of self-reported measurement and increase the validity of the re- 5. Conclusions
sults (Camilla, 2013). Developing a standard tool to evaluate students'
knowledge of EBP would increase the value of research conducted This study demonstrated that student nurses had poor knowledge of
among this population and allow comparisons of the results across EBP. An evaluation of EBP-related content in nursing schools' curricula
studies from different parts of the world, to enhance and accelerate the is needed in order to design and test the effectiveness of implementing
international movement toward evidence-based nursing practice an EBP course in improving knowledge and skills. Critical appraisal and
(Zeleníková et al., 2014). evidence synthesis skills should be honed as they are seen to be very
Students who attended the research methods in nursing course had weak, with much room for improvement. Undergraduate nursing pro-
significantly better knowledge of EBP than those who did not. The re- grammes plans needs to be re-visited to incorporate EBP approach
search course strengthens the students' ability to read, comprehend and within its various content. Meanwhile, research courses could be the
apply the results of nursing research. It also enables them to conduct mainstay for a nursing faculty to introduce the EBP approach for un-
research to provide evidence wherever needed. However, it seems that dergraduate nurses. Further, short courses about EBP for registered
such courses were not enough to supply nurses with the adequate nurses through the continuous education department are also are

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M. Al Qadire Nurse Education Today 72 (2019) 1–5

recommended to develop and hone nurses` knowledge and skills of EBP use and future use of evidence-based practice among baccalaureate nursing students
approach. at two universities. Nurse Educ. Today 30, 521–527.
Camilla, L., 2013. Journal club as a method for nurses and nursing students collaborative
learning: a descriptive study. Health Sci. J. 7.
Funding Acknowledgement Field, A., 2013. Discovering Statistics Using IBM SPSS Statistics. Sage.
Hendricson, W.D., Rugh, J.D., Hatch, J.P., Stark, D.L., Deahl, T., Wallmann, E.R., 2011.
Validation of an instrument to assess evidence-based practice knowledge, attitudes,
This research did not receive any specific grant from funding access, and confidence in the dental environment. J. Dent. Educ. 75, 131–144.
agencies in the public, commercial, or not-for-profit sectors. Heydari, A., Mazlom, S.R., Ranjbar, H., Scurlock-Evans, L., 2014. A study of Iranian
nurses' and midwives' knowledge, attitudes, and implementation of evidence-based
practice: the time for change has arrived. Worldviews Evid.-Based Nurs. 11, 325–331.
Contribution Statement Hickman, L.D., Digiacomo, M., Phillips, J., Rao, A., Newton, P.J., Jackson, D., Ferguson,
C., 2018. Improving evidence based practice in postgraduate nursing programs: a
This manuscript is a single author work. systematic review: bridging the evidence practice gap (BRIDGE project). Nurse Educ.
Today 63, 69–75.
Jalali-Nia, S.F., Salsali, M., Dehghan-Nayeri, N., Ebadi, A., 2011. Effect of evidence-based
Declarations of Interest education on Iranian nursing students' knowledge and attitude. Nurs. Health Sci. 13,
221–227.
None. Means, B., Toyama, Y., Murphy, R., Bakia, M., Jones, K., 2009. Evaluation of Evidence-
based Practices in Online Learning: A Meta-analysis and Review of Online Learning
Studies.
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