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An Integrative Literature Review of Evidence-Based Teaching

Strategies for Nurse Educators


Cecile Breytenbach, Wilma ten Ham-Baloyi, and Portia J. Jordan

Abstract
AIM The aim of the study was to explore and describe the best available literature on evidence-based teaching strategies that
can be used by nurse educators.
BACKGROUND Evidence-based teaching strategies in nursing education are fundamental to promote an in-depth
understanding of information. Although some teaching strategies for nurse educators were identified, no integrative literature
review was found summarizing the best teaching strategies for nurse educators.
METHOD Integrative literature review.
RESULTS Sixteen studies were included encompassing eight teaching strategies (e-learning, concept mapping, Internet-based
learning, web-based learning, gaming, problem-based learning, case studies, and evidence-based learning). Of these, three
(concept mapping, Internet-based learning, and evidence-based learning) significantly increased student knowledge.
CONCLUSION All teaching strategies increased knowledge in some way, indicating that faculties should use a variety of teaching
strategies. However, more research is needed to compare the impact of a variety of teaching strategies and the best use of
different teaching strategies.
KEY WORDS Evidence-Based Practice – Integrative Literature Review – Nurse Educators – Teaching Strategies

T
eaching brings about a change in knowledge, character, knowledge, behaviors, and attitudes, nurse educators must utilize a
mind, and skills or abilities in others (Bruce, Klopper, & variety of teaching strategies that actively engage their students
Mellish, 2011). Teaching is also about discovery and the inte- (Billings & Halstead, 2012), promote an in-depth understanding of in-
gration and application of learning to encourage students to be critical formation, and encourage students to compare new knowledge with
thinkers. Billings and Halstead (2012) define teaching as “a complex, existing knowledge, generating a relationship between the two.
abstract concept and a system of directed and deliberate actions that Teaching strategies that encourage the ownership of one’s own
are intended to induce learning through self-directed activities” learning (Loeffler, 2010) are particularly important for a generation of
(p. 202). Stevens (2013) states that the teaching strategies used by nursing students who are knowledgeable in the use of technology
nurse educators should be based on sound evidence or best prac- and prefer experiential learning (Eckleberry-Hunt & Tucciarone, 2011).
tice. Nurse educators should use evidence-based strategies to sup- Despite the need for teaching strategies that promote active
port their teaching methods. learning, the authors observed that, in South Africa, most nurse
Teaching in nursing begins with basic education in which funda- educators continue to use lecture-based teaching that requires
mental skills, knowledge, natural and behavioral sciences, profes- students to memorize content; they fail to seek out strategies that
sional values, behaviors, attitudes, and basic research are taught are based on evidence. Furthermore, especially at the first author’s
(Aliakbari, Parvin, Heidari, & Haghani, 2015). To teach these skills, educational institution, there is minimal use of technology to actively
engage nursing students in the classroom setting. Students, who
are increasingly skilled in technology, benefit from a diversity of
About the Authors Cecile Breytenbach, MCur, RN, is a nurse teaching strategies based on their needs, including experiential and
educator at Life Health Care College, East London, Port Elizabeth, active learning (Samarakoon, Fernando, & Rodrigo, 2013).
South Africa. Wilma ten Ham-Baloyi, PhD, RN, is a research associate As nurse educators in South Africa are in the process of
at the Faculty of Health Sciences, Nelson Mandela Metropolitan developing a new curriculum to improve nursing education, the
University, Port Elizabeth, South Africa. Portia J. Jordan, PhD, MBA, authors conducted an integrative literature review to summarize the
RN, RM, is an associate professor and head of department, Department best teaching strategies for nurse educators. This study was part of
of Nursing Science, Nelson Mandela Metropolitan University, Port a larger study that aimed to develop best practice guidelines for
Elizabeth, South Africa. The authors acknowledge librarian Madeleine nurse educators. No published studies could be found that were
Clare for assisting with the search strategy. For more information, conducted in any African countries regarding evidence-based
contact Dr. ten Ham-Baloyi at wilmatenham@gmail.com. teaching strategies in nursing.
Supplemental digital content is available for this article. Direct URL cita-
tions appear in the printed text and are provided in the HTML and PDF METHOD
versions of this article on the journal’s website (www.neponline.net). This integrative literature review was conducted following four steps
The authors declare no conflict of interest. adapted from the Joanna Briggs Institute (JBI, 2014). First, a focused
Copyright © 2017 National League for Nursing review question was formulated as follows: What are the best
doi: 10.1097/01.NEP.0000000000000181 evidence-based teaching strategies available that can be used by

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Breytenbach et al

nurse educators? Second, topic-relevant evidence was identified and Critical Appraisal
classified using a systematic search strategy. Third, a critical appraisal A detailed appraisal of the relevant documents was conducted to as-
of the methodological quality of the selected documents was com- sess methodological quality and rigor for inclusion in the final sample.
pleted using standardized critical appraisal tools. Fourth, data were The selected studies were appraised using critical appraisal tools
extracted using a standardized data extraction tool. available from the System for the Unified Management, Assessment
To ensure that the methods and search strategies were exhaus- and Review of Information (SUMARI), the JBI software for systematic
tive and that the search strategy and data analysis were conducted reviews (JBI, 2011). The software used was specific to the type of re-
rigorously, a librarian experienced in systematic and integrative litera- search being considered.
ture reviews was consulted. The search was conducted using multi- All included documents were critically appraised by the first
ple sources of relevant literature including electronic databases, author with the support of an independent reviewer. Three quasi-
catalogues, and gray literature. The following sources were accessed: experimental studies were excluded owing to poor rigor, leaving
PubMed Central, EBSCOhost, CINAHL with Full Text, ERIC, Health 16 studies with good rigor for the final sample. Of these, 3 are sys-
Source: Nursing/Academic Edition, Medline, and Google Scholar. A tematic reviews, 1 is a meta-analysis, 1 is both a systematic review
manual search of reference lists for relevant literature was also con- and a meta-analysis (Level 1), 10 are quasiexperimental articles,
ducted. The following key words were used based on the review and 1 is a qualitative meta-analysis (Level 2). The 16 studies’ primary
question: evidence-based practice or best practice guideline, nursing characteristics were extracted using the JBI’s (2014) standardized
education, and teaching strategies or teaching method. Combina- data extraction tool. A descriptive analysis was done for all included
tions of key words were adapted to suit the database. studies and is outlined in Supplemental Digital Content 2, http://
links.lww.com/NEP/A16.
Inclusion and Exclusion Criteria
RESULTS
Research and nonresearch documents that addressed evidence-
In total, eight teaching strategies were found in the included studies:
based teaching strategies and theoretical teaching of undergraduate
e-learning, concept mapping in place of quizzes, Internet-based
nursing students in the classroom setting were selected for inclusion
learning (IBL), web-based distance learning, educational gaming or
in the review. Documents in Afrikaans or English for the period 2000
computer-based gaming, problem-based learning (PBL), case study,
to 2015 were considered eligible. To ensure rigor, only studies with
and evidence-based interactive strategies. Technology was used in
the highest two levels of evidence (1 and 2) according to the JBI hier-
seven of these studies.
archy of evidence (JBI, 2013) were included. Level 1 included exper-
E-learning, compared with traditional, formal, lecture-based teach-
imental designs such as systematic reviews of randomized controlled
ing strategies, was found significant (p > .001) in the largest of the three
trials (RCTs) and pseudo-RCTs. Level 2 included systematic reviews
quasiexperimental studies (sample size n = 276) (Abdelaziz, Samer
of quasiexperimental studies; quasiexperimental, prospectively con-
Kamel, Karam, & Abdelrahman, 2011). Póljanowicz et al. (2011), using
trolled studies; and pretest/posttest or historic/retrospective control
a smaller sample (n = 146), found that differences in the average final
group studies.
exam score were statistically significant (p < .05), with a slight predom-
Studies conducted in contexts other than nursing education
inance toward e-learning; they concluded that e-learning is not a lesser
(e.g., medical, health care) or non-classroom education teaching
method than traditional teaching in nursing. However, although stu-
such as clinical teaching or simulation teaching were excluded from
dent knowledge improved with both e-learning and the formal lecture
the review, as were studies consisting exclusively of samples of post-
method, Abbaszadeh, Sabeghi, Borhani, and Heydari (2011) found
graduate nursing students. In the case of studies published more
no significant difference between the two groups (p = .983); their study,
than one time, the most complete source was included in the review.
which had a smaller sample (n = 61), found that lecture and e-learning
were equal in improving knowledge outcomes.
Search and Selection Process Concept mapping was studied in one quasiexperimental study.
The search was conducted in 2013 and updated in October 2015. A Jaafarpour, Aazami, and Mozafari (2016) used a sample of 64 nursing
thorough search was conducted by the first author, under the super- students in two groups of 32 to compare concept mapping to the tra-
vision of the second and third authors. First, a scoping review was ditional quiz for teaching the fundamentals of nursing. The groups
conducted of electronic databases; studies were included or ex- switched teaching strategies and were tested for a second time. Con-
cluded based on the reading of titles and abstracts. Second, full- cept mapping was found to have a significant difference in terms of
text articles were obtained and read for possible inclusion. higher test scores compared to quizzing (p < .001). Despite being
The search and selection process using the PRISMA flow chart more time-consuming, concept mapping offered benefits including
can be found in Supplemental Digital Content 1, http://links.lww. the use of teamwork, improved critiquing skills, and deep learning.
com/NEP/A15. PRISMA is the preferred method to depict the flow The effect of IBL was investigated in two systematic reviews by
of information through the different phases of a systematic review Cook and colleagues (2008, 2010). One review, which included 201
or integrative literature review (Moher, Liberati, Tetzlaff, Altman, & studies from 1990 through 2007, compared IBL with no intervention
PRISMA Group, 2009). (Cook et al., 2008). It found that no intervention benefited knowledge
The initial search of databases revealed 990 hits; 494 documents outcomes significantly more than Internet-based interventions
were excluded after reviewing the titles and abstracts. The full text of (p < .001), but the knowledge derived from Internet-based interven-
the 494 remaining documents was obtained; of these, 443 studies tions was more effective than the knowledge derived using non-
were excluded as they did not meet inclusion criteria. After critical re- Internet interventions (p < .001). A follow-up systematic review and
view of the remaining 51 full-text studies, a second reviewer excluded meta-analysis with fewer studies (n = 51) from a similar time period
32 studies, leaving 19 studies for critical appraisal. (1990-2008) found that, although IBL seems to improve knowledge

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Best Teaching Strategies for Nurse Educators

outcomes, major inconsistencies exist. Cook et al. (2010) called To summarize the reviewed studies, each of the teaching strate-
for rigorous studies to determine the effectiveness of IBL as a gies was found to contribute to student learning in some way. The re-
teaching method. sults, however, did not show that gaming increased knowledge in
The effect of web-based distance learning was investigated in comparison to formal, traditional teaching but played a role in enhanc-
one systematic review of nine randomized controlled studies (Du ing enjoyment in learning and possibly influenced knowledge reten-
et al., 2013). In six studies, this teaching strategy was found to play tion. Concept mapping, IBL, evidence-based interactive strategies,
a positive role in knowledge retention. Compared with traditional and web-based and e-learning showed positive effects in increasing
methods, distance learning was found to promote learner indepen- knowledge outcomes but individually did not stand out above other
dence and improve self-efficacy in performing nursing skills while facil- teaching strategies. Case studies were found to be equal to formal
itating the communication process between student and teacher methods of teaching. PBL yielded contradictory results in terms of in-
through chat rooms, bulletin boards, and via email. Student satisfac- creased knowledge in studies with similar research designs and com-
tion using this teaching strategy was generally high. parable sample sizes.
Educational gaming was not confirmed to be a better teaching
method for nurses compared with the formal, traditional teaching DISCUSSION
strategy in two systematic reviews, one with two RCTs (Akl et al., In total, eight different teaching strategies were derived from 16 studies.
2013) and the other with 16 studies (Blakely, Skirton, Cooper, Although all were found to contribute to improved knowledge out-
Allum, & Nelmes, 2009). However, Blakely et al. noted that educa- comes, only three strategies (concept mapping, IBL, and evidence-
tional gaming may enhance student enjoyment and therefore lead based interactive strategy) showed positive effects on increasing
to better retention of knowledge. Both studies indicated the need knowledge outcomes. The use of multiple innovative, evidence-
for more evidence on the advantages and disadvantages of gaming based teaching strategies, integrating the strengths of all, is therefore
as a teaching method. indicated (Abdelaziz et al., 2011; Baumberger-Henry, 2005; Beers,
In a qualitative meta-analysis of 65 studies, computer-based 2005). The learning needs of nursing students, available resources,
gaming was found in 34 studies to be significantly favorable to other and the impact on increasing student knowledge should be consid-
teaching strategies (Fengfeng, 2009). However, Fengfeng stated that, ered (Beers, 2005).
in order to make computer-based strategies more effective in devel-
oping and increasing knowledge, nurse educators should include Implementing Multiple Teaching Strategies
computer games comprehensively in their teaching and determine Based on the findings from this review, the authors propose that mul-
when and how games should be used. tiple teaching strategies should be encouraged in a nursing curricu-
PBL was compared with lecture-based, formal teaching strate- lum to allow for the use of a set of strategies that are suitable for
gies in a quasiexperimental study with 54 participants (Beers, 2005). different learning styles and student needs. To ensure successful im-
The study found PBL to be equal to formal lecturing, with no statistical plementation of such a curriculum, the learning environment should
significance in knowledge outcomes (p < .05). Another two-group be assessed through a context analysis wherein the available and re-
quasiexperimental study (Sangestani & Khatiban, 2013) with a similar quired resources are identified. With regard to the implementation of
sample size (n = 56) found no statistical difference between learning the different teaching strategies identified, the following strategies
progress and student satisfaction between the two groups are recommended.
(p < .005). However, PBL was found to be more enjoyable, with more E-learning must be implemented as it improves documentation
participation in learning as well as a deeper learning of concepts. competency and increases the student’s knowledge of technology
With regard to case studies as compared to formal lectures, no and computer skills as well as the accessibility of learning materials
significant difference was found in knowledge outcomes (p = .05) in (Abbaszadeh et al., 2011; Abdelaziz et al., 2011; Póljanowicz et al.,
two quasiexperimental studies, one with a sample size of 48 partici- 2011). IBL and web-based education should also be utilized as it fa-
pants (Lauver, West, Campbell, Herrold, & Wood, 2009) and the cilitates independence and self-direction and enhances the under-
other with a larger sample of 123 participants (Baumberger-Henry, standing of more complex knowledge (Cook et al., 2008, 2010; Du
2005). Baumberger-Henry concluded that the use of case studies et al., 2013). Therefore, e-learning, IBL, and web-based education
was as reliable as other teaching methods for teaching problem- platforms should be offered with websites and e-books be made
solving and decision-making skills. available to the nurse educator and student.
Kim, Brown, Fields, and Stichler (2009) conducted a quasiex- Concept mapping can greatly increase teamwork, critiquing
perimental study with a sample size of 208 to evaluate an evidence- skills, and deep learning and should therefore be included in a nursing
based interactive strategy. The strategy demonstrated a statistically curriculum. Concept mapping can be effectively utilized by the nurse
significant increase in knowledge about evidence-based practice educator along with lectures.
(p < .001) and the use of evidence-based practice (p = .015) in the in- Games should be utilized to improve the cognitive knowledge of
tervention group. The study further suggests that, for nurses to have nursing students (Akl et al., 2013; Blakely et al., 2009; Fengfeng,
better knowledge outcomes, innovative teaching strategies are 2009). Games can enhance student satisfaction and the retention
needed. In another quasiexperimental study with a smaller sample of learning, but not all students enjoy gaming as a learning method.
size (n = 93; Choe, Park, & Yoo, 2014), action learning as an interac- Games can be used to assess student knowledge, for example, at
tive strategy was found more effective (p < .001) in increasing stu- the beginning of a lecture and then again at the end of the lecture
dents' knowledge than cross-examination debate (p = .003). to assess levels of understanding.
However, there was no statistical difference between the two methods Both PBL and case studies encourage students to be active par-
in terms of how much they improved students' recognition of the im- ticipants in developing critical skills and enhancing problem-solving
portance of the information they were taught. skills for real-life problems (Beers, 2005; Sangestani & Khatiban,

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Breytenbach et al

2013), enhancing the integration of theoretical knowledge with clinical impact on increasing student knowledge be examined in Africa and
practice (Baumberger-Henry, 2005; Lauver et al., 2009). A curricu- especially other low-resource settings. Nurse educators and nursing
lum could include a PBL approach, using case studies in both class students may experience challenges in implementing teaching strat-
and clinical facilities for teaching and assessment. A task team to pro- egies due to a lack of resources in their institutions.
mote the use of PBL and case studies could be formed to develop
case-based scenarios that are contextualized to the health care set- Threats to Validity of the Study
ting in which the educational institution is based. Case studies should It was not always possible to obtain abstracts (or hard copies where
be appropriate to the level of the students and their existing scope of applicable) of the articles as the authors’ university subscribed pri-
knowledge. Case studies from other countries should be adapted, if marily to electronic databases. However, multiple sources to obtain
necessary, to the context of the country where they will be used. studies were used, including manual searches. Although blinding
Evidence-based interactive strategies can be used to discuss ethical was not used during the search or critical appraisal steps, there
dilemmas and enhance ethical decision-making (Choe et al., 2014). It was no conflict of interest as the researchers did not know the ex-
is recommended that nurse educators be competent in the use of perts involved in the field. Finally, although critical appraisal was done
technology in their teaching strategies. by a single researcher, the critical appraisal process was indepen-
dently reviewed by researchers experienced in reviews.
Training for Nurse Educators
In order to implement the teaching strategies discussed in this report, CONCLUSION
nurse educators should be trained to understand the strategies’ ben- This integrative literature review on the best available literature on
efits and their potential impact on knowledge acquisition, critical evidence-based teaching strategies for nurse educators uncovered
thinking, decision-making, and competencies that are essential for limited evidence on best teaching strategies. Based on the findings,
today’s nursing student. The different strategies have different goals the authors recommend using multiple teaching strategies and pro-
and learning outcomes. Time should be made available to train both posed suggestions to implement teaching strategies effectively in
educators and students through the use of workshops or compul- the nursing curriculum by offering training and overcoming barriers
sory training modules, with links to available resources, for example, to implementation. The findings of this study can be used for the de-
websites and databases. It is important to discuss ethical require- velopment of guidelines to assist nurse educators to provide
ments, such as the need to obtain consent for the use of pictures evidence-based teaching strategies in a variety of contexts.
in case studies and copyright considerations when using web- It is recommended that more research should be conducted to
based education. further explain the best use of teaching strategies. Comparing the
benefits and impact of a variety of teaching strategies on the acquisi-
Overcoming Challenges in Low-Resource Settings tion of knowledge should be done to add to the findings already iden-
The implementation of various teaching strategies challenges nurse tified in the literature.
educators, specifically in low-resource settings, to think creatively
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Best Teaching Strategies for Nurse Educators

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