Assessing knowledge, attitudes, and skills toward evidence-based practice among Palestinian nursing students

EBP came into prominence in the 1980s as a paradigm shift toward data-driven care, an extension of Florence Nightingale’s early emphasis on systematic clinical observation. According to Melnyk & Fineout-Overholt, the seminal work of Sackett et al. defined EBP in 1996 as the conscientious integration of individual clinical expertise, patient values, and the best available research evidence [1, 3]. Over time, the development of frameworks stressed competencies in three domains: knowledge, which involves understanding research methods; attitudes, which encompass valuing evidence in decision-making; and skills, which encompass appraising and applying evidence [14]. These competencies are now seen as crucial to bridging the research-practice gap, especially in nursing, where clinical decisions have direct influences on patient outcomes [15].

Despite its established benefits, the adoption of EBP remains inconsistent across the globe. Structured training programs and institutional support have upgraded the level of competency among nurses in high-income countries. For instance, in the United States, 75% of the nurses use EBP in practice, and their access to digital libraries and also clinical mentors ensures this [16, 17]. Systemic barriers to EBP are present in LMICs because of scarce resources, poorly financed curricula, and resistance in culture toward evidence-driven care [5, 13]. In Rwanda, only 12% of nursing students demonstrate proficiency in appraising research, attributed to limited faculty expertise and reliance on outdated textbooks [18]. Similarly, studies in Jordan and Saudi Arabia reveal that nursing graduates lack confidence in EBP skills, with curricula prioritizing theoretical knowledge over practical application [7, 8]. These differences in experiences again point to the need for context-specific strategies aimed at redressing systemic inequalities.

Palestine’s health system has to grapple with some specific constraints, which include political instability, resource constraints, and fragmentation in governance, among others [9, 10]. Recent studies have underlined significant deficiencies in EBP awareness among Palestinian nurses, with only 22% feeling confident to critically appraise research and 18% routinely applying evidence into practice [9]. Barriers include insufficient training, high patient-to-nurse ratios, and limited access to journals; issues exacerbated by geopolitical challenges such as movement restrictions and funding cuts [12]. While Dabak et al. identified these gaps among ICU nurses; no studies have evaluated competencies among nursing students, who represent the future workforce tasked with overcoming these challenges [9]. This is in contrast to other countries, such as Jordan, where student-centered assessments have driven curriculum changes, including the incorporation of EBP modules into clinical placements [19].

There are contradictions in the literature regarding predictors of EBP competence. Whereas some studies report academic progress as a predictor of increased skill [18], others identify self-directed learning as a more significant predictor [11, 17]. There have been similar divisions regarding the influence of formal training, for example; Melnyk et al. found that structured EBP training enhances competency while Cruz et al. reported no significant improvement in poorly designed programs. Such contradictions indicate the role played by context-that of poor and good quality of training as well as institutional support-those local assessments must be done to present interventions [8, 16].

No previous studies have comprehensively assessed EBP competencies among Palestinian nursing students or identified context-specific barriers. While research on EBP competency in LMICs exists, Palestine presents unique structural and geopolitical challenges that hinder EBP integration beyond typical LMIC constraints. Political instability disrupts education (Qadri et al., 2023), resource shortages limit access to research databases [9, 10], and fragmented governance weakens policy enforcement [6]. These factors create an environment where EBP adoption faces distinct obstacles, necessitating localized data to drive effective reforms. Without such research, nursing curricula may remain misaligned with actual barriers faced by Palestinian students, limiting their preparedness for evidence-based practice [5].

This study addresses this critical gap by evaluating knowledge, attitudes, and skills related to EBP among Palestinian nursing students, identifying predictors of competency, and highlighting barriers specific to this setting. Findings will inform tailored strategies to enhance EBP integration in Palestinian nursing education and practice.

A well-defined theoretical framework strengthens research by providing a structured approach to understanding and interpreting findings. This study integrates Stevens’ Star Model of Knowledge Transformation as a guiding framework. The model conceptualizes EBP as a five-stage process: (1) Discovery Research, (2) Evidence Summary, (3) Translation to Guidelines, (4) Practice Integration, and (5) Evaluation [19]. By applying this model, we assess how Palestinian nursing students engage with EBP knowledge and identify gaps in their ability to translate research into clinical practice.

Additionally, Rogers’ Diffusion of Innovations Theory provides insight into the adoption of EBP in nursing education. The theory explains how innovations spread through social systems and identifies factors influencing adoption, including perceived advantages, compatibility with existing practices, and access to resources [20]. This perspective helps contextualize the challenges Palestinian students face in integrating EBP and highlights strategies to accelerate its uptake through curriculum reforms, mentorship, and institutional support.

This study assessed evidence-based practice (EBP) competencies among undergraduate nursing students at Palestine Ahliya University, Bethlehem, Palestine, using a descriptive cross-sectional approach. Data collection occurred from September to October 2023 during the first academic semester. A cross-sectional design was chosen for its ability to measure knowledge, attitudes, and skills at a single point in time, facilitating the identification of gaps and predictors of competency.

Data were analyzed using SPSS 26, with descriptive statistics (mean, standard deviation, and frequencies) used to summarize participant characteristics and competency scores. Pearson’s correlation was applied to examine associations between age, papers read monthly, and EBP competency, while independent t-tests compared competency scores based on gender and prior EBP training. One-way ANOVA was conducted to assess differences in EBP competency across academic years. To identify significant predictors of competency, multiple linear regression analysis was performed. Multicollinearity was checked using variance inflation factors (VIFs), ensuring all values remained below 10, and statistical significance was set at p < 0.05. Incomplete questionnaires (n = 12) were excluded, and no data imputation was performed.

The sample consisted of 273 nursing students, with an average age of 20.7 years (SD = 1.3). Males accounted for 51.6% of the sample (n = 141). Participants were distributed across academic years as follows: second year (31.9%, n = 87), third year (33.3%, n = 91), and fourth year (34.8%, n = 95). Only 22.0% (n = 60) reported previous formal EBP training, indicating limited structured exposure to EBP education. On average, participants read 2.3 peer-reviewed research papers per month (SD = 0.9) (Table 1). Given the relatively low proportion of students with prior EBP training, further exploration of the quality and content of these training programs is warranted.

Table 2 presents the evidence-based practice (EBP) competency scores among Palestinian nursing students, showing a moderate overall competency (59.4%, Mean = 74.3/125) with domain-specific disparities. Attitudes toward EBP were the strongest domain (62%, Mean = 40.3/65), reflecting students’ recognition of EBP’s value in clinical decision-making, while knowledge (58%, Mean = 2.9/5 per item) and skills (58%, Mean = 2.9/5 per item) lagged behind, indicating comparable gaps in students’ ability to critically appraise and apply evidence.

Students demonstrated a foundational understanding of EBP principles, such as research methodologies, but the lower knowledge and skills scores suggest persistent challenges in translating theoretical concepts into practice. A mean knowledge score of 2.9/5 per item implies limited mastery of advanced EBP topics, such as critically evaluating study designs or synthesizing findings, while the identical skills score highlights difficulties in executing EBP steps, such as formulating clinical questions or integrating evidence into care plans.

The higher attitudinal scores (62%) underscore students’ willingness to adopt EBP but also reveal a critical disconnect: positive perceptions alone do not guarantee competency. These findings highlight the need for targeted interventions, including structured workshops to strengthen critical appraisal and application skills, mentorship programs bridging the gap between theoretical knowledge and clinical practice, and curriculum reforms integrating simulation-based EBP activities. Addressing these gaps can better equip Palestinian nursing students to implement evidence-based care in resource-constrained settings.

Table 3 showed a significant effect of academic year on EBP competency was observed (F = 14.72, p < 0.001), with fourth-year students scoring notably higher than those in lower years. Gender differences were non-significant (t = 1.21, p = 0.089), aligning with previous findings. Interestingly, prior EBP training had a significant but paradoxical effect (t = -3.02, p = 0.003), as students who had received training reported lower overall competency.

A multiple linear regression model explained 83.1% of the variance in EBP competency (R² = 0.831, F = 112.4, p < 0.001), indicating a strong predictive model (Table 4). The strongest predictors were fourth-year status (B = 5.982, 95% CI: 4.953–7.011, p < 0.001) and self-directed learning (B = 3.133 for papers read monthly, 95% CI: 2.358–3.909, p < 0.001). Age was also a significant predictor (B = 2.602, 95% CI: 1.816–3.389, p < 0.001).

The high R² value (0.831) raises the possibility of overfitting, potentially due to multicollinearity among predictors. Therefore, a Variance Inflation Factor (VIF) test was conducted to assess collinearity. All VIF values were below the commonly accepted threshold of 10, suggesting that multicollinearity was not a significant concern in this model, as seen in Table 5.

Strategic reforms are necessary to enhance EBP competencies among Palestinian nursing students. Key recommendations include: integrating EBP training throughout all academic years and emphasizing hands-on application through simulated clinical appraisals, partnering with NGOs and academic institutions to provide free access to digital research databases, leveraging diaspora networks to connect students with EBP-competent clinicians for guided skill development, and regularly evaluating EBP training quality to ensure alignment with international standards. These interventions will create an enabling environment for sustainable EBP integration in Palestinian nursing education and healthcare systems.

This study has several limitations. The cross-sectional design prevents causal inferences, highlighting the need for longitudinal studies to track competency progression. Self-report bias may have inflated competency scores, particularly in attitudes and skills assessments. Convenience sampling may have overrepresented highly motivated students, limiting the generalizability of findings. Political instability and resource shortages, critical barriers in Palestine, were not directly measured but likely influenced competency outcomes. Additionally, this study focused exclusively on second, third, and fourth-year nursing students, excluding practicing nurses from the sample. While this approach provides valuable insights into EBP competency at the undergraduate level, it limits the study’s applicability to real-world clinical settings, where professional nurses may encounter different barriers and facilitators to EBP implementation. Since EBP skills continue to develop beyond undergraduate education, this study does not capture how competency evolves in professional practice. Future research should include expert nurses working in clinical settings to assess how EBP knowledge, attitudes, and skills develop with experience and workplace exposure. Another limitation of this study is the unexpected negative correlation between prior EBP training and competency, which requires further exploration. This finding may be influenced by variations in the quality, duration, and delivery methods of EBP training, as well as students’ self-perceived competency before and after training. However, the study did not include qualitative data to assess students’ perspectives on the effectiveness of their training. Future research incorporating qualitative insights, such as focus groups or interviews, could provide a deeper understanding of how training quality impacts EBP competency. These limitations highlight the need for cautious interpretation of the findings and further studies addressing these constraints.

To enhance understanding of EBP competencies in Palestinian nursing education, future research should focus on assessing the quality and content of EBP training programs to detect pedagogical gaps, exploring cultural and geopolitical barriers to EBP adoption through mixed-methods research, and conducting comparative studies in other LMICs to distinguish universal vs. context-specific competency predictors. Furthermore, future studies could consider cross-validation techniques or an independent test sample to further confirm the generalizability of the model and mitigate potential overfitting.