EVIDENCE BASED CLINICAL EXCELLENCE IN UNDERGRADUATE NURSING EDUCATION

1. EVIDENCE BASED CLINICAL EXCELLENCE IN UNDERGRADUATE NURSING EDUCATION Sharon Stahl Wexler, PhD, RN Marie Claire Roberts, PhD, RN Lin Drury, PhD, RN Esma Paljevic, EdD, RN Martha Greenberg, PhD, RN Pace University College of Health Professions, Lienhard School of Nursing New York and Pleasantville, NY

2. Overview • Three part symposium • How to immerse evidence based practice throughout undergraduate curricula across basic, accelerated, and RN to BS programs. • Part 1: Assessing Student Readiness for EBP • Part 2: Engaging Faculty • Part 3: Integrating Student EBP Experiences

3. Pace University Lienhard School of Nursing • A private university with over 13,000 students across four campuses in New York City and Westchester County • Lienhard School of Nursing is part of the College of Health Professions. • Three undergraduate programs (Traditional 4 year, ABSN and RN-BSN completion) • Graduate-Masters level and DNP

4. Introduction • This symposium summarizes 6 years of work funded by Lienhard School of Nursing and Pace University grants. • We began by converting a traditional undergraduate research course to emphasize EBP. • EBP was mentioned in other courses in the curriculum.

5. Introduction • Students did not develop EBP skills that were translatable to the clinical setting or the workplace. • Student feedback indicated a lack of understanding of the relationship of research to practice, little skill in appraising the literature, and lack of confidence applying research findings in the clinical setting.

6. Inspiration to Change • Thanks to Dr. Stevens and her talented team!

7. Motivation to Change: The Baccalaureate Essentials Essential III: Scholarship for Evidence-Based Practice “Baccalaureate nurses integrate reliable evidence from multiple ways of knowing to inform practice and make clinical judgments. In collaboration with other healthcare team members, graduates participate in documenting and interpreting evidence for improving patient outcomes.” (AACN, 2006b)

8. The Baccalaureate Essentials • The 2013 standards for accreditation that went into effect Jan. 1, 2014 refer back to the 2008 essentials and the 2006 Position Statement on Nursing Research which can be found at • http://www.aacn.nche.edu/Publications/pdf/NursingResearch.pdf

9. Changes Made • Step 1: Re-engineering the traditional undergraduate research course to focus on EBP. • Step 2: Integrating EBP into specialty nursing courses: Gerontology; Psych; OB; Peds; Critical Care; Leadership; Public Health. • Step 3:Integrating EBP throughout our three undergraduate curricula: Accelerated BSN; traditional 4-year BS; & RN to BSN.

10. Targeted EBP Outcomes for all Undergraduate Nursing Curricula • Formulate focused clinical questions (PICO). • Find and critically assess the best available research evidence. • Integrate the steps of the EBP process in planning, implementing, and evaluating outcomes of care. • Collaborate in the collection, documentation, and dissemination of evidence.

11. Part 1:Assessing student readiness for EBPSharon Wexler, PhD, RN, Marie-Claire Roberts, PhD, RN, Lin Drury, PhD, RN, Esma Paljevic, Ed.D, RN, Martha Greenberg, PhD, RNPresented by: Sharon Wexler, Phd, RN

12. THE STUDY • Purpose: To assess effectiveness of EBP course in three undergraduate curricula • ACE-ERI instrument chosen based on documented validity, reliability, and ease of use

13. UNDERGRADUATE EBP/ RESEARCH COURSES • Offered in first semester of Accelerated BSN program. • Junior level of traditional four-year program. • First or second semester of RN-BSN program. • All are Online courses with 3 in-person (or virtual) meetings.

14. Unique Features of EBP Course • Each course includes an EBP “Road Map” illustrating how EBP will be used in concurrent and subsequent clinical courses throughout the curriculum. • Development of PICO question focused on CMS “Never Event” related to clinical site. • Completion of “Appollo RN” search strategy modules. • NIH/CITI IRB training certificate. • Embedded librarian supports student searches.

15. Unique Features of EBP Course • Review and appraisal of the research literature for PICO. • Synthesis of evidence/practice improvement paper & poster. • Poster presentation at local/regional conference. • ePortfolio.

16. THE INSTRUMENT: ACE-ERI • The ACE Evidence Based Readiness Inventory (ACE-ERI) is an online instrument that measures self-reported competencies in EBP. • The instrument is based on nationally established EBP competencies and has strong validity and reliability, and is able to pick up changes pre- and post-intervention. • It has been used in both clinician and student populations. • The tool incorporates the EBP competencies, a knowledge test focusing on knowledge transformation, and demographic information. • The ACE-ERI provides a score of EBP readiness.

17. METHODOLOGY • IRB approval obtained • The ACE-ERI instrument was administered to all students in the EBP course in all three curricula. • Students received email invitation with online link to complete ACE-ERI in first week of course and again in last week of course. • Students received certificate of completion.

18. Methodology • The data were analyzed using STATA 13 • Student’s T-test, Fisher’s Exact were used to determine statistical significance.

19. SAMPLE CERTIFICATE OF COMPLETION Thank you Drs. Puga and Patel!

20. RESULTS

21. RESULTS

22. Results • 126 students responded • A final total of 90 students’ responses were analyzed • 28.6% had only submitted either a pre OR a post survey. • The demographics for the “missing” students were not statistically different from the students who had submitted both pre and post surveys.

23. RESULTS • The mean improvement in ALL competency scores is NOT explained by or associated with student demographics • The mean improvement is seen in each semester over the 3 years analyzed.

24. CONCLUSIONS • The EBP course is effective in increasing student competency in all 20 competencies measured by the ACE-ERI. • Student feedback was positive, citing their understanding of the importance of EBP and the relationship between EBP and clinical practice.

25. STUDENT FEEDBACK • “I notice myself being aware in the clinical setting of the need to improve patient outcomes. I am also very proud of the way our group worked together and the way the final poster came out.” • “I value that as nursing students, we have the power to change and improve current clinical practice in hospitals.”

26. STUDENT FEEDBACK • “My greatest achievement is getting the positive feedback from the professors. It’s a good feeling to know that they are interested in our idea and think it can go a long way.” • “It was excellent to see all of our hard work pay off a the poster presentation and to receive such strong, valuable and positive feedback from our faculty. It made it all worth it.” • “I learned a lot about working in a team.”

27. NEXT STEPS • Use the ACE-ERI to measure EBP knowledge and competency on a continuing basis. • Separate out data of traditional four-year students and RN to BSN program students. • Resurvey students with ACE-ERI at program completion (graduation).

29. Part 2: ENGAGING FACULTY MARIE-CLAIRE ROBERTS, PhD, RN, MARTHA GREENBERG, PhD, RN, ESMA PALJEVIC, EdD, RN, LIN DRURY, PhD, RN, SHARON WEXLER, PhD, RN

30. Curriculum Change • The Baccalaureate Essentials fueled movement from traditional UG research courses to revamped courses focused on EBP. • As EBP spread across courses and programs throughout the UG department, the need for multiple faculty “Champions” became clear. • Faculty required support to make the transition from traditional nursing research knowledge to EBP. • Melnyk & Fineout-Overholt (2011) suggest engaging faculty in teaching EBP to increase their knowledge and confidence.

31. Faculty EBP Teams • The department chairperson selected 2 faculty who were experienced in teaching EBP. • Faculty pair (Dr. Drury and Wexler) were designated as “Course Coordinators” for EBP Courses and serve as champions for integration of EBP across curricula. • They lead increasingly large faculty teams in teaching EBP across three undergraduate curriculums on 2 campuses.

32. Supporting Faculty Growth • Course Coordinators revise the course every semester, load the course content, assignments, and rubrics online and assign students and faculty to EBP working groups. • Coordinators work with the groups throughout the course monitoring online communication, checking inter-rater reliability in assignment feedback and grading, organizing in-person and virtual class meetings, trouble-shooting technical problems, and guiding faculty through student issues. • Coordinators also lead faculty meetings to do mid-course corrections, provide weekly “heads-up” emails regarding assignments/deadlines, and orchestrate the final poster presentation event with community partners.

33. Inter-Rater Reliability The EBP team leaders randomly chose and graded three to four student assignments using course rubrics and compared course faculty’s grading. Feedback provided to each faculty member

34. Faculty Outcomes • 60% of faculty who have been mentored into the course express satisfaction with their own growth and pride in their student’s work. • Those faculty request to teach the course again in subsequent semesters. • We wanted EVIDENCE of faculty growth.

35. Measuring Faculty Readiness for EBP • Purpose: To assess EBP knowledge and attitudes of undergraduate faculty • ACE-ERI instrument chosen based on documented validity, reliability, and ease of use

36. THE INSTRUMENT: ACE-ERI • The ACE Evidence Based Readiness Inventory (ACE-ERI) is an online instrument that measures self-reported competencies in EBP. • The instrument is based on nationally established EBP competencies and has strong validity and reliability, and is able to pick up changes pre and post intervention. • It has been used in both clinician and student populations. • The tool incorporates the EBP competencies, a knowledge test focusing on knowledge transformation and demographic information. • The ACE-ERI provides a score of EBP readiness.

37. METHODOLOGY • IRB approval obtained • The ACE-ERI instrument was administered to all full time undergraduate faculty • Faculty received multiple email invitations with online link to complete ACE-ERI during the first week of the semester.

38. Results • There were N=20 Undergraduate faculty who were eligible to respond.

39. Results

40. Results

41. LESSONS LEARNED • Faculty need further education in the differences between critically evaluating evidence and producing evidence • Course Coordinators guide both faculty and students through the courses which is labor intensive. • Administrator had to give teaching credit for Course Coordinators that reflects amount of work done.

42. LESSONS LEARNED • Faculty must have a mastery of EBP to effectively engage students and model EBP skills. • Faculty with current clinical practices adapt most readily. • Faculty need encouragement to take ownership and accept responsibility for ongoing conduct of the course and assignments.

43. Next Steps • Implement an intervention to target “weak” areas • Resurvey all faculty with ACE-ERI, including adjunct faculty who teach in the clinical setting. • Provide certificate of completion to faculty. • EBP champions offer support to all undergraduate faculty as they integrate EBP assignments and experiences into their courses.

44. Part 3: INTEGRATING STUDENT EBP EXPERIENCES ESMA PALJEVIC, Ed.D, RN, MARIE-CLAIRE ROBERTS, PhD, RN, LIN DRURY, PhD, RN, SHARON WEXLER, PhD, RN, MARTHA GREENBERG, PhD, RN

45. EBP Integration Throughout 3 Undergraduate Curricula

46. Our Challenges • Different program lengths • Traditional (RN4) = 8 semesters • Accelerated (ABSN) = 3 semesters • Completion (RN/BS) = variable, part-time students

47. Our Challenges • Different students & skill sets • RN4 students range from 18 year old high school graduates through grandparents. • ABSN students range from bachelors through doctoral degrees in art, dance, law, psychology, etc. • RN/BS students range from 0 – 30+ years of RN experience with Associate degrees or Diplomas.

48. Our Goals • To foster a culture of “EBP mindfulness”, where EBP is viewed as a pillar of professional practice and not just a course or activity to be accomplished and forgotten • To link academic experiences with clinical practice • To provide students with EBP tools for use post graduation

49. Strategies • EBP content for each level of each curriculum • EBP content in every course in each curriculum • Sequence assignments that build upon one another • Map EBP content, assignments, and experiences for all undergraduate curricula

50. Sample EBP Roadmap