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,
mind, and skills or abilities in others (Bruce, Klopper, &
Mellish, 2011). Teaching is also about discovery and the inte-
gration and application of learning to encourage students to be critical
thinkers. Billings and Halstead (2012) define teaching as “a complex,
abstract concept and a system of directed and deliberate actions that
are intended to induce learning through self-directed activities”
(p. 202). Stevens (2013) states that the teaching strategies used by
nurse educators should be based on sound evidence or best prac-
tice. Nurse educators should use evidence-based strategies to sup-
port their teaching methods.
Teaching in nursing begins with basic education in which funda-
mental skills, knowledge, natural and behavioral sciences, profes-
sional values, behaviors, attitudes, and basic research are taught
(Aliakbari, Parvin, Heidari, & Haghani, 2015). To teach these skills,
About the Authors Cecile Breytenbach, MCur, RN, is a nurse
educator at Life Health Care College, East London, Port Elizabeth,
South Africa. Wilma ten Ham-Baloyi, PhD, RN, is a research associate
at the Faculty of Health Sciences, Nelson Mandela Metropolitan
University, Port Elizabeth, South Africa. Portia J. Jordan, PhD, MBA,
RN, RM, is an associate professor and head of department, Department
of Nursing Science, Nelson Mandela Metropolitan University, Port
Elizabeth, South Africa. The authors acknowledge librarian Madeleine
Clare for assisting with the search strategy. For more information,
contact Dr. ten Ham-Baloyi at wilmatenham@gmail.com.
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
versions of this article on the journal’s website (www.neponline.net).
The authors declare no conflict of interest.
Copyright © 2017 National League for Nursing
doi: 10.1097/01.NEP.0000000000000181
knowledge, behaviors, and attitudes, nurse educators must utilize a
variety of teaching strategies that actively engage their students
(Billings & Halstead, 2012), promote an in-depth understanding of in-
formation, and encourage students to compare new knowledge with
existing knowledge, generating a relationship between the two.
Teaching strategies that encourage the ownership of one’s own
learning (Loeffler, 2010) are particularly important for a generation of
nursing students who are knowledgeable in the use of technology
and prefer experiential learning (Eckleberry-Hunt & Tucciarone, 2011).
Despite the need for teaching strategies that promote active
learning, the authors observed that, in South Africa, most nurse
educators continue to use lecture-based teaching that requires
students to memorize content; they fail to seek out strategies that
are based on evidence. Furthermore, especially at the first author’s
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
teaching strategies based on their needs, including experiential and
active learning (Samarakoon, Fernando, & Rodrigo, 2013).
As nurse educators in South Africa are in the process of
developing a new curriculum to improve nursing education, the
authors conducted an integrative literature review to summarize the
best teaching strategies for nurse educators. This study was part of
a larger study that aimed to develop best practice guidelines for
nurse educators. No published studies could be found that were
conducted in any African countries regarding evidence-based
teaching strategies in nursing.
METHOD
This integrative literature review was conducted following four steps
adapted from the Joanna Briggs Institute (JBI, 2014). First, a focused
review question was formulated as follows: What are the best
evidence-based teaching strategies available that can be used by

Nursing Education Perspectives VOLUME 38 • NUMBER 4 193

Copyright © 2017 National League for Nursing. Unauthorized reproduction of this article is prohibited.
Breytenbach et al
nurse educators? Second, topic-relevant evidence was identified and
classified using a systematic search strategy. Third, a critical appraisal
of the methodological quality of the selected documents was com-
pleted using standardized critical appraisal tools. Fourth, data were
extracted using a standardized data extraction tool.
To ensure that the methods and search strategies were exhaus-
tive and that the search strategy and data analysis were conducted
rigorously, a librarian experienced in systematic and integrative litera-
ture reviews was consulted. The search was conducted using multi-
ple sources of relevant literature including electronic databases,
catalogues, and gray literature. The following sources were accessed:
PubMed Central, EBSCOhost, CINAHL with Full Text, ERIC, Health
Source: Nursing/Academic Edition, Medline, and Google Scholar. A
manual search of reference lists for relevant literature was also con-
ducted. The following key words were used based on the review
question: evidence-based practice or best practice guideline, nursing
education, and teaching strategies or teaching method. Combina-
tions of key words were adapted to suit the database.
Inclusion and Exclusion Criteria
Research and nonresearch documents that addressed evidence-
based teaching strategies and theoretical teaching of undergraduate
nursing students in the classroom setting were selected for inclusion
in the review. Documents in Afrikaans or English for the period 2000
to 2015 were considered eligible. To ensure rigor, only studies with
the highest two levels of evidence (1 and 2) according to the JBI hier-
archy of evidence (JBI, 2013) were included. Level 1 included exper-
imental designs such as systematic reviews of randomized controlled
trials (RCTs) and pseudo-RCTs. Level 2 included systematic reviews
of quasiexperimental studies; quasiexperimental, prospectively con-
trolled studies; and pretest/posttest or historic/retrospective control
group studies.
Studies conducted in contexts other than nursing education
(e.g., medical, health care) or non-classroom education teaching
such as clinical teaching or simulation teaching were excluded from
the review, as were studies consisting exclusively of samples of post-
graduate nursing students. In the case of studies published more
than one time, the most complete source was included in the review.
Search and Selection Process
The search was conducted in 2013 and updated in October 2015. A
thorough search was conducted by the first author, under the super-
vision of the second and third authors. First, a scoping review was
conducted of electronic databases; studies were included or ex-
cluded based on the reading of titles and abstracts. Second, full-
text articles were obtained and read for possible inclusion.
The search and selection process using the PRISMA flow chart
can be found in Supplemental Digital Content 1, http://links.lww.
com/NEP/A15. PRISMA is the preferred method to depict the flow
of information through the different phases of a systematic review
or integrative literature review (Moher, Liberati, Tetzlaff, Altman, &
PRISMA Group, 2009).
The initial search of databases revealed 990 hits; 494 documents
were excluded after reviewing the titles and abstracts. The full text of
the 494 remaining documents was obtained; of these, 443 studies
were excluded as they did not meet inclusion criteria. After critical re-
view of the remaining 51 full-text studies, a second reviewer excluded
32 studies, leaving 19 studies for critical appraisal.
194 July/August 2017
Copyright © 2017 National League for Nursing. Unauthorized reproduction of this article is prohibited.
Critical Appraisal
A detailed appraisal of the relevant documents was conducted to as-
sess methodological quality and rigor for inclusion in the final sample.
The selected studies were appraised using critical appraisal tools
available from the System for the Unified Management, Assessment
and Review of Information (SUMARI), the JBI software for systematic
reviews (JBI, 2011). The software used was specific to the type of re-
search being considered.
All included documents were critically appraised by the first
author with the support of an independent reviewer. Three quasi-
experimental studies were excluded owing to poor rigor, leaving
16 studies with good rigor for the final sample. Of these, 3 are sys-
tematic reviews, 1 is a meta-analysis, 1 is both a systematic review
and a meta-analysis (Level 1), 10 are quasiexperimental articles,
and 1 is a qualitative meta-analysis (Level 2). The 16 studies’ primary
characteristics were extracted using the JBI’s (2014) standardized
data extraction tool. A descriptive analysis was done for all included
studies and is outlined in Supplemental Digital Content 2, http://
links.lww.com/NEP/A16.
RESULTS
In total, eight teaching strategies were found in the included studies:
e-learning, concept mapping in place of quizzes, Internet-based
learning (IBL), web-based distance learning, educational gaming or
computer-based gaming, problem-based learning (PBL), case study,
and evidence-based interactive strategies. Technology was used in
seven of these studies.
E-learning, compared with traditional, formal, lecture-based teach-
ing strategies, was found significant (p > .001) in the largest of the three
quasiexperimental studies (sample size n = 276) (Abdelaziz, Samer
Kamel, Karam, & Abdelrahman, 2011). Póljanowicz et al. (2011), using
a smaller sample (n = 146), found that differences in the average final
exam score were statistically significant (p < .05), with a slight predom-
inance toward e-learning; they concluded that e-learning is not a lesser
method than traditional teaching in nursing. However, although stu-
dent knowledge improved with both e-learning and the formal lecture
method, Abbaszadeh, Sabeghi, Borhani, and Heydari (2011) found
no significant difference between the two groups (p = .983); their study,
which had a smaller sample (n = 61), found that lecture and e-learning
were equal in improving knowledge outcomes.
Concept mapping was studied in one quasiexperimental study.
Jaafarpour, Aazami, and Mozafari (2016) used a sample of 64 nursing
students in two groups of 32 to compare concept mapping to the tra-
ditional quiz for teaching the fundamentals of nursing. The groups
switched teaching strategies and were tested for a second time. Con-
cept mapping was found to have a significant difference in terms of
higher test scores compared to quizzing (p < .001). Despite being
more time-consuming, concept mapping offered benefits including
the use of teamwork, improved critiquing skills, and deep learning.
The effect of IBL was investigated in two systematic reviews by
Cook and colleagues (2008, 2010). One review, which included 201
studies from 1990 through 2007, compared IBL with no intervention
(Cook et al., 2008). It found that no intervention benefited knowledge
outcomes significantly more than Internet-based interventions
(p < .001), but the knowledge derived from Internet-based interven-
tions was more effective than the knowledge derived using non-
Internet interventions (p < .001). A follow-up systematic review and
meta-analysis with fewer studies (n = 51) from a similar time period
(1990-2008) found that, although IBL seems to improve knowledge
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outcomes, major inconsistencies exist. Cook et al. (2010) called
for rigorous studies to determine the effectiveness of IBL as a
teaching method.
The effect of web-based distance learning was investigated in
one systematic review of nine randomized controlled studies (Du
et al., 2013). In six studies, this teaching strategy was found to play
a positive role in knowledge retention. Compared with traditional
methods, distance learning was found to promote learner indepen-
dence and improve self-efficacy in performing nursing skills while facil-
itating the communication process between student and teacher
through chat rooms, bulletin boards, and via email. Student satisfac-
tion using this teaching strategy was generally high.
Educational gaming was not confirmed to be a better teaching
method for nurses compared with the formal, traditional teaching
strategy in two systematic reviews, one with two RCTs (Akl et al.,
2013) and the other with 16 studies (Blakely, Skirton, Cooper,
Allum, & Nelmes, 2009). However, Blakely et al. noted that educa-
tional gaming may enhance student enjoyment and therefore lead
to better retention of knowledge. Both studies indicated the need
for more evidence on the advantages and disadvantages of gaming
as a teaching method.
In a qualitative meta-analysis of 65 studies, computer-based
gaming was found in 34 studies to be significantly favorable to other
teaching strategies (Fengfeng, 2009). However, Fengfeng stated that,
in order to make computer-based strategies more effective in devel-
oping and increasing knowledge, nurse educators should include
computer games comprehensively in their teaching and determine
when and how games should be used.
PBL was compared with lecture-based, formal teaching strate-
gies in a quasiexperimental study with 54 participants (Beers, 2005).
The study found PBL to be equal to formal lecturing, with no statistical
significance in knowledge outcomes (p < .05). Another two-group
quasiexperimental study (Sangestani & Khatiban, 2013) with a similar
sample size (n = 56) found no statistical difference between learning
progress and student satisfaction between the two groups
(p < .005). However, PBL was found to be more enjoyable, with more
participation in learning as well as a deeper learning of concepts.
With regard to case studies as compared to formal lectures, no
significant difference was found in knowledge outcomes (p = .05) in
two quasiexperimental studies, one with a sample size of 48 partici-
pants (Lauver, West, Campbell, Herrold, & Wood, 2009) and the
other with a larger sample of 123 participants (Baumberger-Henry,
2005). Baumberger-Henry concluded that the use of case studies
was as reliable as other teaching methods for teaching problem-
solving and decision-making skills.
Kim, Brown, Fields, and Stichler (2009) conducted a quasiex-
perimental study with a sample size of 208 to evaluate an evidence-
based interactive strategy. The strategy demonstrated a statistically
significant increase in knowledge about evidence-based practice
(p < .001) and the use of evidence-based practice (p = .015) in the in-
tervention group. The study further suggests that, for nurses to have
better knowledge outcomes, innovative teaching strategies are
needed. In another quasiexperimental study with a smaller sample
size (n = 93; Choe, Park, & Yoo, 2014), action learning as an interac-
tive strategy was found more effective (p < .001) in increasing stu-
dents' knowledge than cross-examination debate (p = .003).
However, there was no statistical difference between the two methods
in terms of how much they improved students' recognition of the im-
portance of the information they were taught.
Nursing Education Perspectives
Copyright © 2017 National League for Nursing. Unauthorized reproduction of this article is prohibited.
Best Teaching Strategies for Nurse Educators
To summarize the reviewed studies, each of the teaching strate-
gies was found to contribute to student learning in some way. The re-
sults, however, did not show that gaming increased knowledge in
comparison to formal, traditional teaching but played a role in enhanc-
ing enjoyment in learning and possibly influenced knowledge reten-
tion. Concept mapping, IBL, evidence-based interactive strategies,
and web-based and e-learning showed positive effects in increasing
knowledge outcomes but individually did not stand out above other
teaching strategies. Case studies were found to be equal to formal
methods of teaching. PBL yielded contradictory results in terms of in-
creased knowledge in studies with similar research designs and com-
parable sample sizes.
DISCUSSION
In total, eight different teaching strategies were derived from 16 studies.
Although all were found to contribute to improved knowledge out-
comes, only three strategies (concept mapping, IBL, and evidence-
based interactive strategy) showed positive effects on increasing
knowledge outcomes. The use of multiple innovative, evidence-
based teaching strategies, integrating the strengths of all, is therefore
indicated (Abdelaziz et al., 2011; Baumberger-Henry, 2005; Beers,
2005). The learning needs of nursing students, available resources,
and the impact on increasing student knowledge should be consid-
ered (Beers, 2005).
Implementing Multiple Teaching Strategies
Based on the findings from this review, the authors propose that mul-
tiple teaching strategies should be encouraged in a nursing curricu-
lum to allow for the use of a set of strategies that are suitable for
different learning styles and student needs. To ensure successful im-
plementation of such a curriculum, the learning environment should
be assessed through a context analysis wherein the available and re-
quired resources are identified. With regard to the implementation of
the different teaching strategies identified, the following strategies
are recommended.
E-learning must be implemented as it improves documentation
competency and increases the student’s knowledge of technology
and computer skills as well as the accessibility of learning materials
(Abbaszadeh et al., 2011; Abdelaziz et al., 2011; Póljanowicz et al.,
2011). IBL and web-based education should also be utilized as it fa-
cilitates independence and self-direction and enhances the under-
standing of more complex knowledge (Cook et al., 2008, 2010; Du
et al., 2013). Therefore, e-learning, IBL, and web-based education
platforms should be offered with websites and e-books be made
available to the nurse educator and student.
Concept mapping can greatly increase teamwork, critiquing
skills, and deep learning and should therefore be included in a nursing
curriculum. Concept mapping can be effectively utilized by the nurse
educator along with lectures.
Games should be utilized to improve the cognitive knowledge of
nursing students (Akl et al., 2013; Blakely et al., 2009; Fengfeng,
2009). Games can enhance student satisfaction and the retention
of learning, but not all students enjoy gaming as a learning method.
Games can be used to assess student knowledge, for example, at
the beginning of a lecture and then again at the end of the lecture
to assess levels of understanding.
Both PBL and case studies encourage students to be active par-
ticipants in developing critical skills and enhancing problem-solving
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
practice (Baumberger-Henry, 2005; Lauver et al., 2009). A curricu-
lum could include a PBL approach, using case studies in both class
and clinical facilities for teaching and assessment. A task team to pro-
mote the use of PBL and case studies could be formed to develop
case-based scenarios that are contextualized to the health care set-
ting in which the educational institution is based. Case studies should
be appropriate to the level of the students and their existing scope of
knowledge. Case studies from other countries should be adapted, if
necessary, to the context of the country where they will be used.
Evidence-based interactive strategies can be used to discuss ethical
dilemmas and enhance ethical decision-making (Choe et al., 2014). It
is recommended that nurse educators be competent in the use of
technology in their teaching strategies.
Training for Nurse Educators
In order to implement the teaching strategies discussed in this report,
nurse educators should be trained to understand the strategies’ ben-
efits and their potential impact on knowledge acquisition, critical
thinking, decision-making, and competencies that are essential for
today’s nursing student. The different strategies have different goals
and learning outcomes. Time should be made available to train both
educators and students through the use of workshops or compul-
sory training modules, with links to available resources, for example,
websites and databases. It is important to discuss ethical require-
ments, such as the need to obtain consent for the use of pictures
in case studies and copyright considerations when using web-
based education.
Overcoming Challenges in Low-Resource Settings
The implementation of various teaching strategies challenges nurse
educators, specifically in low-resource settings, to think creatively
and utilize available resources effectively and cost-efficiently. The
use of some teaching strategies, such as e-learning and web-
based teaching, may pose barriers to implementation as they require
resources, such as computers and the Internet, that may not be
readily available (Abdelaziz et al., 2011). When resources are not
available, nurse educators are encouraged to submit proposals to lo-
cal, national, or international sponsors to obtain funding.
The findings from this study can be used in the development of
guidelines to assist nurse educators in the implementation of
evidence-based teaching strategies for a variety of contexts. The re-
sources that need to be in place for the effective implementation of
multiple strategies should be considered. The guidelines could in-
clude examples of case scenarios or links where relevant information
or resources can be found to assist the nurse educator to implement
the content.
Further Research
A number of studies included in this report indicate that more re-
search is needed for the best use of teaching strategies. Further-
more, it is important to compare the effectiveness of various
teaching strategies on increasing student knowledge (Akl et al.,
2013; Blakely et al., 2009; Cook et al., 2008, 2010; Du et al., 2013;
Kim et al., 2009). For example, more RCTs and quasiexperimental
studies using rigorous methods could assist in identifying which com-
bination of teaching strategies is best in which context.
As studies conducted in African countries are limited, it is recom-
mended that the effective use of innovative teaching strategies and its
196 July/August 2017
Copyright © 2017 National League for Nursing. Unauthorized reproduction of this article is prohibited.
impact on increasing student knowledge be examined in Africa and
especially other low-resource settings. Nurse educators and nursing
students may experience challenges in implementing teaching strat-
egies due to a lack of resources in their institutions.
Threats to Validity of the Study
It was not always possible to obtain abstracts (or hard copies where
applicable) of the articles as the authors’ university subscribed pri-
marily to electronic databases. However, multiple sources to obtain
studies were used, including manual searches. Although blinding
was not used during the search or critical appraisal steps, there
was no conflict of interest as the researchers did not know the ex-
perts involved in the field. Finally, although critical appraisal was done
by a single researcher, the critical appraisal process was indepen-
dently reviewed by researchers experienced in reviews.
CONCLUSION
This integrative literature review on the best available literature on
evidence-based teaching strategies for nurse educators uncovered
limited evidence on best teaching strategies. Based on the findings,
the authors recommend using multiple teaching strategies and pro-
posed suggestions to implement teaching strategies effectively in
the nursing curriculum by offering training and overcoming barriers
to implementation. The findings of this study can be used for the de-
velopment of guidelines to assist nurse educators to provide
evidence-based teaching strategies in a variety of contexts.
It is recommended that more research should be conducted to
further explain the best use of teaching strategies. Comparing the
benefits and impact of a variety of teaching strategies on the acquisi-
tion of knowledge should be done to add to the findings already iden-
tified in the literature.
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