Effectiveness of an Evidence-Based Practice educational intervention with second-year nursing students 1

ABSTRACT Objectives: to evaluate the effectiveness of an educational intervention on the knowledge, skills and attitudes of evidence-based practice among second-year nursing students. Method: a quasi-experimental before-and-after study. The study population consisted of 120 students enrolled in the Nursing Care in Healthcare Processes course. The educational intervention was based on theoretical and practical classes about the evidence-based practice process and the use of the critical incident technique during the clinical clerkship. Effectiveness was measured with the Evidence-Based Practice Competence Questionnaire in three paired measures using repeated-measures analysis of variance. Results: the mean scores of the Evidence-Based Practice Competence Questionnaire were 79.83 (CI 95% 78.63-81.03) for the basal measurement, 84.53 (CI 95% 83.23-85.83) for the intermediate measurement, and 84.91 (CI 95% 83.26-86.55) for the final measurement, with a statistically significant difference among the three paired measurements (p<0.001). There were statistically significant differences in Attitudes (p = 0.034) and Knowledge (p <0.001) but not in Skills (p = 0.137). Conclusion: this educational intervention based on theoretical and practical classes about the evidence-based practice process and the use of the critical incident technique during the clinical clerkship enhances evidence-based practice competence among second-year nursing degree students.


Introduction
Evidence-based medicine (EBM) first appeared as a clinical learning strategy at McMaster Medical School and, because healthcare professionals from many fields currently adopt this approach in their clinical practice, EBM has evolved into evidence-based practice (EBP), a wider and more comprehensive concept (1) .

EBP involves the integration and implementation
of the best available evidence, including clinical expertise and patients' values and circumstances, in clinical decision-making (2)(3) . Traditional EBP is a five-step process: Ask, Acquire, Appraise, Apply and Assess (3) . Recently, however, some researchers (4) have developed a seven-step EBP process, with the addition of 'Cultivation of a spirit of inquiry' as a step zero and 'Dissemination of the results' as a sixth step.
Both processes comprise other sources of evidence in addition to research evidence so that EBP has come to utilise more than research and now embraces interprofessional teams, patients and the best available evidence to optimise patient outcomes.
Despite the evidence that EBP improves patient outcomes and performance, incorporating EBP into clinical nursing remains a challenge (2)(3)(4) . This incorporation of EBP requires positive attitudes, knowledge and skills related to research. Clinical nurses highlight the lack of time, organisational support and abilities to search, critique and synthesise the literature (5) as barriers to the incorporation of EBP, probably because they were not educated on the EBP paradigm (6) . Today, the introduction of EBP education in nursing curricula is strongly recommended in the United States (7) , Australia (8) and Europe (9) , and in some countries, such as the United Kingdom, EBP competence is compulsory in nursing degree programmes (10) . In Spain, EBP competence is not considered by the specific legislation that stipulates the minimum requirements for the verification of nursing degrees (11) , although some universities do make an effort to incorporate EBP education into their curricula (6,12) .
There are several books on teaching EBP that can help teachers and educators implement EBP education into their curricula (3)(4) , and The Sicily Statement on EBP recommends the minimum standard educational requirements for training health professionals in EBP (1) .
Moreover, the EBP education literature is extensive, and several systematic reviews have been conducted to evaluate the effectiveness of EBP training (12)(13) . These studies assessing the effectiveness of EBP training focus mainly on short-term interventions (6) , although there are authors (14) who outline multifaceted interventions, such as combining lectures, computer lab sessions, journal clubs or portfolios as better ways to improve students' knowledge, skills and attitudes as opposed to single interventions. Conversely, the American Association of Colleges of Nursing (7) does not recommend the inclusion of all the stages of EBP in the baccalaureate nursing curricula as standard practice due to a lack of cognitive maturity among students (15) . The drawback is that the literature does not provide conclusive evidence on the best practices for EBP education, yet some relevant recommendations and areas for debate can be drawn.
Furthermore, there is no consensus on the most appropriate year to start EBP training, although it seems that an early introduction to the EBP process increases students' interest and skills (16) . As such, several authors support the idea that EBP education must be embedded as a cross-curricular competence (4,(16)(17) . Despite these conflicting theories, developing nursing students' critical thinking skills is a requisite for teaching EBP (13) , which coincides with step zero ('Cultivation of a spirit of inquiry') (4) . This could be the most difficult step, but some studies show that problem-based learning (18) , journal clubs (19) or critical incidents (20) are learning strategies that promote critical thinking and EBP. While the development of critical thinking is a necessary step, information literacy is considered the most important skill at the bachelor's level. Some authors (1,13) offer recommendations on educational interventions during this step (theoretical instruction and supervised practical sessions with online content). Another recommendation is the need to integrate the learning of EBP as a routine in the clinical context and to provide continuous opportunities to apply EBP skills (1) so that students can link EBP knowledge and skills with real clinical situations.
To this end, some researchers (18,(20)(21) have developed specific models and strategies to integrate the teaching of EBP with its practice.
The nursing degree was introduced at the Universitat Jaume I (Spain) in 2011 after the establishment of the European Higher Education Area (12) . The learning methodology of the nursing programme integrates theory, simulated practice and clinical practice through learning outcomes, so that  this clerkship, students are supervised by nurses who have passed an initial 40-hour training course covering topics related to the curriculum, the assessment of competences in a clinical clerkship and EBP (22) . The curriculum has four courses; 50% of them are based on clinical clerkship, and the teaching-learning process has at its core the minimum competences established by Spanish legislation (11) . Moreover, the curriculum incorporates a cross-curricular competence in EBP defined as the "capacity to assert clinical judgements to ensure that quality standards are met and that the practice is based on evidence" (12) . With the aim of accomplishing the progressive acquisition of this EBP competence, a four-year cross-curricular EBP programme was designed, based on recent literature and the main recommendations for EBP education. This programme includes learning outcomes and training activities for each year, as well as cross-curricular activities ( Figure 1 shows an overview of the learning outcomes of the cross-curricular EBP programme).

st year
The student knows the structure of a scientific paper The student is able to recognise keywords in scientific papers The student is familiar with the use of keywords and is able to use the MeSH* website The student is able to carry out an initial evidence search through meta-search engines, such as Google Scholar The student knows how to reference the bibliography in a written work using the citation guidelines required for each corresponding subject The student is able to use bibliography management software

nd year
The student knows the definition and process of evidence-based practice The student knows the different stages of the research process The student knows the PICO † framework and is able to establish its basic structure when encountering a problem in their clinical practicum The student knows how to carry out a bibliographic search in different databases using MeSH* standardised language and including Boolean operators The student has the full capacity to formulate a PICO † question and deduce from it the keywords that will be used for the bibliographic search The student is able to choose the most suitable one from the diversity of studies found, depending on the PICO † question that is posed The student is able to identify the study that will be used The student knows different tools that can be used for critical reading

th year
The student has the ability and skills to perform a critical reading of a scientific paper The student researches and writes his/her bachelor's thesis, applying all the knowledge and skills acquired in previous courses * Medical Subject Headings; † Population-Intervention-Comparison-Outcome. To assess EBP education, some authors (23) developed the Classification Rubric for EBP Assessment Tools in Education (CREATE) for classifying EBP learning assessment tools. They recommend the use of the Fresno test and the Berlin Questionnaire as validated tools, although they also highlight the need for further development and validation of EBP learning assessment tools; these tools have not been validated in Spanish.

Thus, the Evidence-Based Practice Competence
Questionnaire (EBP-COQ) has recently been developed and validated to evaluate the self-perceived level of EBP competence in Spanish nursing students (24) . The EBP-COQ consists of 25 items organised in three dimensions  (25) , considering an alpha risk of 0.05 and a beta risk of 0.05 in a one-sided means test in a paired group, taken from a study of the EBP-COQ among Spanish nursing students (25) . A drop-out rate of 20% Students who did not complete the three measures were also excluded from the study.
The educational intervention was carried out with second-year nursing degree students and was framed within the cross-curricular EBP programme described in
All items in the knowledge category showed significant differences among the three measurements (Table 4). Item 1 obtained an average baseline measurement of 2.43 (SD ± 0.88) points, increasing in the following measurements to above 4 points.

Discussion
The main goal of this study was to evaluate the effectiveness of an educational intervention carried out in the second-year nursing degree programme at Universitat Jaume I (Spain) on students' knowledge, skills and attitudes towards evidence-based practice.
This educational intervention was embedded in the crosscurricular evidence-based practice programme developed in the nursing degree programme at the Universitat Jaume I. It was based on recommendations from the literature regarding the use of theoretical and practical classes on the evidence-based practice process (1) and the development of students' critical thinking (12) by using the critical incident technique (19) , and it was developed as a way to provide continuous opportunities to apply evidence-based practice skills during clinical clerkships (1) .
Moreover, the effectiveness was measured using the EBP-COQ, a validated tool developed in Spanish to measure the knowledge, skills and attitudes of nursing students (24)(25)(26) .
Our results show that this educational intervention can improve students' overall evidence-based practice evidence-based practice competence (20) by implementing journal clubs (18) or by involving them in critical incident analysis. Moreover, students can promote evidence-based practice within clinical settings by forming partnerships with clinical nurses (18) . Another factor may be the difficulty students encounter in accessing electronic resources during their clinical clerkships. The use of mobile devices with Internet access may be a solution to this issue by providing fast access to evidence at the point of care; apps have recently been developed to effectively enhance students' evidence-based practice skills (24) . evidence-based practice on students' knowledge, skills and attitudes (6) or on students' cognitive load and learning performance (27) with good results, but they have not addressed learning integrated within the clinical  (12,18) .

The first part of this educational intervention is
It is necessary to consider that this educational intervention was carried out among second-year nursing degree students and was framed within the crosscurricular evidence-based practice programme described earlier. Thus, it is important to consider that students in our programme had learned statistics and epidemiology in their first year, as some authors (6) recommend; moreover, they had the fundamentals of evidence-based practice has only recently been implemented. In subsequent academic courses, there were new interventions related to evidence-based practice that had to be measured.
Moreover, the study sample was limited to two academic years and was carried out in a single institution.
The EBP-COQ is a robust and validated instrument for measuring the effectiveness of educational interventions on evidence-based practice, although it is based on students' perceptions rather than on objective data. The use of subjective measures is suitable, however, because of the correlation between self-reported and objective assessments of evidence-based practice competence (6) .

Conclusion
The findings of this study show that an educational