Effect of an online training intervention on evidence-based practice in clinical nurses. #Evidencer Project

Healthcare quality relies on professionals utilizing evidence to care for patients and communities. While not every nurse conducts research, all must utilize research findings to support their practice, just like any other professional [1]. Evidence-based practice (EBP) is recognized internationally as a standard for making clinical decisions. It provides a framework with which to assess the quality and relevance of scientific research, allowing health professionals to choose more effective and safe interventions, considering their clinical experience and the patient’s preferences as well [2].

The benefits of EBP are well known, with special emphasis on improvements in health and the quality of health systems [3‐6]. However, the utilization of EBP in clinical practice has yet to reach full development. Barriers to utilizing evidence-based practices include insufficient time, resources, and skills for searching and assessing evidence, as well as resistance to change [7]. To overcome these obstacles, health systems must invest in the training and development of their professionals´ EBP competencies [8].

EBP education must start with health professionals’ initial training and continue throughout their professional careers through continuous education [9]. This involves developing the skills to search for and critically appraise scientific literature and effectively apply evidence in clinical practice. To support this, governments, organizations, and international professional associations encourage and promote EBP and its teaching [9‐12].

Traditionally, continuous learning by health professionals has been conducted face-to-face. However, the COVID-19 pandemic completely restricted face-to-face education, increasing online training by health services [13]. Health policies currently emphasize the importance of integrating new technologies in the training of health professionals, including all methodologies that facilitate learning without the necessity of physical presence [13]. A systematic review indicates that nurses are generally satisfied with using e-learning for ongoing education. Additionally, one of the positive outcomes highlighted is an increase in their knowledge and skills. However, it is noted that the effectiveness of e-learning interventions for nurses in the context of continuous training is still unknown, especially regarding how the learning can be transferred to change practice and affect patient outcomes; further advancements are needed in the field of e-learning in nursing education, particularly with a focus on lifelong learning [14].

More specifically for EBP, the studies on online interventions to improve the EBP competence of clinical nurses are scarce and show great variability concerning the content included in the training, the teaching modality, duration, tools utilized (online platforms, visual presentation of the contents, forums, gamification, that is the use of game-like elements in non-game contexts to engage and motivate people to achieve certain goals, use of social networks, etc.), number of hours, and EBP competence dimensions assessed [14‐19]. The effectiveness of the interventions remains unclear. A meta-analysis, which included face-to-face, exclusively online, and blended training interventions, did not demonstrate positive outcomes in any of the commonly assessed dimensions: EBP attitudes, knowledge, skills, and utilization [19]. The poor outcomes may stem from several study limitations, including a small participant pool, high dropout rates, and variations in training content and duration. Additionally, the impact of different methodologies (face-to-face, blended, or online) remains unclear, as does the longevity of the intervention's effects. Therefore, it is essential to conduct rigorous research to address these critical questions.

In a context in which the transition towards online training of health professionals is crucial, there is an important need to reduce uncertainty about the impact of this training modality on the learning of EBP by clinical nurses. For this, the objective of the present study was to assess the effectiveness of an online training program to improve the EBP competence of nurses, focusing on the dimensions of EBP attitude, knowledge, skills, and utilization.

The final sample consisted of 194 nurses. In the IG, 102 nurses completed the three measurements, while 92 nurses in the CG did the same. The socio-demographic and professional characteristics are shown in Table 2. About 80% of the participants were middle-aged women, with an average age ranging from 44 to 49 years. The total professional experience of the participants averaged between 20 and 25 years, with about 13 years of experience in hospital settings. Between 54 and 61% of the professionals held a master’s degree, and about 8 to 11% had a PhD. Statistically significant differences were observed between the groups regarding age, work experience, type of contract, work setting, EBP training, reading of articles, and working in a BPSO® center (Table 2). These variables were considered in the analysis of the effect of the intervention on EBP competence and included in the covariance (ANCOVA) analysis as co-factors.

The analysis of the changes observed in each dimension and the overall EBP competence between the IG and the CG at three different time points (Fig. 1: a, b, c, d, and e) shows a significant group*time interaction in three of the four dimensions of the questionnaire, indicating that the online course increases EBP knowledge (F = 29.256; p = < 0.001; η2 = 0.242); in second place, skills (F = 11.269; p = < 0.001; η2 = 0.109), and lastly, utilization (F = 9.908; p = < 0.001; η2 = 0.097). Concerning the overall competence, a statistically significant effect was observed (F = 21.491; p = < 0.001; η2 = 0.189). A statistically significant effect was not observed only in the dimension of attitude (F = 1.324; p = 0.269; η2 = 0,014).

The comparison of the adjusted mean scores obtained by the IG and the CG in the four dimensions and the overall EBP competence shows no statistically significant differences in the baseline measurements (T1). In the latter measurements at 3 (T2) and 6 months (T3), statistically significant differences were observed, with higher scores in the IG, which had taken the course, in all the dimensions and the overall competence, except for the dimension of attitude (Table 3). At T2, the intervention group (IG) demonstrated a significantly higher mean score in the dimension of knowledge at 46.04 (SD: 6.7) compared to the control group (CG), with a mean of 37.84 (SD: 8.3), p-value < 0.001. This difference slightly decreased by T3, with the IG scoring a mean of 44.02 (SD: 7.0) and the CG at 37.83 (SD: 8.5), p-value < 0.001.

In the dimension of skills, the intervention group (IG) scored a mean of 25.16 (SD: 3.5) at T2, compared to the control group (CG), which had a mean of 22.39 (SD: 3.7), with a p-value < 0.001. At T3, the IG had a slightly lower mean of 24.24 (SD: 3.8), while the CG mean was 23.01 (SD: 3.1), p-value < 0.05.

For the dimension of utilization, at T2, the intervention group (IG) achieved a mean score of 37.36 (SD: 6.1), while the control group (CG) had a mean of 33.16 (SD: 7.4), with a p-value < 0.001. At T3, the IG mean was 36.77 (SD: 6.8), compared to 33.12 (SD: 6.3) for the CG, again with a p-value < 0.001. For overall competence in EBP at T2, the IG obtained a mean score of 146.15 (SD: 16.9), while the CG scored 129.85 (SD: 18.0), with a p-value < 0.001. This difference slightly decreased at T3, with the IG showing a mean of 141.22 (SD: 20.0) compared to 130.34 (SD: 16.7) in the CG, p-value < 0.001.

The analysis of the change between T1, T2, and T3 (intra-subject change) shows a statistically significant effect only in the IG, in the dimensions of knowledge, skills, utilization, and overall competence, with a significant change between T1-T2 and T1-T3. As for the magnitude of the effect, the variation rates showed a higher increase in the dimension EBP knowledge, with a rate of variation of 36.7% between T1-T2, and 32% between T1-T3, followed by skills, with a variation of 15.6% (T1-T2), and 12% (T1-T3), and utilization, with values of 15.2% (T1-T2) and 13.3% (T1-T3) (Table 3).

The study's main findings show that an exclusively online EBP training course, based on self-learning and without tutoring, lasting 3 months (72 h) improved the EBP knowledge, skills, and utilization, as well as overall EBP competence, of clinical nurses. The dimension of attitude was not significantly modified, as observed in most of the studies on nurse training, independently of the type of intervention performed [16, 19, 20, 26]. In our case, this dimension showed very high scores from the baseline measurement, which limits its potential for improvement and explains the lack of significant changes.

The learning behavior in the IG showed significant improvement across all three dimensions and overall competence in EBP. Specifically, using the national standardized norms [20], our results show a significant increase in percentiles, indicating a substantial effect of the intervention. In the IG, the dimension of knowledge changed from the 50th percentile to the 80th percentile (P80) after the training, remaining between P70-P75 after three months. In the dimension of skills, a change was observed from P40 to P60 in T2, decreasing to P50 after three months. Concerning EBP utilization, the IG started at P50 at baseline, increasing to P75 after the course and decreasing to P70 at T3. Globally, the EBP competence of the professionals changed from P40 at baseline to P75 at T2 and P70 at T3. Therefore, an important increase was observed in EBP after the training, which decreased moderately after 3 months.

The international literature has shown that EBP knowledge is the facet of learning on which an effect of EBP training of nurses is clearly observed, independently of the teaching method utilized [19, 27, 28]. In line with this evidence, our findings showed the greatest effect of the intervention in the dimension of knowledge, with a rate of variation of almost 37%, which remained at 32% at the end of the study. Similarly, other studies conducted with blended EBP courses for nurses in Spain [16], as well as other countries [29, 30], showed positive changes in knowledge. Other distance learning initiatives, such as online nursing journal clubs, observed a significant increase in EBP knowledge up to 3 months after the intervention [31].

Our findings provide new evidence regarding the other learning dimensions, such as EBP skills and utilization of EBP. On one hand, a positive effect was observed in the dimension of skills throughout the study, with variation rates slightly lower than those observed in knowledge. In this case, the changes observed were between 15% after the intervention (T2) and 12% after 3 months (T3). This dimension has been less studied in the specialized literature. When research has been conducted, it has not shown significant results in favor of training, such as in an e-mentoring study lasting 12 weeks [32], or in another study in which an EBP online 3-week training course was compared [33]. It is not known if the lack of effectiveness of these studies was due to the duration of the training and its characteristics or to methodological aspects such as the small sample size.

The effect of the training on the utilization of EBP in nurses is more controversial. On the one hand, previous studies on online training experiences have not shown changes in the utilization of EBP [16, 33]. Conversely, our results show that following the training, an improvement in the utilization of EBP was produced, with a 15% increase (T2) compared to the baseline measurement, which remained at 13% (T3). These findings raise several questions regarding the long-term durability of this effect and whether conducting maintenance sessions could contribute to the sustainability of the learning.

Our study allows us to address some methodological and practical matters that have yet to be resolved. The content of our EBP online training course encompassed the seven steps of the model proposed by Melnyk in 2010 [22], including aspects related to the promotion of a culture that values and practices the use of evidence in the making of decisions, the analysis of the results of the changes observed, the process of implementation of evidence, and the dissemination of the findings obtained. Previous educational interventions did not incorporate these specific contents, regardless of the methodology applied [19].

Also, it is necessary to address alternative modes of education based on new technologies to increase the EBP competence of nurses, which facilitates the learning of professionals and adapts to their schedules and pace of work. In this sense, the methodology used in our study suggests that this type of training, in which the participants access the learning platform to independently read and answer the self-reflection tasks without the support of tutors or peer groups, is a successful approach to improving the EBP competence of nurses. This finding is particularly promising at a time when health organizations have increasingly adopted online training methods [13].

Lastly, knowing the ideal duration of the training for it to have a positive effect is a much-discussed subject. Different factors, such as the duration or intensity of the training, the type of tasks, and the characteristics of the subjects, influence the duration of the training. The specialized literature coincides in that the training periods of longer duration lead to better retention [34]. Our results are consistent with this evidence, showing that training that lasts 3 months, with a teaching load of 72 h, is enough for obtaining a positive impact at least 3 months after the intervention in improving EBP knowledge, as well as EBP skills and utilization. It could be interpreted, as shown by the #EvidencerMUSEBP, which describes the comprehensive relationship of diverse determinant factors on nurse’s EBP competence, that EBP training, independently of the methodology applied, requires a large number of hours to have an impact at least on the EBP knowledge of nurses [35].

Healthcare organizations worldwide strive to enhance the implementation of EBP among nursing personnel to reduce variability, increase the quality of care, and improve patient outcomes. This is one of the few research studies with a quasi-experimental design with two groups that assessed the impact of the online EBP education program on clinical nurses' learning to acquire EBP competencies. The results suggest that this type of intervention can be sustainable and cost-effective for other target populations across different work environments, healthcare specialties, and cultures.

It has been demonstrated that training through an online learning platform lasting 3 months (72 h) is an efficient and desirable tool for improving the EBP competence of clinical nurses. The greatest effect was produced in the dimension of knowledge, with an increase higher than a third of the baseline value. Significant increases were also found in the dimensions of EBP skills and utilization, with a more moderate impact. The performance of these online courses, which can be adapted to the characteristics and availability of professionals, can be an efficient resource for preparing nurses for EBP competence and improving its applicability in a clinical setting.