Content area
Aim
To describe and discuss mechanisms for integration of evidence-based healthcare (EBHC) skills within nursing curricula informed by a conceptual model and the Sicily Statement.
BackgroundThe integration of evidence-based health care (EBHC) skills into health care education varies significantly across nursing programs. While common educational goals exist, educational disparities persist. The 2005 Sicily statement outlines foundational competencies for EBHC: formulating clinical questions, systematic evidence retrieval, critical appraisal and application of findings. Despite these competencies, EBHC is often viewed as peripheral in both undergraduate and postgraduate education.
MethodsWe compared congruency between a conceptual model for EBHC against the Sicily statement.
ResultsWe emphasize the need for a unified approach to teaching EBHC, highlighting the JBI Model of EBHC as a comprehensive framework that aligns with the Sicily statement. The JBI Model encompasses evidence generation, synthesis, transfer and implementation, providing a structured method for embedding EBHC into health care curricula. By promoting a transdisciplinary pedagogical approach, the JBI Model seeks to enhance student engagement and competency in the EBHC skills and knowledge crucial for developing health care professionals equipped to adapt to evolving evidence and practice needs.
ConclusionsThe authors call for an international methodology group to foster the adoption and evaluation of the JBI Model in diverse educational contexts, ultimately aiming to cultivate a workforce that is proficient in applying the best available evidence in clinical settings. The integration of EBHC into educational frameworks is positioned as essential for improving health care outcomes and promoting evidence-informed practice globally.
The integration and teaching of evidence-based health care (EBHC) skills and concepts varies widely across professional education programs and curricula for undergraduate and postgraduate health care students ( Avilés et al., 2024; Du et al., 2023). While the health professions share common goals in equipping graduates with the requirements for high-quality patient care and the use of evidence in clinical decision-making, pedagogical models vary within and across professions ( Li et al., 2024). A common denominator that underpins observed variation may be how EBHC is conceptualized and applied across tertiary education policy and sectors.
Some health care education programs leading to degree qualifications such as nursing and medicine or allied health have a skills-based approach—that is, they focus on techniques for clinical skills or procedures ( Mackintosh-Franklin, 2016). However, a 2016 United Kingdom evaluation found a systemic disconnect between pedagogical principles and curriculum content, with most educators focused on operational and functional requirements, alongside the acquisition of knowledge and skills and fitness to practice ( Mackintosh-Franklin, 2016). Additional pressures on curriculum and programming include regular calls for increasingly specialist content to be embedded and for curriculum changes to reflect workforce issues ( Bell et al., 2023; Garbrah et al., 2017).
With significant demands on curriculum space, EBHC skill and knowledge requirements have been considered peripheral rather than integral to much undergraduate education ( Xia et al., 2024). At postgraduate level, the focus on specialist clinical education for advanced practice roles means that programmatic knowledge for EBHC is rarely, or incompletely, addressed.; often fit around core and specialist curriculum requirements for professional practice ( Bell et al., 2023; Jager et al., 2020). This observation, that EBHC is peripheral rather than integral to undergraduate and postgraduate education and training is the raison d’être for this paper as a call to action for a unified conceptualization of core skills and knowledge open and available to the global community for integration
2 Re-engaging the global discussion on core skills and knowledge for EBHCIn recognition of the challenges involved with integrating EBHC skills and knowledge into curricula, we want to re-engage the global discussion on core skills, knowledge, resources and attitudes to benefit teaching and clinical practice. One of the foundational documents for minimum educational standards related to EBHC is the Sicily statement on evidence-based practice (EBP) ( Dawes et al., 2005). The Sicily statement was an attempt to integrate and standardize operational definitions of EBHC and to establish an evidence-informed curriculum outline. Published in 2005, the statement recommended a pathway to integrate educational content that would move the conceptualization and teaching of EBHC toward building global capacity for evidence-informed practice ( Dawes et al., 2005).
The Sicily statement on evidence-based represents one of the clearest internationally derived consensus descriptions of core skills and knowledge for EBHC, based on the premise that “all health care professionals need to understand the principles of EBP, recognize EBP in action, implement evidence-based policies and have a critical attitude to their own practice and to evidence” ( Dawes et al., 2005, p. 4). The Sicily statement on EBP challenges the academic community, decision makers and health care professionals to incorporate knowledge, skills and attitudes of EBHC into health professionals’ training; to develop curricula that include training in EBHC competencies, in accordance with five core skill and knowledge requirements; to establish programmatic research regarding the pedagogical models for each step; and to develop validated tools for student assessment at each step. Our position is that more should be done to advocate for these goals, that EBHC course coordinators should have effective methods for teaching and evaluating all the steps and that resources to achieve this should be shared internationally via open collaboration ( Cardoso and Lockwood, 2025; Dawes et al., 2005).
The Sicily statement advocates the integration of the following five steps into the curriculum to ensure graduates have an established set of minimum core competencies ( Dawes et al., 2005):
- Translation of uncertainty into an answerable question;
- Systematic retrieval of the best evidence available;
- Critical appraisal of evidence for validity, clinical relevance and applicability;
- Application of results in practice;
- Evaluation of performance.
In 2018, the Journal of the American Medical Association (JAMA) published an analysis of core EBHC competencies for health professionals. This analysis was based on a systematic review and Delphi Survey and was inspired by Sicily statement, Institute of Medicine reports and the Informed Health Choice key concepts ( Albarqouni et al., 2018). A total of 68 competencies was grouped into six EBP domains: Introductory; Ask; Acquire; Appraise and Interpret; Apply; and Evaluate. The JAMA paper described each competency and the level of detail or delivery for each one. There is a clear overlap between these six domains and the five core competencies established in the Sicily statement ( Dawes et al., 2005).
3 Evidence-based skills, knowledge and university curriculaLehane and colleagues (2019) emphasized that educators, regardless of teaching setting, need to be able to “draw out evidence-based components” from all aspects of curriculum content, including their incorporation into assessments and examinations. They argued that the integration of EBP into clinical curricula, was essential for successful learning and practice outcomes ( Lehane et al., 2019). This approach has been found to be beneficial among undergraduate nursing students, particularly for the acquisition of EBHC skills and knowledge and to avoid dissociation between learned knowledge and practical application and relevance ( Bhatarasakoon et al., 2024; Lehane et al., 2019).
Curricula have traditionally been owned rather than shared, meaning that universities and university colleges seek distinctive rather than common educational items ( Organisation for Econonic Co-operation and Development, 2020). The 2020 report by the OECD highlights that curricula are positioned as university-specific, often derived from education and sociology or driven by national policy frameworks. However, there is a clear opportunity for significant benefits through an international, consolidated evidence base. This evidence base could establish cross-disciplinary skill sets and provide adaptable pedagogical strategies that cater to varied knowledge transfer methods. This would enable measurable progress in skills and knowledge transfer as students’ progress through academic and clinical stages, resulting in future-oriented curricula ( González et al., 2024; OECD, 2020).
Currently, EBHC teaching and learning fits within a two-tier system where EBHC is secondary to the core curriculum. In contrast, specialist programs outside the tertiary model emphasize the transfer of EBHC knowledge and skills as a primary outcome of learning ( Wang et al., 2025; Xia et al., 2024). These programs facilitate and demonstrate learning outcomes evidenced by the conduct and publication of projects or programs, including implementation or types of evidence synthesis ( Du et al., 2023; González et al., 2024). Groups such as JBI via its Evidence Implementation Training Program, the Oxford Centre for Evidence-based Medicine and the European Evidence-based Medicine initiative draw on research findings to inform program development that focuses on EBHC skill and knowledge transfer ( Albarqouni et al., 2018; Cardoso et al., 2019).
4 Pedagogical models and congruency with the sicily statementA persistent challenge to the uptake or integration of EBHC skills and knowledge is the wide range of pedagogical models and frameworks that are available. This is further complicated by the tendency of the professions to create additional layers of complexity in curriculum design that is specific to their academic markets, or the omission of steps advocated in the Sicily statement ( Avilés et al., 2024; Oliveira Silva et al., 2025; Wang et al., 2025).
EBHC models and frameworks provide a process for transforming evidence into clinical practice; they also allow organizations to determine readiness and willingness for change in complex hospital systems ( Melnyk et al., 2010). These models and frameworks could play a more substantive role in assisting leaders, educators and clinicians in their strategies to advance EBP in individual point-of-care providers as well as throughout organizations ( Melnyk et al., 2017). However, choice of model or framework is important as many describe the production and critical synthesis of knowledge, its dissemination, its adoption and its implementation at the point-of-care, with less emphasis on the evaluation of the implementation or its impact on patient outcomes ( Melnyk et al., 2017).
5 Inclusive model for global uptake of sicily statement core competenciesA scoping review by Larsen et al. (2019) found that skill and knowledge training on question development, searching and appraisal are frequently taught (Steps 1–3), while learning to integrate the evidence with clinical expertise and patient preferences to make a practice decision. Conversely, application to practice and evaluating the change or outcome (Steps 4–5) are rarely taught. The JBI Model has been widely used as a conceptual basis for teaching EBHC skills, knowledge, methods and practical techniques for the application of evidence to practice, as well as for the evaluation of processes and outcomes. The model has been translated into several languages and has been used in more than 85 universities and tertiary referral centers worldwide ( Jordan et al., 2019). As shown in Table 1, the JBI Model mapped against the Sicily statement is more comprehensive in terms of domains and sub-domains for EBHC. It is also more inclusive, addressing diverse types of evidence (feasibility, appropriateness, meaningfulness and effectiveness), whereas the Sicily statement is silent on this issue. The model could therefore be of potential benefit for the education of practicing health professionals ( Dawes et al., 2005; Jordan et al., 2019).
Our vision is for a consistent pedagogical model of EBHC as a relational, constructivist human endeavor and not a transactional or technical process. However, the reality of EBHC as an integrative approach to patient care has yet to be realized ( Jordan et al., 2023). Unfortunately, while EBHC is integral to all health care professions, a persistent gap remains between its inclusion in curricula and its structured integration into program delivery. This gap is as challenging to address as the widely recognized research-to-practice gap, leading to inconsistent application in healthcare. ( Du et al., 2023; González et al., 2024; Xia et al., 2024).
6 Conceptual robustness for EBHC and pedagogical applicabilityThe JBI Model of EBHC conceptualizes and visually maps how diverse types of evidence inform synthesis, transfer and implementation to improve global health ( Jordan et al., 2018, 2019). This integrated model aligns with an implementation process framework, both of which have been used to assist health professionals with the uptake, completion and publication of important implementation topics. The model also informs national and international education programs, providing useful knowledge and skills across each of the core Sicily statement recommendations. These model-informed programs offer in-depth learning through a combination of innovative, theory-rich pedagogical strategies and hands-on experiences, grounded in constructivist theories of teaching and learning ( Jordan et al., 2018, 2019).
Over the course of the last decade, the JBI Model has been shaped and adapted through international discourse relating to evidence and its translation into policy and practice by framing the diverse evidence needs associated with health care practice ( Jordan et al., 2019). Although updated in 2019, the original definition of EBHC remains congruent, namely, “clinical decision-making that considers the best available evidence; the context where the care is delivered; client preference; and the professional judgment of the health professional” ( Pearson et al., 2005, p. 209).
The JBI Model of EBHC comprises five domains around a diverse and inclusive definition of evidence (FAME), as described below ( Jordan et al., 2019):
- • Global Health is positioned as the “driving force” of EBHC, in local contexts. Nursing and health professions have a significant effect on global health, both as a workforce and political force for good. This is reflected in the uptake of EBPs that lead to sustainable improvements in the quality of care and patient outcomes. These are based on mutual engagement to address and respond to knowledge needs in applied, practical ways in our global health services and systems.
- • Evidence Synthesis is the evaluation or analysis and collation of research evidence and opinion on a specific topic to aid in decision-making in health care. The three main synthesis products in health care are systematic reviews, evidence summaries and guidelines. However, the core of evidence synthesis remains the systematic review of literature on a particular condition, intervention, or phenomenon of interest. Conducting a high-quality synthesis project fulfills the first three skill and knowledge domains of the Sicily statement.
- • Evidence Transfer is fundamentally a pedagogical process. It is a co-active, participatory process that advances access to and uptake of evidence in local contexts. Evidence Transfer is a causal phenomenon that incorporates active dissemination, systems integration and education.
- • Evidence Implementation best captures the final two domains of the Sicily statement—application of results to practice and evaluation. The JBI Model conceptualizes Evidence Implementation as a purposeful and enabling set of activities designed to engage key stakeholders with research evidence; the aim is to inform decision-making and generate sustained improvements in the quality of health care delivery. Components of Evidence Implementation include context analysis, facilitation of change and evaluation of processes and outcomes to determine impact and sustainability.
Central to the model is ‘FAME’, representing diverse types of evidence, including qualitative, quantitative, economic and textual. We reject a singular focus on randomized controlled trials to inform policy or practice. Instead we advocate for educational programs that include evidence of Feasibility, Applicability, Meaningfulness as well as Effectiveness to more comprehensively address curriculum requirements for clinical or culturally relevant evidence ( Jordan et al., 2019). Diverse types of evidence, informed by conceptual model, aligned with curriculum development and postgraduate education may be a effective and impactful delivery mechanism to guide curriculum developers and teachers through the large number of theories, models and frameworks that are available and the terminology variations associated with Implementation Science ( Lizarondo et al., 2025). However, as illustrated in Table 1, the JBI Model of EBHC is aligned with the Sicily statement’s core competencies for health professionals. We envision a learning environment where each year of undergraduate education incrementally introduces EBHC theory, knowledge and skills to prepare clinicians, whereas postgraduate study would include a deeper dive into career-ready expertise. The JBI Model provides a logical, step-by-step process, illustrating the connection within and between these domains and the ability to understand and apply EBHC based on knowledge needs associated with global health, to synthesis through to implementation and evaluation of sustainability ( Jordan et al., 2019, 2023).
7 A collaborative way forward for education and EBHC frameworksWe propose the JBI Model of EBHC as a conceptual pedagogical framework in the context of undergraduate and postgraduate education of health care students to integrate EBHC early into their professional training. The model introduces students to mechanisms that facilitate EBHC while building on their clinical experience and prior knowledge gained in clinical practice. This is critical in facilitating defined pedagogical processes that align with and expand on the Sicily statement ( Wang et al., 2025). As shown in Table 1, comprehensive EBHC models have capacity to provide comprehensive frameworks for shared teaching domains across undergraduate and postgraduate health professional education and to expand into use cases beyond the Sicily statements domains.
The Sicily statement may have been driven by clinical teaching imperatives and early understandings of core competencies for EBHC, hence the focus on question development and appraisal and synthesis, rather than on a broader EBHC perspective that includes transfer and implementation across diverse types of evidence ( Cardoso et al., 2019; Dawes et al., 2005). The five key domains of the JBI Model of EBHC align with each of the five core Sicily domains. However, the JBI Model also includes a series of sub-domains (see outer edge, Fig. 1) that are important to clinical policy and practice change. These sub-domains are therefore linked with important educational skills and knowledge requirements not captured in the Sicily statement ( Jordan et al., 2023).
The adoption of effective pedagogical strategies and practical methods to achieve successful learning and understanding of EBHC is also emphasized in the literature ( Lehane et al., 2019). Although the literature describes many programs promoting EBHC knowledge and skills among health care professionals, a thematic literature review by Horntvedt et al. (2018) indicates inadequate consideration of EBHC teaching strategies. Although interactive teaching strategies are used, these primarily focus on searching for and critically appraising research for practice-based application; very few incorporate the integration of evidence into decision-making, together with evaluation ( Horntvedt et al., 2018).
The findings of Horntvedt et al. (2018) highlight the need for more research investigating interactive and clinically integrated teaching strategies to further enhance undergraduate nursing students’ EBP knowledge and skills. Often, courses focus on one of these elements—most commonly critical appraisal—but a balance of skills in each of the steps is needed to take a student from question through to application.
Table 1 summarizes the Sicily statement teaching objectives congruent with the JBI Model of EBHC. This does not imply that prescriptive teaching approaches are being proposed; instead, we recognize that a wide variety of teaching tools and strategies could be aligned to any subject or course with a focus on or inclusion of EBHC in the learning objectives. This is presented in Table 2, which demonstrates overlap and gaps between the JBI EBHC Model, the Sicily statement and a published analysis of a 4-year graduate MD program comparing course content with the Sicily statement.
8 ConclusionEBP is recognized as a foundational element of health care professional education. Achieving competency in this area is a complex undertaking, as reflected in the disparities between “best EBP” and actual clinical care ( Cardoso et al., 2021). We note that the consistent teaching of core EBP skills and knowledge across diverse geographic regions, cultures and contexts has been demonstrated to be feasible, appropriate and effective ( Aromataris et al., 2022; Stern et al., 2018).
While the adoption of the JBI Model of EBHC in existing health care education programs has yet to be formally evaluated, we firstly call for logical and sound mechanisms to align EBHC requirements in education standards and learning outcomes and specifically, that this be informed by models consistent with global evidence ( Duff et al., 2020). A model that can be tailored to suit the program and the subjects geared toward teaching EBHC offers pedagogical flexibility and adaptability and is nuanced to culture, profession, practice settings and policy settings ( Burns and Weston, 2022).The JBI Model has been subject to extensive real-world application across topics, professions, cultures, settings and geographic regions. It is a framework to guide program content development and delivery. Moreover, it provides a point of reference, emphasizing the interconnection between what is learned and the application of that learning to global health, indicating which skills and knowledge are core to sustainable action ( Jordan et al., 2023).
We have demonstrated that the JBI Model of EBHC conceptually and practically integrates the different components of EBP (generation, synthesis, transfer and implementation). The inclusion of such models in the curriculum assists students to develop a critical and reflective understanding of how seemingly diverse skills integrate within the EBHC paradigm. This enhances the clinical leadership potential of individuals, who gain EBP knowledge, attitudes and skills. In turn, this will pave the way for health care professionals who not only have acquired the requisite professional skills, but also have understanding and confidence in the process of using the best available and reliable evidence at the point of care.
The primary outcome we call for in this paper is the creation of an open, international methodology group for pedagogy, framed on models of EBHC and congruent with the intent of the Sicily statement. We believe JBI, with its 85 + Collaborating Entities embedded in universities around the world, is well placed to lead the uptake and integration of such an initiative. In this way, evidence-based skills and knowledge could be mapped to a conceptual model across undergraduate and postgraduate programs, inclusive of the principles of equity, diversity and inclusivity across cultures, geographic regions and intended degree qualification. This, we believe, will be the hallmark of a career-ready future workforce.
CRediT authorship contribution statementBjerrum Merete: Writing – review & editing, Conceptualization. Cardoso Ana Filipa: Writing – review & editing, Writing – original draft, Project administration, Conceptualization. Montayre Jed: Writing – review & editing, Writing – original draft, Conceptualization. Lockwood Craig: Writing – review & editing, Writing – original draft, Project administration, Methodology, Conceptualization. Lizarondo Lucylynn: Writing – review & editing, Writing – original draft, Conceptualization. Wu Yanni: Writing – review & editing, Conceptualization.
Declaration of Competing InterestThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
AcknowledgementsWe gratefully recognise Ms Camilla Smolicz who provided timely and comprehensive copy editing services which greatly improved the overall quality and readability of this paper.
| | |
| Synthesis and Implementation | Translation of uncertainty into an answerable question |
| Synthesis and Transfer | Systematic retrieval of best available evidence |
| Synthesis and Transfer | Critical appraisal of evidence for validity, clinical relevance, and applicability |
| Implementation | Application of results in practice |
| Implementation | Evaluation of performance |
| Synthesis sub-domains:
| Not addressed |
| Transfer sub-domains:
| Not addressed |
| Implementation sub-domains:
| Not addressed |
| | | |
| Synthesis and Implementation | Translation of uncertainty into an answerable question | Pre-clinical training
Clinical training Community training Elective training |
| Synthesis and Transfer | Systematic retrieval of best available evidence | Pre-clinical training
Clinical (POEM: patient-orientated evidence that matters) Training Community training Elective training |
| Synthesis and Transfer | Critical appraisal of evidence for validity, clinical relevance, and applicability | Pre-clinical training
Clinical training Community training Elective training |
| Implementation | Application of results in practice | Pre-clinical lectures
Clinical lectures Community |
| Implementation | Evaluation of performance | Clinical lectures |
| Synthesis sub-domains:
| Not addressed | Not addressed |
| Transfer sub-domains:
| Not addressed | Not addressed |
| Implementation sub-domains:
| Not addressed | Not addressed |
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