Evidence-based Nursing Education - a Systematic Review of Empirical Research

Abstract

The project „Evidence-based Nursing Education – Preparatory Stage“, funded by the Landesstiftung Baden-Württemberg within the programme Impulsfinanzierung Forschung (Funding to Stimulate Research), aims to collect information on current research concerned with nursing education and to process existing data. The results of empirical research which has already been carried out were systematically evaluated with aim of identifying further topics, fields and matters of interest for empirical research in nursing education. In the course of the project, the available empirical studies on nursing education were scientifically analysed and systematised. The over-arching aim of the evidence-based training approach – which extends beyond the aims of this project - is the conception, organisation and evaluation of vocational training and educational processes in the caring professions on the basis of empirical data.

The following contribution first provides a systematic, theoretical link to the over-arching reference framework, as the evidence-based approach is adapted from thematically related specialist fields. The research design of the project is oriented towards criteria introduced from a selection of studies and carries out a two-stage systematic review of the selected studies. As a result, the current status of research in nursing education, as well as its organisation and structure, and questions relating to specialist training and comparative education are introduced and discussed. Finally, the empirical research on nursing training is critically appraised as a complementary element in educational theory/psychology of learning and in the ethical tradition of research.

This contribution aims, on the one hand, to derive and describe the methods used, and to introduce the steps followed in gathering and evaluating the data. On the other hand, it is intended to give a systematic overview of empirical research work in nursing education. In order to preserve a holistic view of the research field and methods, detailed individual findings are not included.

Theoretical framework

Although the term “evidenz” in colloquial German has connotations of manifestness or obviousness, “evidence” in Anglo-American usage means validity derived from an empirical base [1]. In the context of the research endeavour presented here, the term “evidence” is used in its Anglo-American rather than its German sense, that is, to mean that the phenomenon is to be investigated scientifically or - more specifically here - empirically. The concept of being evidence-based arose primarily in a clinical context and has been adapted in the following to meet the educational demands of investigations at university level.

Clinical reference models

In a medical context “evidence-based medicine” (EBM) means a process which integrates the individual clinical expertise of staff providing medical care or therapy and the best possible external evidence concerning concrete treatment options. Here, external evidence is derived from research results. In this approach, medical care is thus based on both the knowledge and experience of the physician (internal evidence) and on the most recent findings of empirical (external) research. Both serve as an equally important basis for making medical decisions concerning a specific patient, although certain framework conditions may also be taken into account [2]. Analogously, evidence-based nursing and caring (EBN) stands for nursing care practice which involves external evidence when making specific nursing care decisions, i.e. has a detailed procedure for including and implementing findings from nursing science research. In this, the cared-for person also plays a central role alongside the expertise and experience of nursing staff and the framework of nursing care practice – according to internal evidence as formulated by Behrens and Langer (2006), in “communication with our particular, unique patient” [3]. In this approach, the cared-for person has considerable influence on nursing care decisions. Alongside the professional relationship between care staff and the cared-for person, there is also a personal relationship [3]¹. In both approaches (EBM and EBN), the focus is on decisions concerning a concrete therapeutic or nursing intervention. Evidence-based medicine or nursing care describes not only an attitude but also the care which results from it.

Educational reference models

Physicians who are involved in education and training and who are interested in an evidence-based approach are also concerned with the evidence for their teaching. “Best evidence medical education” (BEME) is the adaption of EBM to university medical education. By this, we mean that the ethos and practice of teachers involves the application of approaches and methods with the highest possible degree of evidence [4].

Similarly, Winteler and Forster (2007) searched for emipirical answers to the question of what distinguishes good teaching from a university perspective. While the discourse on this question has until now concentrated on the theory of education, these authors ask about the strength of effects shown by already existing studies. They define evidence-based teaching (EBT) as “the conscious, explicit and well-founded application of the best current evidence in order to make decisions concerning the type of learning experience to be made available to students” [1].

In using the principle of evidence-bases in education, we are not talking about a specific concrete case about which a decision has to be made. Rather, our focus is the continual development of educational quality through orienting our teaching activities towards findings from empirical research on teaching and learning. The student perspective is included only insofar as the studies measure direct and indirect learning effects.

Methods

The object of the project described here will be referred to as “nursing education”. In this context, the term is limited to those vocational training courses which lead to a nursing qualification; that is, advanced and specialist training courses are not included. The term “nursing education” involves training for the professions of nurse, children’s nurse and geriatric nurse. These three professional fields demonstrate great similarities which is why they are included in different model projects concerned with integrated/generalist educational approaches [5].

The questions addressed are shaped by the overall framework of evidence-based nursing education and have empirical data concerning nursing education as their focus. In this, three dimensions must be distinguished: learning processes which take place in school or college, learning processes which take place at the workplace, and theory-to-practice transfer. These three dimensions were investigated by taking into account empirical findings concerning the conditions, course and results of vocational training processes.

The selection and evaluation of studies was guided by the QUESTS criteria from the BEME approach [4]:

• QUALITY: type and reliability of the studies

• UTILITY: general usefulness of the results

• EXTENT: coverage of the study

• STRENGTH: explanatory power, clarity and consistency

• TARGET: general validity of the study aims

• SETTING: general validity of the situation & context

The criteria quality, extent and strength are criteria intrinsic to the studies (ebd.). They were assured in the first study selection step: from the focus of the project, it follows that selection was limited to studies concerned with nursing education. Publications were only included in the investigation if their quality, extent and strength fulfilled the quality assurance criteria of scientific investigation:

1. dissertations: scientific quality assurance in the form of an evaluation (n=10);

2. advisory and evaluation research within the framework of model projects and training studies, whose results are available in the form of a scientific publication: scientific quality assurance in the form of methodologically derived procedures adhering to scientific principles (n=9);

3. further refereed publications from newspapers, conference transcripts, or other research findings on the topic: scientific quality assurance in the form of peer review (n=4)

In a second step, the studies were evaluated using the criteria utility, target and setting. To ensure current relevance, a time limit of the last decade was set. Thus only work with a publication date of later than 2000 was included.

Winteler and Forster (2007) identify two general approaches to the analysis and synthesis of empirical findings for evidence-based learning: systematic reviews and meta-analyses. They define the latter as their “gold standard” [1], especially when the study results are combined with statistical analysis to demonstrate the strength of the effects found (ebd.)². Because in this context, the results are from both quantitative as well as qualitative research, a meta-analysis was not possible. The analysis and synthesis was carried out in the form of a systematic review.

To evaluate the data, the evaluation dimensions were first theoretically derived, then induced empirically from the material [6]. A preliminary look at the material yielded the following areas of evidence:

• content of the nursing education

• structure and conditions of the nursing education, also in historical and international comparison

• implementation of changes specified by the legislative framework

• theory-to-practice transfer

• effects of specific educational methods and approaches.

In these areas of evidence, the dimensions structure, process and results can be recognised; these were used as theory-derived dimensions.

• Structure: here, study findings were included which yielded information about which structures had a beneficial or inhibitory effect on nursing education.

• Process: this dimension included study results which yielded empirical results concerning the effects of process characteristics on learning. Content-related and methodological aspects were hereby differentiated.

• Results: here, findings were included which demonstrated a positive or negative effect on the results of the education.

This preliminary coding was carried out taking into account the type of study or publication (see Figure 1 (Fig. 1)). To do this, primary studies were categorised by means of a code and the resulting data were inserted, in the form of a synopsis, into an overall schema (c.f. methodological procedure [7]):

Figure 1. Coding schema used to identify studies.

In this step, therefore, three synopses were produced on:

1. dissertations,

2. advisory and evaluation studies and

3. further refereed publications.

These generated paraphrases of the results of empirical investigations on educational structures, educational processes concerned with content-related and methodological aspects and educational results. Results which did not fit into one of the other categories were classified under “other”.

Similarly, a second step was carried out to identify an empirically derived coding schema for over-arching terms that were derived from the data - also within the division of types of study or publication. These over-arching terms, which were drawn from the studies and publications, were evaluated to identify over-arching links between the different types of study or publication. Thus it was possible to derive over-arching categories for evaluating the entire material:

• structural framework conditions and professional profile

• educational framework conditions

• demands on the school/college as a place of learning

• demands on the practical phases of nursing education

• theory-to-practice transfer

• the students in nursing professions

• content of nursing education programmes

These data-collection and evaluation methods constitute an independent methodological procedure which transcends by far the usual summarising of the state of current research which takes place at the beginning of new studies (c.f. criticisms of “evidence-based educational research” [8]).

Results on the status of current research

Because it is beyond the scope of a journal article to present the results of the dimensions described above, I will limit myself to at this point to presenting the overall project findings in the form of a systematic overview of current empirical research on nursing education.

There is a range of specialist empirical research work which provides information about the constitutive contents of nursing education curricula and their structure [9], [10], [11], [12], [13] Further, there are also the results of evaluation research on model projects in which integrated or generalist forms of education have been tried and tested (e.g. [14]). From these, findings on the implementation of changes specified by the legislative framework can be derived. Further, there are also evaluation studies on individual model projects, e.g. on theory-to-practice transfer [15], [16], on the organisation of practical training in the vocational field of nursing [17] or on innovative forms of training [18], [19]. Both the national nursing education studies BEA [20] and PABIS [21] provide information on training structures and conditions in the nursing professions; the study carried out by the German Association of Protestant Hospitals (Deutschen Evangelischen Krankenhausverbandes) focusses especially on the training situation in schools of nursing funded by the Protestant Church [22]. Additionally, there are empirical works which compare nursing education in an international [23], [24] and historical context [25] and which can be classified as comparative educational research. There is only one study which gives information about professional socialisation during training [26]. Moreover, there are individual studies, e.g. on the effectiveness of teaching [27], on developments in nursing education in the face of wide-reaching social change [28] and on the influence of informal learning processes on the formal development of competences [29].

Discussion

The project shows that the greater part of research concerned with professional qualifications is empirical and qualitative work. Thus, in nursing teaching research, tried and trusted empirical methods, such the qualitative or hermeneutic analysis of interviews, have become well established. Work on professional qualifications focus on the social dimensions of nursing competences, such as the communication of respect, caring competences and treating the patient as an equal. Five of the studies included in this investigation have an emphasis on professional education [9], [10], [11], [12], [13]; this allows us to conclude that there is a corresponding research focus on qualifications. Only three dissertations examine nursing education from the perspective of the acquisition of knowledge and skills [26], [29], [13] by posing questions about the ways in which students undergoing professional training subjectively process their practical experiences and the thoughts and learning processes connected to them. Thus there is an urgent need for research into the “inside” of learning which could help us to draw conclusions about individual cognitive constructions and patterns of meaning as well as their counterpart in social negotiation processes. Building on this, it also makes sense to initiate research endeavours which concentrate on the connections between learning and the development of competences and teaching, supervision, advising and mentoring – that is, which elucidate the interdependence between instruction and construction.

In advisory and evaluation research we are concerned with both qualitative and quantitative research work. On the positive side, it is important to mention that numerous model projects which have been initiated since legislative reform of the health care system and care of elderly people have been scientifically evaluated. In the evaluation results that were examined here, these model projects achieved good marks; this can be interpreted as a good sign for the future of such forms of nursing education and training.

Similarly, it is clear that these forms of education place great demands on students: prospective candidates require good pre-training knowledge and experience in order to cope with the quantitatively and qualitatively considerable challenges of contemporary nursing education. This finding has great significance in the educational and political arena, particularly concerning entrance qualifications to nursing education: successful completion of the school leaving qualifications at age 16 is the minimum that can be expected.

Due to the new educational and examination regulations, it can be stated that there is a real need for research into the contents and direction of nursing education. Here it should be asked whether the stronger social sciences emphasis in curricula has had an effect on nurses’ professional profiles and whether the changes in nursing education have changed the spectrum of activities undertaken by nursing staff.

Other research work concerned with nursing education used in this study are qualitative and quantitative studies. The object of the investigation was to examine either the quality of the education in general or specific aspects such as special methods or particular topics. In this, not only nursing students, but also teachers were involved, as were trained staff who were asked to give their opinions retrospectively.

The results provide an overview of the current status of traditional nursing education at schools of nursing. In general, it can be seen that the quality of training is perceived as high and that nursing students’ identification with their profession grows during training. However, differentiated observations show deficits in training, especially in the area of theory-to-practice transfer as well as in certain contents and methods used. Alongside the scant research on the specialist content of nursing education, these qualitative and methodological deficits should also be addressed in further research. By focussing on the reasons for these deficits, it can be hoped that improvements in quality could be achieved.

Conclusions and future perspectives

Providing a synopsis and systematisation of empirical studies on nursing education and its consequences allows us to assess and evaluate the status of research. This is all the more important as this field is still relatively young in terms of having an established research tradition. We are talking here about a survey of the field with the aim of pulling together the threads of different empirical studies and determining what the next research desiderata are. Finally, it must be stressed that the focus on empirical research does not in any way detract from other types of research. There is a range of seminal work on nursing education which is built on educational theory discourse involving learning psychology and educational ethics; this provides a basis upon which nursing education can be further developed. Alongside the empirical studies dealt with here, this work has considerable significance for the development of theory although it was not the focus of this project.

Note

¹ See the corresponding distinction between nursing and caring by these authors.

² On the inconsistent use of the term “meta-analysis”, c.f. [30].

Competing interests

The author declare that she have no competing interests.