Effectiveness of differentiated instruction on learning outcomes and learning satisfaction in the evidence‐based nursing course: Empirical research quantitative

Abstract

Aim

Diversified students in higher education and the complexity and difficulty of the evidence‐based nursing course perceived by students challenge nursing educators. Differentiated instruction can provide students with various opportunities to learn and meet the learning needs of students with different academic abilities and strengths, which may be a solution. This study aimed to apply differentiated instruction to design the undergraduate evidence‐based nursing course and evaluate the effects of differentiated instruction on students' learning outcomes and learning satisfaction.

Design

One‐group pretest–posttest pre‐experimental design was applied.

Methods

Ninety‐eight undergraduate nursing students enrolled in the evidence‐based nursing course 2020 participated in this study. Students' learning outcomes including preferred learning styles, classroom engagement, collaborative learning, attitudes towards evidence‐based nursing, learning satisfaction and evidence‐based nursing knowledge were measured using validated questionnaires.

Results

The differentiated instruction increased students' learning interests, promoted focused and independent thinking, and enhanced academic achievement. Students' classroom engagement, attitudes towards evidence‐based nursing, evidence‐based nursing knowledge and learning satisfaction were improved after the course. The course designed with differentiated instruction provided a supportive learning environment and furnished a vivid pedagogical way for the unique nursing profession.

Patient or Public Contribution

Positive results of the study support the application of differentiated instruction in the evidence‐based nursing course. The study indicates that the application of differentiated instruction in mixed‐ability classrooms in the evidence‐based nursing course improved students' learning outcomes, attitudes towards evidence‐based nursing, evidence‐based nursing knowledge and learning satisfaction. In clinical settings where nurses are even more diverse in academic education, clinical experiences and learning preferences, differentiated instruction can be a suitable application for in‐service training and education to promote nurses' enthusiasm for professional learning.

1. INTRODUCTION

The importance of educating healthcare professionals with competency in providing evidence‐based practice (EBP) to enhance quality and safety care has been declared. The American Nurses Credentialing Center Magnet Recognition program stresses hospitals to prepare their nurses with the ability to apply EBP to ensure exemplary professional practice (Nelson‐Brantley et al., 2020). The evidence‐based nursing (EBN) bridges the gap between research and practice by looking at the quality of research methods and findings that help nursing professionals make appropriate and effective decisions for clinical practice. Nursing students, who are future nursing professionals, are naturally expected to have competency in applying the best available evidence and be prepared with the ability of EBP before graduation (American Association of Colleges of Nursing [AACN], 2021).

With the increasing emphasis on EBN, nurse educators face two major issues. One is that nursing students regard the EBN course as complicated and difficult for them to understand or apply the knowledge and skills in clinical settings (Tlili et al., 2022). The other is the challenge that students are more diversified in higher education due to their varied educational and life experiences (Trolian & Parker III, 2022). Because of the diversified characteristics, students demonstrate varying learning abilities, learning styles and academic levels in classrooms (Ramdani et al., 2021). Tomlinson (2001) asserts that students learn best when their teachers accommodate the differences in their readiness levels, interests and learning profiles. Unfortunately, traditional and undifferentiated instruction that does not assist knowledge construction for students with various learning capacities causes problems of inequality and inequity in education (Tomlinson, 2001).

Student‐centred pedagogies, which place learners at the centre of the learning process, can meet learners' individual learning needs and styles and engage them in the process of learning (An & Mindrila, 2020). Examples of student‐centred pedagogies include active learning, which involves students in their own learning process (Nguyen et al., 2021); collaborative learning, which engages students working together towards the attainment of goals (Lumatauw et al., 2020); and problem‐based learning, which provides a learning environment for learners to actively collaborate with others and develop problem‐solving skills (Trullàs et al., 2022). These student‐centred pedagogies focus more on the process of learning during class time. Differentiated instruction is another student‐centred approach (Gheyssens et al., 2020) that emphasizes flexibility in the areas of content, process and product to provide more opportunities for students to choose appropriate content and access to content, learning activities that showcase their individual strengths, and methods that are suitable for them to demonstrate their learning outcomes (Tomlinson, 2000).

The Hallmarks of Excellence in nursing education proposed by the National League for Nursing (NLN) provides nursing faculties a guide to design and evaluate their education programme. One of the hallmarks emphasizes that teaching/learning strategies should meet the learning needs of a diverse student population (NLN, 2020). Differentiated instruction is teaching strategies that address the diverse learning needs of students (Tomlinson, 2001). These teaching strategies can meet the learning needs of students with different academic abilities and strengths and give various opportunities for students to learn (Boelens et al., 2018; Tomlinson, 2001). Differentiated instruction has been broadly applied in elementary and high schools internationally, yet, very little evidence is reported in higher education (Turner et al., 2017). Nevertheless, differentiated instruction is supposed to be demanded more in higher education since student populations in higher education systems are more culturally, socially and academically diverse (Boelens et al., 2018).

To the best of our knowledge, there is currently no research empirically testing the effectiveness of applying differentiated instruction in nursing students' learning outcomes in an EBN course. Because of the importance of possessing competency in EBN and the diverse student characteristics, the purpose of this study was to apply differentiated instruction in designing the EBN course to increase undergraduate nursing students' learning interests in and better understanding of the EBN. The study also examined the effects of differentiated instruction on students' learning outcomes and learning satisfaction. Two research questions were set to guide the study:

1. What are the effects of differentiated instruction on students' preferred learning styles?

2. What are the effects of differentiated instruction on the degree of students' classroom engagement, collaborative learning, attitudes towards EBN, learning satisfaction and EBN knowledge?

2. BACKGROUND

2.1. Theoretical background of differentiated instruction

According to differentiated instruction, teachers proactively remodel curricula, teaching methods, resources, learning activities and student products to offer a range of learning opportunities that cater to students' individual learning abilities (Tomlinson, 2001). Differentiated instruction can be closely associated with several adult learning theories, including Humanism, Self‐Determination Theory, Sociocultural Constructivism and Multiple Intelligences. Humanism places the learner at the centre and emphasizes self‐actualization. It suggests that learning is self‐directed, and adults are capable of taking responsibility for their own learning (Mukhalalati & Taylor, 2019). Self‐Determination Theory gives students the responsibility to make choices about their learning, leading to increased motivation and a sense of control in the learning process (Alrabia, 2021). Sociocultural Constructivism proposes that individuals construct new knowledge based on their existing skills and knowledge. Learning occurs through active social interactions with peers, teachers and engagement in social activities (Mukhalalati & Taylor, 2019). Multiple Intelligences asserts that individuals possess different types of intelligence, and effective learning occurs when instruction is tailored to an individual's strengths and preferences in relation to a specific task (Magableh & Abdullah, 2020).

Differentiated instruction aligns with these theories in several ways. Firstly, it empowers students to have control over their learning and cater to their individual needs and preferences. Secondly, it promotes collaborative learning and knowledge construction by creating opportunities for students to engage in meaningful interactions with others. Thirdly, it recognizes and accommodates the diverse strengths and preferences of students, enabling them to engage with content in ways that align with their unique intelligence. These adult learning theories share common characteristics with differentiated instruction, as they emphasize learner‐centredness, autonomy, active engagement and the recognition of individual differences.

2.2. Effects of differentiated instruction

The combing use of differentiated instruction and student‐centred teaching strategies provides opportunities for students to transform their learning behaviour (Ismail & Allaq, 2019). Studies applying differentiated instruction in mixed‐ability classrooms revealed that students significantly and positively improved their learning achievements (Hapsari & Dahlan, 2018).

Although differentiated instruction is proposed to be useful at all levels of education, not many empirical studies reported its application in higher education (Boelens et al., 2018). Published studies that applied differentiated instruction among non‐nursing students reported that students enhanced their learning interests (Sapan & Mede, 2022), developed independence and autonomy towards their learning (Chen & Chen, 2018; Sapan & Mede, 2022), grew positive attitudes towards the course (Darra & Kanellopoulou, 2019) and were satisfied with the classes and course design (Ismail & Allaq, 2019; Sapan & Mede, 2022). Some studies also reported that differentiated instruction significantly improved students' academic performance (Darra & Kanellopoulou, 2019) and achievement (Chen & Chen, 2018), increased students' cooperation, interaction, classroom engagement (Sapan & Mede, 2022), active learning (Darra & Kanellopoulou, 2019) and learning motivation (Chen & Chen, 2018; Sapan & Mede, 2022). Educators using differentiated instruction combined with student‐centred learning strategies found positive outcomes of students' successful learning skills and experiences, classroom engagement, learning interests or social interaction (Ismail & Allaq, 2019).

2.3. Definition of differentiated instruction

Differentiated instruction was first proposed as a teaching practice by Tomlinson in response to the extensive scope of student discrepancies in mixed‐ability classrooms. Tomlinson (2000) defines differentiated instruction plainly as tailoring instruction to meet students' needs. When teachers vary their teaching in order to fit individuals or small groups for the best experience, they are differentiating.

2.4. Description of the differentiated instruction

Differentiated instruction contains three sections: content and access to content, process and product. It emphasizes a flexible course design that allows curricula for differences in content, process and product sections to provide learners with the excellence of learning and satisfy their unique learning needs (Tomlinson, 2001).

2.4.1. First section: Content and access to content

The content refers to topics, concepts or themes. The differentiating content includes what students are to learn and how students access the material taught. It involves providing students with various resources and choices that match their readiness, interests and learning profiles to select and access the materials taught (Tomlinson, 2000).

Several ways are proposed for differentiating content. Teachers may use flexible grouping where students can work in small groups or alone to reinforce content; highlight or summarize key portions of content with illustrations or colours; present material in visual, auditory or kinaesthetic ways; provide lecture videotapes; use books, pictures or Internet as a means of developing understanding and knowledge of the topic or concept; use examples that relate to students' experiences or knowledge to practice situations or explain contents (Tomlinson, 2001).

2.4.2. Second section: Process

The process refers to how students make sense or understand and assimilate the information, concepts or skills. The differentiating process involves applying varying activities and techniques which can provide more opportunities for students to learn best and display individual strengths (Tomlinson, 2001). It concerns not only how teachers teach but also involves strategies that teachers encourage students to use to facilitate exploring the content taught. This can be done by tiering the course content and activities that can make students learn step by step; providing guidelines for every step of learning; using differentiated tactics to increase student interaction, engagement, higher order thinking and critical thinking during class time (Tomlinson, 2000, 2001).

In addition, educators emphasized that differentiated instruction places students in the centre, provides opportunities for higher order thinking and group collaboration to solve problems, and changes students from passive acquisition of knowledge to an active learning process through student‐centred teachings such as teamwork learning, problem‐based learning or project‐based learning (Ismail & Allaq, 2019). Therefore, in the spirit of this phase, combining the use of student‐centred teaching methods to design classroom activities for the EBN course was considered.

2.4.3. Third section: Product

The differentiating product involves providing various choices of evaluations that permit students to express how much they comprehend and how well they are able to administer their knowledge and skills learned from the content (Tomlinson, 2000). The traits of successfully differentiated products contain providing evident and proper guides for success, focusing on real‐world application, advancing creative and critical thinking, requiring analysis or synthesis of information, permitting diverse methods of expression and providing opportunities for peer and self‐evaluation (Tomlinson, 2001).

To differentiate product, teachers can encourage students to express what they have learned in varied ways, offer opportunities for student‐derived topics for projects; allow for varied working arrangements—alone or with a group; provide clear guidelines for independent work that matches individual needs; and use a wide variety of assessments or assignments for students (Tomlinson, 2001).

3. METHODS

3.1. Study design

This study used a one‐group pretest–posttest design to evaluate students' learning outcomes after the implementation of teaching/learning activities designed based on differentiated instruction. The one‐group pretest–posttest design is proposed to be useful for discovering the effectiveness of an intervention in a homogeneous group (Norwood, 2000). The research design, therefore, is suitable for this study because participants in the study were nursing students in the same age group and university.

3.2. Participants and setting

The participants were students in a 2‐year Registered Nurse‐to‐Bachelor of Science nursing programme who enrolled in the EBN course at the primary investigator's serving university in southern Taiwan in 2020. All students that enrolled in the EBN course taught by the researcher (a total of 100 students) were invited to participate in this study. Of them, 98 students completed and returned both the pre‐ and post‐test questionnaires with a response rate of 98%.

According to the concept of patient and public engagement and involvement (PPEI), the researched population is actively involved in the research design, is informed of research information and knowledge and participates in the research. The insights provided by these participants contribute to the research design and enhance the researcher's understanding of the condition under investigation.

In this study, although students were not directly involved in the course design, feedback from previous students who had taken the course was taken into consideration during the course design process. Students had the power to choose their preferred methods of learning under the guidance of the instructor. They had the freedom to select their learning mediums and materials, form groups for collaboration, explore research topics and articles of interest and determine their preferred modes of presentation. Moreover, students shared their discussion results throughout the course, presented their final work in class and participated in evaluating both their own and their peers' final presentations.

3.3. Development of the EBN course based on the differentiated instruction

3.3.1. Course description

The EBN course was a required, 2‐credit h undergraduate course for nursing students. The course was designed mainly based on the five steps of EBN: (1) asking an answerable clinical question, (2) acquiring the best evidence, (3) appraising the evidence, (4) applying the evidence and (5) auditing or evaluating the outcomes of the practice (Melnyk & Fineout‐Overholt, 2019). Since nursing students are not currently clinical nurses, the course focused more on the first three steps. The semester lasted 18 weeks. Excluding introduction, holiday, exam and project report weeks, seven programme units in 11 weeks were designed for the course. Table 1 presents the course objectives and teaching strategies derived from differentiated instruction.

TABLE 1.

Course objectives, sections of differentiated instruction and teaching strategies designed in the study.

Overall goal: Nursing students will be able to search health‐related literature with empirical findings based on their answerable questions or topics of interest. Students will also be able to assess the quality of evidence from the studies.
Week	Unit topic	Unit objectives	Strategies designed in the study	Section
1	Introduction to EBN	1. Understand the definition of EBN 2. Understand the importance of EBN 3. Understand the steps of EBN	1. Teaching aids development: ‐Non‐electronic materials: Books, supplemental articles in English and Chinese, reading and assignment guidelines ‐Electronic materials: Videos with PowerPoint slides embedded with highlighted key portions of content and vivid illustrations, colours or graphs ‐Case scenarios related to EBN steps 2. Materials uploaded onto the school's electronic platform	Content and access to content
2 and 3	Asking PICO questions	1. Understand the main concepts in the unit: foreground/background problem, PICO and types of PICO questions 2. Understand how to ask a PICO question 3. Establish a topic for EBN and ask a PICO question based on scenarios.	1. Flexible grouping: Students decide on group size (alone, in pairs or in small or large groups) for all classroom activities. 2. Flexible class time proportion: based on unit topic and instructional instruction. 3. Literature search: A 2‐h laboratory session guided by the school librarian. 4. Flexible topic and article selection: Students select the article to read from searched literature based on their own interests. 5. Hands‐on practice: students demonstrate their abilities in accessing electronic databases and searching for publications. 6. Guided reading: Students are guided to read research articles based on the unit. 7. Literature circle: Students read and answer the guiding questions based on their selected article, and decide the way to share in class. 8. Learning sheets: Contain different question types and vivid illustrations in a variety of styles for each unit. 9. Independent study: Allow students to work with whomever they felt comfortable. 10. Clinical expert speeches: sharing the role and application of the EBN in clinical.	Process
4 and 5	Acquiring the best evidence	1. Understand the types of PICO questions. 2. Understand the 6S Pyramid. 3. Understand the search strategy for the best evidence. 4. Understand the PRISMA flow diagram. 5. Search evidence based on the scenario and PICO question.
6	Research design and level of evidence	1. Understand the levels of evidence pyramid. 2. Understand types of research designs. 3. Understand study types and biases. 4. Identify the research design and level of evidence of the selected research articles.
7–9	Appraising critically the quality of healthcare‐related research	1. Understand tools for appraising different study designs. 2. Understand critical appraisal principles of quantitative studies. 3. Critically appraise the study design of the selected research articles.
10 and 11	Speech: Evidence translation and clinical nursing practice	1. Understand the importance of applying evidence‐based knowledge to practice. 2. Understand the process of transferring evidence into practice.
	Speech: Trans‐disciplinary EBP and quality of patient care	1. Understand the concept of transdisciplinary care. 2. Understand the importance of transdisciplinary care for quality patient care.
12	Final examination	Evaluate students' knowledge and skills gained from the course.	1. Allow flexible grouping for all evaluations. 2. Research article reading test using the article selected by students themselves. 3. Complete a mini‐project using the guideline and appraisal tool. 4. Self‐determine the topic of interest for the project. 5. Present the mini‐project publicly in ways preferred. 6. Both the instructor and all students evaluate all presentations.	Product
13 and 14	Project report

The overall learning objectives of the course were first established and proposed for students. Each unit also had unit objectives that guided students to learn from that unit. The overall goal of the course was that nursing students learned how to search health‐related literature with empirical findings based on their answerable questions or topics of interest and assess the quality of evidence from the studies. A pre‐assessment to assist the understanding of individuals' readiness, interests and learning styles was provided to students before the class began.

3.3.2. Strategies for differentiated instruction

According to differentiated instruction, after understanding how students learn best, a course can be developed with differentiating content and access to content, differentiating process and differentiating product. Information from the pre‐assessment guided the instructor to appropriately differentiate the content, process and product of the EBN course throughout the semester.

The first section differentiating content involves providing students with various learning resources and choices to select and access the materials taught (Tomlinson, 2000). To differentiate content and access to content, teaching aids were developed as electronic and non‐electronic materials. For non‐electronic materials, books, extra supplemental articles in English and Chinese and reading and assignment guidelines were prepared and used in response to varied learning levels of complexity. When developing textual materials, we highlighted key portions of content in PowerPoint slides for each unit and used vivid illustrations, colours or graphs to help students to understand more about the content and made the contents more attractive to students. Case scenarios related to EBN steps were developed as examples for students to practice and explain contents.

For electronic materials, videos with PowerPoint slides for each unit lecture were made. All these materials were uploaded onto the school's electronic platform for courses, the E‐Campus, to allow students to access and learn the subject in a self‐paced format. The design of these materials can make the conceptual abstraction of the content more concrete and practical to students, provide opportunities for independent study, help and stimulate students to stay focused and clarify the content. In addition, supplemental instruction outside of the scheduled class times was offered for individuals or groups to reinforce contents.

The second section differentiating process encompasses using diverse activities and techniques which can furnish more chances for students to learn best (Tomlinson, 2001). To differentiate the process, we first applied flexible grouping for all classroom activities. Students decided the size of the group, such as working alone, in pairs or in small or large groups. Flexible grouping was also applied to the term project, oral presentation and final exam. Arranging appropriate class time proportions for various instructional strategies was then planned based on the unit topic. Combining the use of differentiated instruction and student‐centred teaching strategies which were proposed by researchers to transform students from passive learners to active learners and promote students' learning interests were also administered (Ismail & Allaq, 2019). In addition, 4 h of the class were arranged as independent study hours. Students could use the 4 h to work with whomever they felt comfortable.

The classroom activities designed for the EBN course included first, a 2‐h laboratory session for literature search was arranged. The school librarian was invited to guide students to use physical and online library resources. Students were asked to specify a topic of interest and turn in one searched research article based on the topic to demonstrate their ability to search for and access publications. Second, two clinical experts were invited to give speeches to share the role and application of the EBN in clinical to foster students' learning interests in EBN. Third, to provide information to the instructor and students about students' understanding of the core concepts and contents taught in the unit, learning sheets were developed and used at the end of each class. The items in the learning sheet were designed in various styles to meet the learning needs of students of varying levels. These item styles included single choice, multiple choice, fill‐in‐the‐blank, connecting the dots, short answer or essay questions that were helpful to cultivate students with different thinking abilities. These learning sheets were also designed with vivid illustrations to attract students' attention and interest.

Fourth, the literature circle activity was applied to help students integrate what they have learned in the module content with real hands‐on practice and to increase students' understanding of the content. The instructor first guided students to read the section in the selected research article in accordance with the course unit for that week. Using flexible grouping, students were then instructed to choose a research article they preferred, read the article and answer the guiding questions based on the chosen article. Finally, students decided on a way to share in class what they have discovered from the article.

The third section differentiating product involves providing various ways of evaluations for learners to exhibit their comprehension of the course and ability to apply the gained knowledge and skills learned from the content (Tomlinson, 2000). According to differentiated instruction, the teacher may combine tests with product options so that students have more opportunities to ponder, apply and display what they have learned from the content (Tomlinson, 2001). In the EBN course, project‐based learning with a presentation was designed to meet the general goal of the course so that students were able to evaluate the quality of evidence. Students were requested to finish a mini project by following a provided project guideline and a critical appraisal tool. Students were allowed to work on the project alone or in a group with two or more people. In addition, students decided on the topic of the project by themselves. At the end of the semester, students were asked to present their project publicly in ways they preferred. The class instructor and all students were responsible for the presentation evaluation. For the test, an academic article reading test was used. Students first decided to take it alone or in a group and the group size. They were allowed to find a health‐related research article in English or Chinese in accordance with their own interests before the test. Eight short answer questions were developed for students to answer based on the research article they selected. Two hours were scheduled for the test.

3.4. Outcome variables and measurements

Preferred learning style was measured by the Perceptual Learning‐Style Preference Questionnaire (PLSPQ) created by Reid (1987, 1995). The PLSPQ consists of 30 items with six learning styles (five items for each learning style) including visual, auditory, kinaesthetic, tactile, individual and group learning. The scale is rated on a 5‐response Likert scale scoring from 1 (strongly disagree) to 5 (strongly agree). Since individuals may utilize a combination of senses to optimize their learning outcomes while preferring one particular sensor mode, each learning style is categorized into major, minor or negligible (or negative) preference. Major means the learners' preferred learning style; minor indicates learners who do not prefer to learn in such a way but can still function using such learning method, whereas negligible means they may have difficulty learning in that way. The cut‐off points for each of these categories are as follows: 40 or above for major, 25–39 for minor and 24 or less for negligible. The reliability of the original scale was confirmed by the split‐half reliability. In the study, Cronbach's alpha for the six subscales of the PLSPQ were 0.73, 0.66, 0.71, 0.67, 0.89 and 0.89 for visual, auditory, kinaesthetic, tactile, individual and group learning respectively.

The Value of Teams (VT) developed by Levine et al. (2004) was used to measure students' value of collaborative learning. The VT consists of 17 items scored on a 5‐point Likert scale from 1 (strongly disagree) to 5 (strongly agree). A higher score indicates greater agreement about the value of collaborative learning. The validity of the scale development study was confirmed by a factor analysis that showed two subscales: the value of group work and the value of working with peers. Cronbach's alphas for these two dimensions were 0.79 and 0.81 respectively (Levine et al., 2004). In this study, Cronbach's alpha was 0.85. Exploratory factor analysis showed that the VT explained 48.46% of the variation in the value of collaborative learning. The first factor (value of group work) explained 37.67% of the variation while the second factor (value of working with peers) added another 10.79%.

The Classroom Engagement Survey (CES) developed by O'Malley and colleagues (O'Malley et al., 2003) was used to measure students' level of classroom engagement. The CES is a 9‐item scale with Likert‐type response options ranging from 1 (strongly disagree) to 5 (strongly agree). A higher score indicates a higher level of agreement in classroom engagement. Reliability (Cronbach's alpha was 0.84) and validity were confirmed by factor analysis in the original study. In this study, Cronbach's alpha was 0.92. Exploratory factor analysis showed that the CES as a single factor explained 41.35% of the variation in classroom engagement.

The short form of Individual Development and Educational Assessment (IDEA) developed and validated by the IDEA Center was used to evaluate students' satisfaction with the course learning. The scale, which contains 18 items and uses a 5‐point Likert scale (item score ranges from 1 to 5), has been utilized at a variety of universities in the USA with confirmed reliability and validity (Benton & Li, 2015). A higher score indicates a higher level of satisfaction with the designated course. In the study, Cronbach's alpha was 0.90. Parallel analysis resulted in two factors and exploratory factor analysis was done by requesting two factors. Results showed that the IDEA could explain 58.44% of the variation in learning satisfaction. The first factor (12 items), named knowledge and skills gained, explained 47.45% of the variation in learning satisfaction while the second factor (six items), named perceived course quality, added another 10.99%.

The 15‐item Attitudes Towards Evidence‐based Nursing scale (ATEN) was used to rate nursing students' attitudes towards EBN. The ATEN was developed by the researchers based on literature and rated on a 5‐response Likert scale scoring from 1(strongly disagree) to 5 (strongly agree). In the study, Cronbach's alpha for the scale was 0.85. Parallel analysis resulted in two factors and exploratory factor analysis was done by requesting two factors. Results showed that the ATEN explained 54.83% of the variation in attitudes towards EBN. The first factor (nine items), named importance of EBN, explained 36.49% of the variation in attitudes towards EBN while the second factor (six items), named perceived competence in EBN, added another 18.34%.

The 16‐item Concept Inventory (CI) was developed by the research team to measure students' level of EBN knowledge and was used to assess students' academic performance. The CVI validity of the Concept Inventory was confirmed (CVI = 0.94) in this study.

A demographic sheet was used to understand individual characteristics such as age, grade level, learning experiences and achievement, and educational and career plans. Questions about the role of differentiated instruction in facilitating students' EBN learning were also asked.

3.5. Ethical considerations

We began to conduct the study after obtaining approval from an Institutional Review Board in Taiwan (REDACTED). In the first class, the course syllabus, the purpose and procedures of this study and participants' rights were verbally explained to the students. Participants were assured that they had the right not to fill out the questionnaires or answer any questions that they did not feel comfortable answering and that such a refusal would not influence their academic grades. All participants signed a consent form before data collection. Since the EBN course is a required course, all students in the course were required to participate in all designed activities.

3.6. Procedures

Before the class began, the EBN course syllabus that outlined course objectives, unit contents, classroom activities, project guidelines and methods of performance evaluation, supplementary reading articles, learning sheets, PowerPoint slides and lecture videos of the EBN course were all uploaded to the school's online learning platform, the E‐campus. Students who were willing to participate in the study received a packet containing a cover letter, a set of questionnaires and a set of multiple‐choice test questions at the beginning of the first and last class days. Students could choose to answer the questionnaires at any place they felt comfortable with and send the completed questionnaires back to the research assistant using the prepared envelope.

3.7. Statistical analysis

All data were entered and analysed using the Statistical Package for the Social Sciences (SPSS) version 23.0. Demographic information was summarized using descriptive statistics. There are no missing values for measured variables. Before doing inferential statistics, all measured variables were tested for normality using the Shapiro–Wilk test. Results showed that except for learning style‐visual at the pretest and attitudes towards EBN at the pretest and posttest, all other variables were not normally distributed. Therefore, to test the effects of differentiated instruction, the Friedman test and Wilcoxon signed‐rank test were used to compare differences before and after the differentiated instruction on classroom engagement, collaborative learning, learning satisfaction, preferred learning styles and EBN knowledge. Paired t‐test was used to compare differences before and after the differentiated instruction on attitudes towards EBN. All tests were two‐sided and p‐values of less than 0.05 were considered to be statistically significant.

4. RESULTS

4.1. Descriptive results

The mean age of the participants was 20.81 (SD = 1.06) years and 94.9% were females. As shown in Table 2, most students expressed that their academic performance was either fair or good at their previous college and current school, and considered their current academic performance improved. More than half of the students planned to obtain a bachelor's as their last academic degree and had a moderate or strong willingness to work as clinical nurses after graduation. Over 70% of the students expressed that they had a great sense or sense of academic accomplishment in the EBN course learning and agreed or strongly agreed that the differentiated instruction was worth applying to other courses.

TABLE 2.

Demographic information of the participants.

Variables	n	%
Performance at previous school
Poor	4	4.1
Fair	53	54.1
Good	34	34.7
Excellent	7	7.1
Performance at current school
Poor	1	1.0
Fair	64	65.3
Good	29	29.6
Excellent	4	4.1
Performance improvement at current school
Significant	14	14.3
Some improvement	69	70.4
About the same	15	15.3
Last academic degree plan to obtain
Bachelor	56	57.2
Master	41	41.8
Doctoral	1	1.0
Willingness to be a nurse after graduation
Strong	15	15.3
Medium	41	41.8
Fair	42	42.9
Weak	0	0
Learning experience in the EBN course gives me
Greatest accomplishment	22	22.5
A sense of accomplishment	50	51.0
Fair	21	21.4
No sense of accomplishment	4	4.1
Worst accomplishment	1	1.0
Differentiated instruction is worth applying to other courses
Strongly agree	27	27.6
Agree	56	57.1
Fair	14	14.3
Disagree	1	1.0
Strongly disagree	0	0

As shown in Table 3, at posttest, students regarded differentiated instruction played an important role in facilitating their EBN learning, such as increasing learning interests, helping them to think independently and improving concentration on learning and learning aggressively. As a result, their acceptance of the EBN course augmented and they agreed that the EBN course was worth taking. The number of passive learners decreased while active learners increased. More students considered that the nurses with a bachelor's degree need to do EBN; this percentage was higher than the percentage of nurses with a master's or doctoral degree.

TABLE 3.

Differentiated instruction course design in facilitating students' learning.

Variables	Pretest		Posttest
	n	%	n	%
EBN course design can increase my learning interests
Disagree	4	4.1	1	1.0
Neither agree nor disagree	36	36.7	18	18.4
Agree	58	59.2	79	80.6
EBN course design can help me think independently
Disagree	0	0	0	0
Neither agree nor disagree	22	22.4	9	9.2
Agree	76	77.6	89	90.8
EBN course design can help me concentrate on learning and learn aggressively
Disagree	0	0	1	1.0
Neither agree nor disagree	30	30.6	12	12.3
Agree	68	69.4	85	86.7
Level that I accept the EBN course
Low	0	0	2	2.0
Median	54	55.1	34	34.7
High	44	44.9	62	63.3
EBN course is worth taking
Disagree	0	0	2	2.0
Neither agree nor disagree	21	21.4	14	14.3
Agree	77	78.6	82	83.7
I prefer just following instructor's direction (passive learning)
Yes	70	71.4	64	65.3
No	28	28.6	34	34.7
I prefer to have more time and space to learn by myself and will seek teachers' help if needed (active learning)
Yes	72	73.5	83	84.7
No	26	26.5	15	15.3
Who needs to perform EBN (select all that apply)
Bachelor's degree nurses	74	75.5	77	78.6
Master's degree nurses	73	74.5	66	67.3
Doctoral degree nurses	65	66.3	53	54.2

4.2. Preferences of learning styles among nursing students

At the pretest, the percentage of students owning more than one major or preferred learning method was: 23.5% for two, 23.5% for three, 20.4% for four, 10.2% for five and 7.1% for six methods. Other 11.2% of the students had only one and 4.1% did not have any major or preferred learning methods. At posttest, the percentage changed to 18.4% for two, 24.5% for three, 30.6% for four, 9.2% for five and 9.2% for six methods. Other 5.1% of the students had only one and 3.1% did not have any major or preferred learning methods. The number of students who had unimodal or no major or preferred learning method decreased from pretest to posttest.

As shown in Table 4, according to the mean cut‐off points stated by Reid (1995), at both pretest and posttest, the learning styles of kinaesthetic, tactile, and group fell into the major category of learning styles whereas the visual, auditory and individual learning styles fell into the minor category. At the pretest, the Friedman test showed that scores of visual and individual learning styles were lower than scores of the other learning styles (Chi‐square = 155.64, p < 0.001). At posttest, the score of the individual learning style was the lowest while the group learning style had a higher score than visual, auditory, kinaesthetic and individual learning (Chi‐square = 240.23, p < 0.001).

TABLE 4.

Students' preferred learning styles.

Variables	Pretest			Posttest
	n (%)	M	SD	n (%)	M	SD
1. Visual		34.24	6.03		34.51	5.92
Major	20 (20.4)	43.10	2.79	22 (22.5)	41.82	2.30
Minor	74 (75.5)	32.51	3.66	69 (70.4)	33.54	3.31
Negligible	4 (4.1)	22.00	2.31	7 (7.1)	21.14	2.80
2. Auditory		39.24	4.95		39.10	6.22
Major	47 (48.0)	43.23	3.43	55 (56.1)	43.13	3.59
Minor	50 (51.0)	35.80	2.30	38 (38.8)	35.53	2.35
Negligible	1 (1.0)	24.00	0.00	5 (5.1)	22.00	2.00
3. Kinesthetic		40.49	4.31		41.12	5.22
Major	66 (67.3)	42.67	3.13	75 (76.5)	42.96	3.83
Minor	32 (32.7)	36.00	2.59	22 (22.5)	35.91	2.86
Negligible	0	—	—	1 (1.0)	18.00	0.00
4. Tactile		40.88	4.56		41.94	5.02
Major	69 (70.4)	42.96	3.46	77 (78.6)	43.53	3.97
Minor	29 (29.6)	35.93	2.65	20 (20.4)	36.90	1.77
Negligible	0	—	—	1 (1.0)	20.00	0.00
5. Individual		32.57	7.82		29.88	8.36
Major	22 (22.5)	43.36	3.87	17 (17.4)	43.29	3.80
Minor	54 (55.1)	32.22	3.92	50 (51.0)	30.92	3.57
Negligible	22 (22.4)	22.64	1.68	31 (31.6)	20.84	3.00
6. Group		40.88	6.06		42.65	5.35
Major	74 (75.5)	43.27	3.74	86 (87.8)	43.86	4.07
Minor	22 (22.5)	34.91	3.69	11 (11.2)	35.27	3.61
Negligible	2 (2.0)	18.00	0.00	1 (1.0)	20.00	0.00

Note: The cut‐off point for major: 40 or above, minor: 25–39 and negligible: 24 or less.

4.3. Effects of differentiated instruction on measured variables

As shown in Table 5, the scores of group and tactile preferred learning styles increased significantly from pretest to posttest whereas the score of individual learning style decreased (p < 0.05). The score for classroom engagement, collaborative learning, learning satisfaction and attitudes towards EBN and EBN knowledge increased significantly from pretest to posttest.

TABLE 5.

Effects of differentiated instruction on measured variables.

Variables	Pretest				Posttest				Z or t	p
	Range	M	SD	Median	Range	M	SD	Median
Preferred learning styles
Visual	20–48	34.24	6.03	34.00	16–48	34.51	5.92	36.00	−0.39	0.70
Auditory	24–50	39.24	4.95	38.00	20–50	39.10	6.22	40.00	−0.03	0.98
Kinesthetic	28–50	40.49	4.31	40.00	18–50	41.12	5.22	40.00	−1.57	0.12
Tactile	26–50	40.88	4.56	40.00	20–50	41.94	5.02	40.00	−2.33	0.02
Individual	20–50	32.57	7.82	32.00	12–50	29.88	8.36	30.00	−3.34	0.001
Group	18–50	40.88	6.06	40.00	20–50	42.65	5.35	40.00	−2.39	0.02
Classroom engagement	24–45	34.14	4.47	34.00	17–45	35.63	4.38	35.00	−3.53	<0.001
Collaborative learning	42–84	69.30	7.42	67.00	50–85	70.69	8.01	69.00	−2.16	0.03
Learning satisfaction	52–90	72.91	8.51	72.00	18–90	76.13	10.53	73.00	−3.19	0.001
Attitudes towards EBN	42–73	55.33	6.85	55.50	38–75	60.37	7.54	59.50	7.96	<0.001
EBN knowledge	0–75	42.86	13.82	43.75	31–100	71.36	14.80	68.75	−8.16	<0.001

Note: Paired t‐test was used to compare scores of attitudes towards EBN, whereas Wilcoxon signed‐rank test was used to analyse all the rest variables at pretest and posttest.

5. DISCUSSION

The purposes of this study are to apply differentiated instruction for an EBN course presented to nursing students in Taiwan and test the effects of differentiated instruction on students' learning outcomes. Although not many studies reported the application of differentiated instruction in higher education, research findings from this study provided meaningful evidence for the contribution of differentiated instruction to undergraduate nursing students' learning in the EBN course. Generally, students demonstrated positive standpoints towards the role of differentiated instruction in facilitating their EBN course learning and gained substantial growth at the end of the semester. Most of the students said that they benefited from the EBN course designed with differentiated instruction and believed that the strategies employed in the three sections of differentiated instruction increased their learning interests, promoted their focused and independent thinking and gave them a sense of academic achievement. In addition, nursing students' acceptance of the EBN course was enhanced. The number of passive learners decreased while active learners increased.

The study's positive results support the use of differentiated instruction in the EBN course. These findings align with the principles of student‐centred pedagogies, emphasizing flexibility, choice, collaboration and active participation in the learning process, all of which are key traits of differentiated instruction (An & Mindrila, 2020). Moreover, the study's results are congruent with some adult learning theories such as Self‐Determination Theory (Alrabia, 2021) and Sociocultural Constructivism (Mukhalalati & Taylor, 2019) that emphasize student autonomy and motivation. Students take responsibility for their own learning and choose how they learn and knowledge is constructed collaboratively by collaborating with others.

Similar to the results of previous studies with non‐university students, differentiated instruction provides students with opportunities to choose learning methods that meet their learning styles and progress their learning at a pace suitable for their needs and abilities (Iqbal et al., 2020). When students are offered meaningful opportunities to select learning methods and demonstrate their abilities, strength, or talents, they relish learning more, become more self‐directed and turn into focused thinkers (Darra & Kanellopoulou, 2019; Sapan & Mede, 2022). All the benefits of differentiated learning lead students to positive outcomes including academic achievement, active learning, group interaction and cooperation, self‐confidence and satisfaction with the class (Chen & Chen, 2018; Darra & Kanellopoulou, 2019; Gheyssens et al., 2020;Ismail & Allaq, 2019; Sapan & Mede, 2022).

In addition, in this study, nursing students regarded the EBN course designed with differentiated instruction as worth taking and considered differentiated instruction worth applying to other courses. These results are congruent with previous studies that students generally responded favourably to differentiated instruction and preferred to experiment with applying the course design in other classrooms (Ismail & Allaq, 2019; Sapan & Mede, 2022). More surprisingly, at the end of the course, more nursing students agreed that nurses with a BSN degree needed to perform EBN when compared to nurses with a master's or doctoral degree. Two reasons might explain this result. One is that while students might not understand the master's and doctoral programmes, they gained learning interests in the subject designed with differentiated instruction. The other might be that healthcare‐related institutions have asserted that healthcare professionals should use the most validated research findings as evidence to make decisions for patient care (AACN, 2021). Therefore, students were aware that the EBN is a growing trend and momentum in clinical nursing practice.

The learning styles preferred by students in the study were kinaesthetic, tactile and group learning. These results indicated that nursing students preferred to learn through hands‐on practices, physical and active involvement in classroom, and valued group work and interaction with teammates. These findings were quite different from previous studies with nursing students. Mckenna et al. (2018) found that students in the Master of Science in Nursing programme preferred kinaesthetic learning to auditory learning, whereas undergraduate nursing students preferred either auditory (Soliman, 2017) or visual learning style (Alharbi et al., 2017). Some other studies found that dental students preferred an auditory learning style (Akhlaghi et al., 2018). Different cultural backgrounds might be the reason for this difference.

Researchers proposed that embedded use of differentiated instruction with various teaching strategies could develop opportunities for students to maximize individual growth and success in learning (Gheyssens et al., 2020; Ismail & Allaq, 2019; Ramdani et al., 2021). Our study found that the individual learning style score significantly decreased but the group learning style score significantly increased at the end of the semester. The combining use of differentiated instruction and other teaching strategies such as collaborative learning with flexible grouping in this study created a more supportive learning environment for students to meet their multiple learning needs. Collaborative learning constructs a learning environment that offers opportunities for students to work with peers who own different learning styles. This environment enables individuals to experience and learn different learning styles from group members and promote individuals' performance achievement from the newly gained learning styles and from the help of higher achievers in the team (Ismail & Allaq, 2019). Our study also found that at the end of the semester, the number of preferred learning styles used by students increased.

We found in the study that differentiated instruction had positive effects on students' classroom engagement, and attitudes towards EBN and EBN knowledge. These results were congruent with previous studies that differentiated instruction positively impacted students' learning process and academic performance by improving student engagement and learning attitude towards the lessons (Darra & Kanellopoulou, 2019; Haelermans, 2022; Ismail & Allaq, 2019). In other words, the learning environment influences students' learning experiences. A learning environment that provides students with insufficient motivation to learn might lead to students' disengagement with the classroom. The EBN course was developed based on the spirit of differentiated instruction, which has been considered as contributing to the creation of a comfortable learning environment and the formation of positive motivation to learn (Iqbal et al., 2020; Sapan & Mede, 2022). In addition, differentiated instruction is a student‐centred approach that has been suggested as conducive to behaviourally, emotionally or cognitively engaging students in learning through participation in classroom activities, and interaction with teachers and classmates (Ismail & Allaq, 2019; Sapan & Mede, 2022). The student‐centred learning environment also offers opportunities for students to transform their learning behaviour from passive to active (Ismail & Allaq, 2019).

Nursing students' attitudes towards EBN were significantly more positive at the end of the course. The result is similar to one previous research finding that the differentiated instruction approach had a positive effect on non‐nursing undergraduate students' attitudes towards course learning (Darra & Kanellopoulou, 2019). Students' EBN knowledge significantly improved at the end of the semester as well was supported by other studies that used differentiated instruction. These previous studies exhibited results of improvement in academic performances among non‐university students such as greater gains in calculus or mathematical understanding (Chen & Chen, 2018), and outperformance in the course examination (Haelermans, 2022). Learning satisfaction for the EBN course among nursing students also significantly increased at the end of the course. Differentiated instruction that furnishes students with diverse learning methods to choose from can meet individuals' learning needs and is conducive to students' learning (Iqbal et al., 2020), motivation (Chen & Chen, 2018; Sapan & Mede, 2022) and performance (Chen & Chen, 2018; Haelermans, 2022). When students' learning needs are satisfied, naturally, they are satisfied with the course.

6. STUDY LIMITATIONS

Although differentiated instruction exhibits positive effects on nursing students' learning outcomes, the results of differentiated instruction designed for the EBN subject are still preliminary. The study findings are limited because of the incapability to build a substantial, causal relationship test between the effectiveness of differentiated instruction and the learning outcomes. The major limitation of this study is the single‐group research design, which is susceptible to threatening the effectiveness of the intervention. Without a comparison group, it is challenging to confirm whether the intervention can be successfully performed in other contexts. The study is also limited due to the insufficiency of generalizability of its study population, such as few samples and a homogenous cultural background in the study participants. Therefore, further studies are recommended for researchers to include a comparison group to furnish more vigorous experimental evidence for the effectiveness of differentiated instruction. Including more study participants as nursing students in other nursing programmes, such as the regular 4‐year bachelor's degree or 5‐year diploma programme or inviting a variety of other nursing schools, are encouraged to increase the strength of the generalizability of the results.

7. IMPLICATION FOR PRACTICE

Nurses demonstrating competence in providing EBN is emphasized in current clinical practice. Nursing students, the future nurses, need also to have the EBN ability to seamlessly connect to future clinical nursing practice. This study indicates that the application of differentiated instruction in mixed‐ability classrooms in the EBN course improved students' learning outcomes, attitudes towards EBN and EBN knowledge and learning satisfaction. These results are different from the previous findings that students consider the EBN course as complicated and difficult since courses designed with differentiated instruction meet the learning needs of students with different academic abilities and strengthen and give various opportunities for students to learn. In clinical settings where nurses are even more diverse in academic education, clinical experiences and learning preferences, differentiated instruction can be a suitable application for in‐service training and education to promote nurses' enthusiasm for professional learning.

8. CONCLUSION

Differentiated instruction has been popularly applied in elementary and secondary schools internationally. Yet, limited empirical study has been reported about this approach applied in higher education, especially for nursing education. Moreover, there is a paucity of literature reporting the application of this pedagogy, specifically, the outcome evaluations of application in EBN courses. The study designed the EBN course based on differentiated instruction for undergraduate nursing students in order to provide a supportive learning environment and to furnish a vivid pedagogical way for the unique nursing profession. The findings indicate that implementing differentiated instruction in the EBN course improved students' classroom engagement, group learning style, learning satisfaction, attitudes towards EBN and EBN knowledge. The positive results of the study contribute to the existing body of knowledge by providing evidence of the positive effects of differentiated instruction in the EBN course. Differentiated instruction has the potential to be beneficial not only in academia but also in clinical in‐service training and education, by addressing the diverse academic backgrounds, clinical experiences and learning preferences of nurses. Further research in this field can expand upon these findings and establish a stronger foundation for effectively implementing differentiated instruction in nursing education, both in academic and clinical contexts.

AUTHOR CONTRIBUTIONS

Conceptualization: SRL, CYC, CHC and TPC; Data curation: SRL, CYC and CHC; Formal Analysis: CYC and CHC; Funding acquisition: SRL and CYC; Investigation: SRL and HCL; Methodology: SRL, CYC and HCL; Project administration: SRL, CYC, HCL and TPC; Supervision: SRL and CYC; Validation: SRL, CYC and TPC; Writing—original draft: SRL, CYC and TPC; Writing—review and editing: SRL, CYC, CHC, TPC and HCL.

FUNDING INFORMATION

This research was funded by the Chang Gung Medical Research Program, grant number CMRPF6K0051 and the Ministry of Science and Technology (MOST 107‐2511‐H‐255‐002‐) in Taiwan.

CONFLICT OF INTEREST STATEMENT

The authors have no conflict of interest to declare.

ETHICS STATEMENT

Ethical approval for the study was obtained from the Institutional Review Board of the investigator’s serving institution. Written consent was obtained from all participants, ensuring confidentiality, anonymity, and the option to participate. The participants were assured that refusal to participate or answer certain questions would not affect their academic grades.

Liou, S.‐R. , Cheng, C.‐Y. , Chu, T.‐P. , Chang, C.‐H. , & Liu, H.‐C. (2023). Effectiveness of differentiated instruction on learning outcomes and learning satisfaction in the evidence‐based nursing course: Empirical research quantitative. Nursing Open, 10, 6794–6807. 10.1002/nop2.1926

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are openly available in Mendeley Data at http://doi.org/10.17632/7fmswnmyft.1.