A Global Approach to Promoting EBP Knowledge: Validating the Translated Version of EKAN Into Spanish

Sunday, 30 July 2017: 10:15 AM

Jan M. Nick, PhD
School of Nursing, Loma Linda University, Loma Linda, CA, USA
Amy Hagedorn Wonder, PhD, RN
Indiana University School of Nursing, Bloomington, IN, USA
Alfa Rigel Suero, MD
Vice rector Academico, Universidad Adventista Dominicana, Villa Sonado, Dominican Republic
Darrell Spurlock Jr., PhD, RN, NEA-BC, ANEF
School of Nursing, Widener University, Chester, PA, USA

Purpose:  This study is part of a multi-site research project aimed at documenting the evidence-based practice (EBP) knowledge of nursing students on a global scale. Although the benefits of EBP are widely known, EBP is still not consistently implemented across care settings. A variety of subjective instruments are used in countries to gauge what nursing students know about EBP. The documented lack of correlation between subjective and objective knowledge measures (Zell & Krizan, 2014) coupled with a lack of consistent instrumentation to enable generalizability of findings are two factors that inhibit a global approach toward promoting EBP and collaboratively advancing the science of nursing. The availability of a common, standards-based objective EBP knowledge measure would: a) enable a universal assessment of the state of EBP knowledge in nursing students and nurses, and b) facilitate a collaborative approach toward developing and testing educational strategies across levels of nursing education and practice around the world. The Evidence-based Practice Knowledge Assessment in Nursing (EKAN) instrument was selected for use due to its objective approach to knowledge measurement and solid psychometric properties.

The purposes of this research were to: a) translate the EKAN instrument into Spanish and conduct a validation study in the Dominican Republic, a geographic area that expressed interest in integrating EBP in their nursing curriculum, and b) supply a baseline knowledge assessment for the program to gauge the success of their curriculum enhancement. A secondary purpose included strengthening programs of research at the site institution through a collaborative relationship.

Methods:  Using a cross-sectional, descriptive, correlational design, 139 actively enrolled baccalaureate nursing students from a program in Dominican Republic volunteered to participate in the study. Subjects were invited via posters, verbal announcements, and email communication. They were asked to take the EKAN exam, translated into Spanish.

The EKAN is a 20-item multiple-choice objective measure of EBP knowledge with an established item reliability of .98 and strong evidence of validity with infit statistics centering on 1.0, when tested with a similar population in the United States (Spurlock & Wonder, 2015). Using Brislin’s (1970) traditional translation method, the EKAN was translated into Spanish by three individuals, then back to English by two additional translators who had not previously seen the original English version. The back-translation was then compared with the original instrument for content, semantic, technical, and conceptual equivalence (Squires et al., 2012) while maintaining focus on cultural and linguistic considerations for the geographic area of study (Palmieri, 2014). A 7-item demographic questionnaire, developed for use with the EKAN, was also incorporated to describe the sample characteristics. Subjects were also asked to self-rate their confidence in delivering evidence-based care using a 5-point Likert-type scale.

The investigators obtained IRB approval from the home institution of the PI and the host institution in Dominican Republic. Subjects completed the Demographic Questionnaire and EKAN-Spanish in paper/pencil format during a proctored data collection session. Most subjects completed the study forms within 35 minutes. Data were later entered into SPSS v.24 for analysis. Additionally, jMetrik (Meyer, 2014) was used to conduct 1-parameter item response theory (IRT) Rasch analysis of the EKAN responses.

Results: After excluding responses from subjects with more than one missing response to EKAN items (because the EKAN is a sum-scored instrument), complete data were available from N = 123 subjects. Subjects were 93.5% female with an average age of 29.6 (SD= 7.8) years. The majority (92.7%) of subjects reported the Dominican Republic as their country of origin with 5.7% reporting Haiti and 1.6% reporting another country. Sixty-six percent of subjects were seniors, and reported being in their eighth or ninth term of enrollment in the nursing program (with a range of five to ten terms). A large majority (83.6%) of subjects reporting having already completed a statistics course with 7.4% reporting current enrollment and 9.0% reporting not having yet taken a statistics course. Most (65.5%) subjects reported having completed a special EBP workshop of 1-2 days in length, while 23% reported having completed no special EBP courses.

Using Rasch model analytics, validity indices of the EKAN produced a difficulty index ranging from ϴ = -1.78 to 2.22. Mean infit and outfit statistics narrowly centered on 1.0 (WMS M = .978; UMS M= .988) indicating strong evidence of trait unidimensionality. For reliability indices, separation index values of > 2.0 is a desirable goal. The EKAN-Spanish item separation was robust at 4.27 but person separation was somewhat limited at .38. Item reliability was .94 and person reliability was .13, indicating trait (EBP knowledge) restriction among the study sample. These results compare similarly to the English version of EKAN. Additionally, differential item functioning (DIF) analysis produced no evidence of language-related concern on any of the EKAN’s 20 items, supporting translational accuracy.

For baseline knowledge assessment, the mean EKAN EBP knowledge score for the group was 6.52 (SD = 2.03) out of 20 possible points, with scores ranging from 2-12 points. No statistically significant differences in mean EKAN scores were found when comparing subjects by level of completion of the nursing program (F = 1.81, df = 5, 117, p = .117) or whether subjects had completed a special EBP course or not (F = .302, df = 4, 117, p = .876). Current enrollment in a statistics course however was associated with higher scores on the EKAN when compared to subjects having not yet taken or having previously taken the course (F = 4.51, df = 2, 119, p= .013).

While subjects’ self-rated competence to deliver evidence-based care on a scale from 1 = strongly disagree to 5 = strongly agree was quite high (M = 4.16, SD = .80), the correlation between self-reported confidence and objectively measured EBP knowledge was small, negative, and statistically nonsignificant (r = -.041, p= .654).

Conclusion: This is a first step in using a unified, standards-based approach to EBP assessment, and the results indicate the ability to use the EKAN instrument in populations outside the U.S. The findings from this study align with those reported previously (Spurlock & Wonder, 2015), with evidence reported here of a slightly lower and narrower EBP knowledge trait range among the study sample. The EKAN-Spanish translation produced good validity and reliability parameters under the Rasch model. This study provides baseline EBP knowledge level information useful for future score norming and educational intervention research among Spanish-speaking populations like those in the Dominican Republic. Also congruent with findings from an increasing number of studies, subjects’ self-evaluations of EBP confidence were not related to objectively measured EBP knowledge.

Future translation and validation studies are currently planned for Japan, Korea, Colombia, and Brazil within the next year. Once psychometric properties are demonstrated for each country, nurse scientists can use the EKAN to describe student knowledge across different levels of preparation (AS, BS, MS, Doctoral), or differentiate knowledge within a particular level (i.e., year 1, year 2), thereby providing evidence for curricular decisions or gauge effectiveness of EBP training. In addition, EKAN translations can also be tested in practice settings and provide clinical leaders information on the knowledge base of nurses practicing in their institutions.

Because education is commonly acknowledged as a barrier to the implementation of evidence-based care, it is essential for academic faculty and clinical leaders to accurately evaluate EBP knowledge. Enabling use of the EKAN in non-English language countries will provide nurse leaders the ability to expand EBP knowledge through accurate and systematic measurement in educational and clinical environments.

The collaborative research relationship between countries has provided a validated instrument in Spanish, baseline knowledge of EBP in junior and senior nursing students, a system for annual assessment for nursing knowledge, and a research trajectory for faculty at the host institution. The validation of EKAN into Spanish now has the ability to transform EBP assessment in over 21 Spanish speaking countries.