Teaching evidence-based practice: starting with the learner.

In the first two columns on evidence-based practice (EBP), we emphasized its importance and what it is and is not. In this column, the focus is on how to inculcate EBP into the work setting by educating nursing faculty and students about EBP. By now we are all familiar with the IOM report (2003) mandate that "all health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches and informatics" (p. 3). While much of the discussion surrounding EBP in the literature has been about how to introduce and/or expand its use in the clinical setting, a significant challenge has been introducing and integrating the content in the curricula of nursing schools and integrating the processes of EBP into clinical teaching. This is an even greater challenge given the fact that curriculum change is generally a slow, deliberative process involving many stakeholders. Curriculum change can be thought of in similar terms to EBP since both involve decision making, both make use of the best available evidence, both use the expertise of frontline people (clinician expertise vs. educator expertise), and both incorporate values and preferences (patients vs. students). Both are systematic efforts that require thoughtful analysis, documentation, and outcomes. Both enable stakeholders to respond to the knowledge explosion that clearly affects best practices in patient care and nursing education. So where do we start? The art and science of curriculum development is a thesis of its own and the subject of many courses and programs in nursing. We are not going to expound on how to develop curricula but would rather like to address what needs to be done to change curriculum to incorporate EBP. Perhaps the best place to start is with what we know best, our present work at Pace University. For example, Levin has been working with faculty to help them determine how to best integrate EBP into undergraduate curricula. The sessions with faculty have involved four "rules," namely, letting go of sacred cows, using EBP as a framework for clinical learning, revising the traditional research courses, and providing evidence-based teaching. The first rule is a practice that many schools have used to facilitate change. One example of a sacred cow is the practice of assigning nursing students to write nursing process papers on their patients every week as the sole tool to reinforce clinical learning versus the use of various strategies such as case studies, grand rounds, nursing process papers, and student presentations in postconference. What are the principles that have guided educational experiences for our students, and which of those do we need to push aside in favor of a different mind-set? If we identify these "sacred cows" early in the change process and are able to let go of them, we can then come to the conversation with an open mind and find it easier to embrace the change. The second rule involves a number of steps to inculcate new ideas. In order to use EBP as a framework for clinical learning, we must first identify the basis for practice policies, procedures, and protocols. An exercise that we have used for a number of years engages students in this process when we ask them to go to a clinical agency where they are affiliated either through work or the educational experience, find a written nursing procedure, and then ascertain how it was developed. More often than not, there is little to no evidence to support the use of that particular procedure. Faculty are often surprised by this, so the exercise serves as a wonderful opening gambit. Second, faculty learn about answering burning clinical questions (as opposed to the traditional nursing process approach to problem solving) and uncovering primary evidence for a nursing intervention. During this time they focus on identifying types of searchable, answerable questions, using the PICO strategy for framing questions (patient population, intervention/treatment, comparison treatment, and outcome expectation) and the PCD format (patient population, comparison cue or cue cluster, and differential diagnosis) for asking answerable diagnostic questions in nursing, and how to identify different levels of evidence, from systematic reviews to various types of research studies, to case reports, to opinions of respected authorities. …